BREASTFEEDING, INFANT FEEDING AND THE MILLENNIUM DEVELOPMENT GOALS
e-Consultation on Hunger, Food and Nutrition Security
Submission from Carol Bartle New Zealand to [email protected] January 2013
The relationship between breastfeeding and infant feeding and the MDG
MDG 1
Eradicate extreme
poverty and hunger
MDG 2
Achieve universal
primary education
Malnutrition – both under- and over – sets in during the first two years of life, mostly during infancy. Food and nutrition
security during this period means ensuring early and exclusive breastfeeding during the first six months, followed by the
introduction of complementary foods along with continued breastfeeding for up to two years or beyond. These optimal
feeding practices constitute a public health recommendation by the World Health Organisation (WHO) for normal growth,
health and development. A growing body of evidence points to the key role of infant and young child feeding practices,
especially early and exclusive breastfeeding, in mitigating both forms of malnutrition and in the prevention of child
mortality. Nonetheless interventions that address these practices have not received adequate attention during the MDGs
era, and thus there is an unused potential for achieving progress in food and nutrition security in childhood. In conditions
of poverty breastfeeding is life-saving and the use of breast-milk substitutes is a huge risk to infant survival.
Breastfeeding and quality complementary foods significantly contribute to cognitive development. In addition to the 150
polyunsaturated long chain fatty acids in breast milk which support neurological development, initial exclusive
breastfeeding and complementary feeding address micronutrient and iron deficiency needs, support appropriate
neurological development and enhance later school performance.
Research related to cognitive development and breastfeeding

Small for gestational age children (growth-restricted) demonstrated improved cognitive function when exclusively
breastfed for the first six months of life (Rao, 2002, Acta Paediatrica 91:267-274)

Significant association between duration of breastfeeding and verbal IQ. Conclusion was that these findings add
to a growing body of evidence to suggest that breastmilk feeding may have small long term benefits for child
cognitive development (Horwood, Darlow & Mogridge, 2001 Archives of Disease in Childhood, Fetal and Neonatal
Edition Vol 84 No 1, 23-27)
MDG 3
Promote gender
equality and empower
women

Duration of breastfeeding and childhood cognitive abilities and academic achievement between ages 8 to 18. 18year longitudinal study of a birth cohort of more than 1000 children showed that Increasing duration of
breastfeeding was associated with consistent and statistically significant Intelligence scores / IQ at ages 8 and 9.
The findings persisted after taking into account the age of the mother and her socio-economic status
(Breastfeeding and later cognitive and academic outcomes – Horwood & Ferguson 1998, Pediatrics 9, 99)

Significant benefit to child development conferred by breastfeeding and it is related independently to longer
periods of breastfeeding: Increase in scores with increased BF duration. 3880 children followed from birth to 5
years. (Quinn, O’Callaghan, Williams, Najman, Andersen & Bor, 2001 Journal of Paediatrics and Child Health,
October Vol 37, No 5,465-469)

Breastfeeding and developmental delay: findings from the millennium cohort study (n = 14660) UK. The
proportion of infants who mastered the developmental milestones increased with duration and exclusivity of
breastfeeding, Infants who had never been breastfed were 50% more likely to have gross motor coordination
delays than infants who had been breastfed exclusively for at least 4 months. Infants who had never been
breastfed were 30% more likely to have gross motor delays than infants who were given some breast milk for up
to 2 months. (Sacker, Quigley & Kelly 2006)

Largest randomised control trial ever conducted in the area of human lactation. Strong evidence that prolonged
and exclusive breastfeeding improves children’s cognitive development. 17,046 breastfeeding infants and 31,889
followed up at 6.5 years (81.5%) (Kramer et al., 2008 - Arch Gen Psychiatry, 65, 5, 578-584)
Women’s unique roles of child bearing and breastfeeding place them in vulnerable positions, socially, economically and
nutritionally. Globally, women are disproportionately affected by poverty, illiteracy, discrimination and violence. Women’s
reproductive rights and productive roles require adequate support to ensure that they obtain equality at all levels of
society.
Breastfeeding is an integral part of women’s reproductive health and as such, represents a right for women. However,
women can only enjoy the full health benefits of breastfeeding when they receive accurate information to make an
informed choice about infant feeding, are able to exercise their right to breastfeed without coercion and pressure, and
when governments, communities, health professionals and families protect this right. Maternity protection is critical for
the promotion and protection of gender equality and this includes access to health services, adequate paid
parental/maternity leave provision, mother/breastfeeding friendly workplaces and breastfeeding protection. It is
important for the empowerment of women to create environments that make it possible for women to make informed
decisions about infant feeding.
It is important to note that the main reason given by majority of working mothers for ceasing breastfeeding is their return
to work [following maternity leave]. The challenge in terms of breastfeeding protection is the adoption and the monitoring
of an adequate policy of maternity entitlements that facilitate six months of exclusive breastfeeding for women employed
in all sectors, with urgent attention to the non-formal sector
MDG 4
Reduce child mortality
It has been reported that within the World Health Organisation’s global dataset of 65% of the world’s infant population
aged one year or less, only 35% are exclusively breastfed between birth and four months of age. The UNICEF State of the
World’s Children Report in 2012 found that 136.7 million babies were born globally and only 32.6 % were exclusively
breastfed to 6 months. On 1 May 2012 UNICEF issued a statement of concern about the major declines in breastfeeding
rates across East Asia in relation to deteriorating infant and child health. This was linked in the report with a lack of
maternity protection and aggressive marketing of breast-milk substitutes throughout the region. The inequity between
industry and health departments is of note here. US$100 million per year spent on advertising breast milk substitutes in
the Philippines which is over half the Dept of Health’s annual total budget – for everything. In the Philippines, on average,
less than half the infants born are exclusively breastfed by three months of age and by six months less than 25% are
exclusively breastfed.
Lauer, et al., (2006) report that as many as 1.45 million lives are lost due to suboptimal breastfeeding in ‘developing
countries’. Stuebe & Schwarz (2009) confirmed that infant feeding decisions significantly affect mother-child health
outcomes globally, even in settings with clean water and good sanitation. Not-breastfed infants are exposed to increased
risk of infections and non-infectious morbidity and mortality.
During disaster and emergency situations, which are increasing on a global scale, interrupted breastfeeding and
inappropriate complementary feeding heighten the risk of malnutrition, illness and mortality, and uncontrolled
distribution of breast-milk substitutes, for example in refugee settings, can lead to early and unnecessary cessation of
breastfeeding (WHO/UNICEF, 2005).
Support for pregnant women, breastfeeding mothers, continued breastfeeding, relactation and wet-nursing saves infant
lives and prevents further morbidity. Breastfeeding is the only sustainable, safe way to feed and protect infants in nondisaster times, as well as during times of disaster and emergency.
The World Health Assembly resolutions in 2010 contained these statements:
 Concerned that in emergencies, many of which occur in countries not on track to attain Millennium Development
Goal 4 and which include situations created by the effects of climate change, infants and young children are

particularly vulnerable to malnutrition, illness and death
Recognizing that national emergency preparedness plans and international emergency responses do not always
cover protection, promotion and support of optimal infant and young child feeding
Breastfeeding has established itself significantly within research as the optimal method of feeding infants. The American
Academy of Pediatrics (AAP) first released a policy statement on breastfeeding and the use of human milk in 1997, which
cited 111 research articles. This statement was revised both in 2005 and 2012, due to “significant advances in science and
clinical medicine” which utilised new research to further establish the importance of breastfeeding (AAP, 2005 & 2012).
The AAP statements identify health, nutritional, immunologic, developmental, psychological, social, economic and
environmental benefits. The AAP recognises the protective effects of human milk against sudden infant death syndrome
(SIDS), insulin dependent diabetes mellitus, allergic diseases, Crohns disease, ulcerative colitis and other chronic digestive
diseases. It also emphasised that research shows strong evidence that human milk feeding decreases the incidence and
severity of diarrhoea, lower respiratory tract infection, otitis media, bacteraemia, bacterial meningitis, botulism, urinary
tract infection, necrotising enterocolitis and late-onset sepsis in preterm infants.
Optimal breastfeeding is at the top of the list of effective preventive interventions for child survival. With breastfeeding
and appropriate complementary feeding there is a more positive impact than that achieved with immunisation, safe water
and sanitation.
Breastfeeding reinforces immunization. Breastfeeding provides the baby with anti-bacterial, anti-viral and anti-parasitic
agents and strengthens the infant's developing immune system. Breastfeeding confers active and passive immunity,
primes the infant's immune system and improves the ‘take up’ of antibody response to vaccines. Colostrum is so rich in
antibodies and so high in anti-infective properties that it considered to be ‘the first immunisation’ an infant receives. The
immune system of human milk provides a continuum of the maternal immune protection that extends from the transfer of
immunoglobulin G (IgG) from the mother via the placenta to the baby in utero, and then from the mother via
breastfeeding and breastmilk to the child up until the second year of life (Slussor & Powers, 1997). Cregan (2008) also
discusses how this continuum of support for the immature human infant unfolds by describing how a new mother’s
mammary glands take over from the placenta to provide developmental guidance.
The complex components of breastmilk which are uniquely human are irreproducible and include lactoferrin, a single
polypeptide chain glycoprotein which forms two lobes, both of which bind iron (Hanson, 2004). Lactoferrin is quite
resistant to degradation in the gut and the stools and urine from a breastfed baby contain significant amounts of
lactoferrin, including large fragments. Special receptors in the baby’s gut uptake lactoferrin and the large lactoferrin
fragments. Lactoferrin is bactericidal for many gram-negative and gram-positive bacteria and it also has anti-viral and antifungal properties. Lactoferrin destroys microbes without inducing tissue engagement and inflammatory responses and
also prevents production of several pro-inflammatory cytokines (Hanson, 2003). It is thought that lactoferrin protects
breastfed babies against urinary tract and bowel infections.
MDG 5
Improve maternal
health
Lactational amenorrhoea (LAM) is linked to optimal breastfeeding, mother-baby contact and reduction in conception and
pregnancy due to ovulation suppression. Exclusive breastfeeding for six months, and continuation of breastfeeding for up
to two years and beyond, with the addition of appropriate foods from six months, is optimal. Hrdy (1999) describes
breastfeeding as the foundation of family planning in primates, including people. Lactational amenorrhoea for eighteen
months is described as requiring, on average, about eighty minutes of a baby suckling at the breast per day which occurs
over a minimum of at least six breastfeeding episodes (Hrdy 1999). Other factors described as important by Hrdy were
maternal nutritional status, workload, and environmental conditions. It has been suggested that lactational amenorrhoea
is responsible for the prevention of more pregnancies in ‘developing’ countries than all the other methods of
contraception available (Madani et al. 1994). Radwan et al. (2009) found a ninety-eight percent protection rate against
pregnancy after childbirth for six months in a cohort of 593 women in the United Arab Emirates. Duration of LAM was
significantly related to the age of infant formula and solid foods introduction. Child spacing is beneficial for maternal
health.
Breastfeeding has a positive impact on the health of mothers. Previously identified health protective effects include a
reduced risk of pre-menopausal breast cancer (Zheng et al., 2001); a protective effect of duration of lactation and a 25
percent reduction in both premenopausal and postmenopausal breast cancer in women who were breastfed as babies
(Freudenheim et al., 1997; Freudenheim et al., 1994); a reduction in the risks of ovarian cancer (Su & Pasilich et al 2013,
Riman, Nilsson & Persson, 2004; Tung et al., 2003); a possible reduction in the risks of osteoporosis and hip fracture
(Karlsson, Ahiborg, & Karlsson, 2005); contraceptive effects reported at 98 percent in the first six months after the birth
(Kennedy, Rivera, & McNeilly, 1989). Important studies have emerged related to cardiovascular health:

Incidence of myocardial infarction in middle to late adulthood – Stuebe et al., (2009) assessed the duration of
lactation and maternal incident myocardial infarction in the prospective cohort of 89,326 parous women in the
Nurses’ Health Study. Women who breastfed for a lifetime total of two years or longer had a 37 percent lower
risk of coronary heart disease. After adjustment for early adult adiposity, parental history and lifestyle factors,
women who had breastfed for a lifetime total of two years or longer had a 23 percent risk reduction.

Duration of lactation and risk factors for cardiovascular disease – Schwarz et al., (2009) examined data from
139,681 postmenopausal women. Dose-response relationships were seen and women who reported a lifetime
history of more than twelve months of lactation were less likely to have hypertension, diabetes high cholesterol
or cardiovascular disease than women who had never breastfed.

Anxiety reduction and lower blood pressure in breastfeeding women – Unväs Moberg (2003) has contributed a
huge body of work to increase the understanding of the hormone oxytocin. When mothers nurse their babies,
their blood pressure decreases and the levels of the stress hormone cortisol decrease. This indicates a reduction
in the activity of the sympathetic nervous system and a diminished adrenal response (Unväs Moberg, 2003, p. 97)
Measurements of brain activity in nursing animals show that many sleep while they nurse their young. The
positive behavioural and physiologic changes persist through the entire duration of breastfeeding. Unväs Moberg,
Johansson, Lupoli and Svennersten-Sjauna (2001) suggest that oxytocin facilitates not only relaxation and calm in
the mother but it also stimulates maternal interaction and the attachment process.
MDG 6
Combat HIV/AIDS,
malaria and other
diseases
The World Alliance for Breastfeeding Action HIV and Breastfeeding Resource has been written for use by policy-makers,
national breastfeeding committees, health workers and others working for public health globally. Research shows that
HIV-positive mothers who receive effective ARV treatment can have a close to zero transmission rate of HIV to their
babies during pregnancy, birth, and the recommended period of breastfeeding - exclusive breastfeeding for 6 months and
continued breastfeeding with the introduction of age-appropriate complementary feeding for up to 2 years or beyond.
There is now enough evidence to recommend ARVs during breastfeeding.
MDG 7
Ensure environmental
sustainability
The cost, to the purchasing consumer, of the breast-milk substitute products on the shelf represents a miniscule part of
the total negative cost to the planet and human health. Increasing numbers of dairy herds, unnatural intensive farming
methods potentially involving bovine growth hormones, the resulting need for expensive antibiotic use for chronic
mastitis-sick cows, the associated damage to land and infrastructures, pollution, significant water contamination, nitrate
contamination, water wastage and consumption, increase in greenhouse gases, manufacture of powdered milk,
production of novel ingredients to add to the product, packaging, transport internally on roads and overseas by air and
sea, waste products created by both the manufacturing process and the packaging designed to entice product usage, add
up to a giant carbon footprint and contribute to an unsustainable future. Gabrielle Palmer provides a comprehensive list of
the waste associated with infant formula feeding in her book ‘The Politics of Breastfeeding’. For example, tins for
packaging infant formula to supply one million babies use 23,706 tonnes of metal and the paper resources amount to 341
tonnes, plus the added costs of all the paper promotional material supplied to not only parents but paediatricians, nurses,
midwives and other health workers. Palmer reports that just one of the many baby bottle and teat manufacturers
reported distribution of twenty million bottles a year and to add to this is the problem of non-biodegradable/nonrecyclable tetra-pak cartons used for liquid ready-to-feed products.
MDG 8
Develop a global
partnership for
development
The Global Strategy for Infant and Young Child Feeding (GSIYCF) fosters multi-sectoral collaboration, and can build upon
the existent partnerships for support of development through breastfeeding and complementary feeding. In terms of
future economic productivity, optimal infant feeding has major positive implications. Supporting and encouraging
countries to establish national breastfeeding/infant and young child feeding coordinators and national
breastfeeding/infant and young child feeding committees will keep infant feeding issues on agendas and work towards
meeting obligations under human rights treaties including the United Nations Convention on the Rights of the Child, the
GSIYCF, and the International Code of Marketing Breast-milk Substitutes and subsequent, relevant World Health Assembly
resolutions. Protecting and supporting breastfeeding and adequate complementary feeding is essential. Promotion of
breastfeeding alone is not sufficient. The negative impact of inappropriate and misleading promotion of breastmilk
substitutes requires action. The Code, adopted by the World Health Assembly (WHA) in 1981 and followed by numerous
resolutions, is a minimum global standard, aiming to promote appropriate infant and young child feeding by protecting it
from commercial malpractice. In the preamble of the International Code it states “In view of the vulnerability of infants in
the early months of life and the risks involved in inappropriate feeding practices, including the unnecessary and improper
use of breast-milk substitutes, the marketing of breast-milk substitutes requires special treatment, which makes usual
marketing practices unsuitable for these products”
Advocacy and action (adapted from Melton, 1987)

Representation for vulnerable people – infants and young children, pregnant, recently birthed and post-birth mothers

Empowerment – appropriate education, instilling confidence, skills, ability, increasing capacity

Enabling - development, growth, opportunity, strengthening

Raising status – of breastfeeding, women, infants and children

Taking action - Allocation or reallocation of resources

Increasing accountability of governments, institutions and corporations
Proposal for action *
1. Adopt a human right-based approach to the protection, promotion and support of breastfeeding and infant and young child feeding at international, national, and
community levels.
2. Establish institutional mechanisms to avoid and manage conflicts of interest in health and nutrition decision-making and programme implementation.
3. Support all women with a comprehensive system of maternity protection at work, including the non-formal sector – to include an appropriate length of paid maternity
leave (minimum 26 weeks) with flexibility and to include support for breastfeeding women returning to the paid workforce – breastfeeding and lactation/expressing
breaks provision.
4. Ensure appropriate and adequate education and training of all health care professionals and allied health and community so they can provide skilled support to
breastfeeding women. This includes education about health worker responsibilities under the International Code and resolutions.
5. Establish clear budget lines for breastfeeding and infant and young child feeding policy and programme interventions to ensure adequate resources to enhance optimal
practices.
6. Invest in the Baby Friendly Initiative programme – both BFHI and BFCI and include mother/family friendly practices.
7. Ensure that neonatal intensive care services start working towards avoidance of separation of mother and infant and commence work towards the development of
single family room/spaces. Paying attention to the issue of parents bonding to their NICU babies is critical, and attention to breastfeeding support is also paramount, as
not being breastfed has been suggested as a risk factor for child abuse and neglect. Support of Kangaroo-Mother-Care practice should be mandatory from care levels 3-1.
8. Ensure universal access to accurate information and counselling on breastfeeding and infant and young child feeding to all mothers. Provide skilled counsellors
throughout health facilities, not just in maternity facilities, as breastfeeding women admitted to hospital and breastfeeding mothers with infants and young children
admitted to hospital generally have minimal, if any, access to assistance with breastfeeding and lactation needs. Skilled support also needs to be available in the
community.
9. Monitor and track the Global Strategy for Infant and Young Child Feeding in every country using World Breastfeeding Trends Initiative (WBTi).
10. Protect breastfeeding by enforcing the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant World Health Assembly Resolutions.
11. Promote the use of affordable and diverse, locally grown, indigenous foods for timely and appropriate complementary feeding after six months along with continued
breastfeeding.
12. Enhance and support breastfeeding related research with public funding.
* Adapted from work submitted by IBFAN
Relevant Human Rights Treaties for a HR Framework
1.
Universal Declaration on Human Rights
Article 16:3

The family is the natural and fundamental group unit of society and is entitled to protection by society and the state
Article 25:2

Motherhood and childhood are entitled to special care and assistance
2.
International Covenant on Economic, Social and Cultural Rights
Article 10:2

Special protection for mothers during a reasonable period before and after childbirth
Article 10:3

Special measures of protection and assistance should be taken on behalf of all children
Article 12:1

The rights to the highest attainable standard of physical and mental health. The provision for the healthy development of the child
3.
Convention on the elimination of discrimination against women (CEDAW)
Article 12

1. States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality
of men and women, access to health care services, including those related to family planning.

2. Notwithstanding the provisions of paragraph I of this article, States Parties shall ensure to women appropriate services in connection with pregnancy,
confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation.
4.
United Nations Convention on the Rights of the Child
54 articles
Articles divided into three main types of rights
Provision rights

Minimum standards of family life and access to parental care, health, education, physical care, play, recreation, culture and leisure

Rights to a healthy toxic free environment
Protection Rights

Rights to be safe from exploitation, childhood injury, family violence, physical punishment
Participation Rights

Rights to physical integrity and to have views and opinions respected
Preamble

Childhood is entitled to special care and assistance

Recognises that children are living in difficult conditions globally
Article 2

All rights apply to all children without exception. It is the State's obligation to protect children from any form of discrimination and to take positive action to
promote their rights
Article 3

The best interests of the child shall be the primary consideration
Article 6

State parties shall ensure to the maximum extent possible the survival and development of the child
Article 24

The rights of the child to the enjoyment of the highest attainable standard of health.
Article 24
1. States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation
of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.
2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures: (a) To diminish infant and child mortality;
(b) To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care;
(c) To combat disease and malnutrition including within the framework of primary health care, through the application of readily available technology and through the
provision of adequate nutritious foods and clean drinking water, taking into consideration the dangers and risks of environmental pollution;
(d) To ensure appropriate pre-natal and post-natal health care for mothers;
(e) To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of
child health and nutrition, the advantages of breast-feeding, hygiene and environmental sanitation and the prevention of accidents;
(f) To develop preventive health care, guidance for parents and family planning education and services.
3. States Parties shall take all effective and appropriate measures with a view to abolishing traditional practises prejudicial to the health of children.
4. States Parties undertake to promote and encourage international cooperation with a view to achieving progressively the full realization of the right recognized in the
present article. In this regard, particular account shall be taken of the needs of developing countries.
Contact details - Carol Bartle RN, RM, IBCLC, PGDip Child Advocacy (Otago), MHealSc (Otago)
[email protected] Christchurch New Zealand