Increasing exclusive breast feeding
Authors: Maria A Quigley
Journal: BMJ (2007)

In this week's BMJ, a randomised controlled trial by Su and colleagues compares the effect of two different strategies on the rate of exclusive breast feeding in 450 healthy pregnant women in a tertiary hospital in Singapore.1 The World Health Organization (WHO) recommends that, wherever possible, infants are exclusively breast fed for the first six months after birth2; during this period they should receive breast milk only, and no other liquids (except drugs) or solids. In developing countries, where the risk of infection is high and facilities for adequate sterilisation are scarce, breast feeding protects against infant mortality, particularly mortality related to infection.3 Rates of breast feeding are high in such countries, but rates of exclusive breast feeding are lower as a result of certain cultural practices, such as delaying the initiation of breast feeding and giving prelacteal feeds.4 However, starting breastfeeding on the first day after birth protects against neonatal mortality.4 Exclusive and predominant breast feeding compared with partial breast feeding or no breast feeding protect against mortality in the first half of infancy.5

In more developed countries, where infection and inadequate sterilisation pose less of a problem, the health benefits of exclusive breast feeding persist. A cluster randomised trial of promoting breast feeding in Belarus resulted in significantly more exclusive breast feeding and significantly less diarrhoeal disease in the intervention clusters compared with the control clusters.6 In recent observational studies from Spain7 and the United Kingdom,8 exclusive breast feeding protected against hospital admission for infection in infancy. In the UK, rates of mothers starting breast feeding have increased from 62% in 1990 to 76% in 2005, but rates of sustained exclusive breast feeding remain low.9

The trial by Su and colleagues includes an antenatal and postnatal intervention to promote exclusive breast feeding and compares these interventions with routine hospital care.1 The first group of women were shown a 16 minute video about breast feeding in the antenatal period. Women in the second group had two 30 minute sessions with a lactation consultant, one within the first three days after birth before discharge from hospital, and another during their first routine postnatal visit one to two weeks after delivery. Both strategies doubled the rate of exclusive breast feeding at most time points between two weeks and six months compared with usual care. About 64% of women in the trial had only primary education or less, 40% were primiparous, and 21% had a caesarean section.

Among the strengths of the trial are the evaluation of two separate hospital based interventions and a primary outcome of exclusive breast feeding. The initial increase in the rate of exclusive breast feeding in both groups suggests that exclusive breastfeeding was defined as being “exclusive within a defined period” (usually the previous 24 hours). This definition will tend to overestimate the rate of exclusive breast feeding since birth,10 although such overestimation is unlikely to differ between the trial arms.

How generalisable are these findings to other settings? A systematic review of breastfeeding interventions reported conflicting evidence on the effectiveness of antenatal education and postnatal support for breast feeding.11 Many breastfeeding support strategies are effective in particular settings only. When the breastfeeding practices observed in the control arm of the Singapore trial are compared with the 2005 UK infant feeding survey,9 some striking contrasts are apparent (figure​(figure).). In Singapore, mixed feeding is common and, therefore, breastfeeding rates are relatively high, but rates of exclusive breast feeding are low. Here, the challenge will be to increase the duration and exclusivity of breast feeding, as was shown in the intervention arms. In the UK, breastfeeding rates are lower than in Singapore, but the rate of exclusive breast feeding is higher, at least in the first few months.



Rates of breast feeding in the Singapore trial1 and the UK Infant Feeding Survey 2005.9 The denominator is all women who breast fed in the UK trial and women who intended to breast feed in the Singapore trial (estimated at about 95%). The definition of ...



The postnatal intervention in the trial by Su and colleagues included a visit by a lactation consultant within the first three days after birth before discharge. It would be difficult to implement this intervention in the current UK setting, as many women are discharged within 24 hours of delivery. A recent UK study found that delivering in “baby friendly” accredited maternity units was not associated with a longer duration of breast feeding.12 In contrast, in the Belarus trial, where the mean length of stay after birth was six to seven days, the baby friendly intervention was successful.

Further research should focus on evaluating the cost effectiveness of these hospital based interventions in Singapore and similar settings. In the UK, the National Institute for Health and Clinical Excellence is currently developing public health guidance on maternal and child nutrition (expected to be available at www.nice.org.uk in February 2008). The guidance will include recommendations aimed at promoting breast feeding, particularly in low income households. The next step will be to implement and evaluate the cost effectiveness of this guidance.