Current Research in Nutrition and Food Science Vol.

2(2), 56-72 (2014)

Importance of Exclusive Breast Feeding and

Complementary Feeding Among Infants
ASHMIKA MOTEE1 and RAJESH JEEWON2*

1
Department of Health Sciences, Faculty of Science, University of Mauritius, Réduit, Mauritius
2
Department of Health Sciences, Faculty of Science, University of Mauritius, Réduit, Mauritius.

http://dx.doi.org/10.12944/CRNFSJ.2.2.02

(Received: August 13, 2014; Accepted: August 25, 2014)

ABSTRACT

The aim of this review is to document the advantages of exclusive breastfeeding along
with concerns which may hinder the practice of breastfeeding and focuses on the appropriateness
of complementary feeding and feeding difficulties which infants encounter. Breastfeeding, as
recommended by the World Health Organisation, is the most cost effective way for reducing
childhood morbidity such as obesity, hypertension and gastroenteritis as well as mortality. There
are several factors that either promote or act as barriers to good infant nutrition. Factors which
influence breastfeeding practice in terms of initiation, exclusivity and duration are namely breast
engorgement, sore nipples, milk insufficiency and availability of various infant formulas. On the
other hand, introduction of complementary foods, also known as weaning, is done around 4 to 6
months and mothers usually should start with home-made nutritious food. Difficulties encountered
during the weaning process are often refusal to eat followed by vomiting, colic, allergic reactions
and diarrhoea.

Key words: Exclusive breastfeeding, Weaning,

Complementary feeding, Feeding difficulties.

INTRODUCTION liquids, tea, herbal preparations or food in the first

six months of life, with the exception of vitamins,
Adequate nutrition during infancy and early mineral supplements or medicines 4. Breastfeeding
childhood is essential to ensure the growth, health an infant exclusively for the first 6 months of life
and development of children to their full potential1. It carries numerous benefits such as lowered risk of
has been recognised worldwide that breastfeeding gastrointestinal infection, pneumonia, otitis media
is beneficial for both the mother and child, as breast and urinary tract infection in the infant while mothers
milk is considered the best source of nutrition for return to her pre-pregnancy weight very rapidly and
an infant 2. Economic and social benefits are also have a reduced risk of developing Type 2 diabetes
5, 6, 7
provided to the family, the health care system and .
the employer.
Moreover, studies have shown that many
The World Health Organization (WHO) mothers find it difficult to meet personal goals and to
recommends that infants be exclusively breastfed adhere to the expert recommendations for continued
for the first six months, followed by breastfeeding and exclusive breastfeeding despite increased rate
along with complementary foods for up to two years of initiation 8. Some of the major factors that affect
of age or beyond 3. Exclusive breastfeeding can be exclusivity and duration of breastfeeding include
defined as a practice whereby the infants receive breast problems such as sore nipples or mother’s
only breast milk without mixing it with water, other perceptions of producing inadequate milk 4, 9, 11
57 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014)

and societal barriers such as employment, length The objectives of this study are to:
of maternity leave 9, inadequate breastfeeding 1. Appraise the advantages of exclusive
knowledge 11, lack of familial and societal support breastfeeding.
and lack of guidance and encouragement from 2. Provide an overview of problems which
health care professionals 2, 9. hinder the practice of breastfeeding among
mothers.
Another factor that leads to early cessation 3. Discuss the appropriateness of complementary
of breastfeeding is the advertisement of infant feeding and feeding difficulties which infants
formulas which encourages mothers to opt for the use encounter.
of pacifiers and bottle feeding 3, 9. Additionally, many
mothers opt for breast milk substitutes because they Breastfeeding practices
need to resume work while others claim that they The determinants of children’s growth
produce insufficient milk 10. To date, there are various include genetic potentialities, family size, lifestyle,
types of infant formulas available on the market, and socio-economic environment, infections, nutrition
which are designed to meet the nutritional needs of and the availability of medical care20. However,
infants with a variety of dietary needs 12. However, nutrition is the most prominent factor which can
there are some problems associated with infant either directly or indirectly influences children’s future
formulas such as the nutritional content either does development. For instance, those children who are
not meet or exceeds the infant’s needs. For instance, malnourished and manage to survive do not enjoy a
it was reported that some infants who were fed on good health and experience impaired development in
formula milk have had occasional water soluble the long run 21. Along, there is a rising concern about
vitamins deficiencies 13. Another problem associated overweight and obesity in children. Therefore, proper
with bottle feeding involves high risk of exposing the nutrition and nurturing during the early years of life
child to pathogens owing to unhygienic practices is crucial for an infant to achieve optimal health and
during handling and preparation of infant formula 3. well-being. Hence, there is no more precious gift in
infancy than breastfeeding.
On the other hand, when breast milk “Breastfeeding is an unequalled way of
or infant formula no longer supplies infants with providing ideal food for the healthy growth and
required energy and nutrients to sustain normal development of infants; it is also an integral part of
growth and optimal health and development, solid the reproductive process with important implications
foods should be introduced 14. This process is known for the health of mother”22. Saha et al. 23 reported that
as complementary feeding. According to the WHO the current recommendations of WHO and UNICEF
recommendations, the appropriate age at which on breastfeeding are as follows:
solids should be introduced is around 6 months •฀ Initiation฀of฀breastfeeding฀within฀the฀first฀hour฀
15
owing to the immaturity of the gastrointestinal after the birth;
tract and the renal system as well as on the neuro- •฀ Exclusive฀ breastfeeding฀ for฀ the฀ first฀ six฀
physiological status of the infant 15. However there are months;
concerns about the timing of complementary feeding •฀ Continued฀breastfeeding฀for฀two฀years฀or฀more฀
as evidence demonstrates that this recommendation and proper introduction of solid foods starting
for delayed introduction of complementary foods in the sixth month which are nutritionally safe
may have detrimental consequences 17. Furthermore and adequate.
there are different types of weaning that mothers
adopt namely child-led/natural, mother-led, gradual, Exclusive breastfeeding
partial or abrupt weaning 18. It should be noted Exclusive breastfeeding as defined by
that during the weaning process many mothers WHO and UNICEF is the practice whereby an
encounter infant feeding problems such as refusal- infant receives only breast milk from the mother
to-eat, colic, and vomiting among others 19. All these or a wet nurse or expressed breast milk 24. The
problems that mothers encounter during the feeding WHO and UNICEF, both recommend that mothers
processes either directly or indirectly influence the should breastfeed their child exclusively for the first
feeding pattern. 6 months and continue breastfeeding up to 2 years
 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014) 58

or longer rather than stop EBF practice as from 4-6 Expressed breast milk
months 25. Breastfeeding is beneficial both to the
infant and the mother27. However, owing to certain
Although breastfeeding an infant exclusively circumstances, mothers are unable to breastfeed,
for the first 6 months of life carries numerous benefits, so they wish to express their milk because it is the
many studies are centered on the “weanling’s only opportunity for the infant to have the human
dilemma” in developing countries which involves milk 28. Expressing is simply a way of taking milk
choosing between the protective effects of exclusive from the breast without the baby suckling and this
breastfeeding against infectious diseases and the can be achieved either by the hand or manual pump
(theoretical) insufficient breast milk to meet the or electric pump 29. The reasons why some mothers
infants’ energy and micronutrient needs beyond four express breast milk are shown in Figure 2.1.
months of age 26. However, the author claimed that
there is no data giving an estimate of the proportion While breast milk in a bottle is far superior
of exclusively breastfed infants at risk of specific to any infant formula, expressing or pumping breast
nutritional deficiencies. milk do have some disadvantages unlike direct
breastfeeding as shown in Figure 2.2.
Table. 1: Comparison of composition of human colostrum,
human mature milk, cow’s milk and standard formula37

Nutrients Human Human Cow’s Standard

Colostrum mature milk milk Formula

Kcal/100ml 67 67 67 67
CHO (Lactose- gm/dl) 5.7 7.1 4.7 7.0 - 8.5
Protein (gm/dl) 2.9 1.06 3.1 1.5 - 2.2
Whey : casein 80 : 20 0 18 : 82 60 : 40
Fat (gm/dl) 2.95 4.54 3.8 3.5 - 4.5
Sodium (g/1) 0.50 0.17 0.77 0.25
Potassium (g/l) 0.74 0.51 1.43 0.80
Chloride (g/l) 0.59 0.37 1.08 .057
Calcium (g/l) 0.48 0.34 1.37 46 - 73
Phosphorus (g/l) 0.16 0.14 0.91 32 - 56
Calcium/ Phosphorus 3.1 2.4 1.5 1.3 - 1.5
Magnesium (g/l) 0.04 0.03 0.13 5.6
Copper (mg/1) 1.34 0.51 0.10 0.40
Zinc (mg/l) 5.59 1.18 3.90 5.0
Iodine (mg/l) 0 0.06 0.08 0.01
Iron (mg/1) 1.0 0.50 0.45 0.15
Vitamin A (mg/1) 1.61 0.61 0.27 1.5
Vitamin D (IU) 0 4 - 100 5 -40 41 - 50
Tocopherol (mg/l) 14.8 2.4 0.6 8.liu
Thiamine (mg/l) 0.02 0.14 0.43 0.47
Riboflavin (mg/l) 0.30 0.37 1.56 1.0
VitaminB6 (mg/l) 0.0 0.18 0.51 0.50
Nicotinic Acid (mg/l) 0.75 1.83 0.74 6.7
Vitamin B12 (ug/l) 0.06 0.34 2.48 2.0
Pantothenic acid (mg/l) 1.83 2.46 3.4 3.0
Folic acid (ug/l) 5.0 14.0 90.0 10 - 13
Vitamin C (mg/1) 72 52 11 6.7
Osmolality 290 - 300 0 0 300 - 380
59 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014)

Table. 2: Benefits of breastfeeding 46

Full Term Infants Outcomes:

a. Atopic Dermatitis:
It has been noted that the results of several studies have been conflicting in regard of the protective
effect of breastfeeding on the development of atopic dermatitis. According to Ghaderi&Makhmalbaf43,
general studies have revealed that formula fed infants or those who have consumed soy based protein
milk have a higher incidence of atopic dermatitis and wheezing illnesses in early childhood. On the
other hand, Dattner44 reported that other studies have shown that exclusive prolonged breastfeeding
(i.e 9 months or more) were associated with AD and food hypersensitivity at 5 years of age and with
food sensitivity at 11 years of age in those with a family history of allergy. Additionally, a study carried
out in Denmark revealed that current breastfeeding was not associated with AD while exclusive
breastfeeding for the first 4 months was, however linked to the incidence of AD whose parents had no
history of allergy 44. Nevertheless, Ghaderi&Makhmalbaf43 highlighted the reasons for this controversy
being methodological differences and flaws in the studies done to date, the immunologic complexity
of breast milk itself and, possibly, differences in the genetic profile among patients that would affect
whether breast-feeding was protective against the development of allergies or is in fact sensitizing.
Therefore, one way to reduce the risk of AD among infants is that mothers need to reduce their intake
of dietary allergens that increase the risk of translocation of allergenic and pharmacologically active
peptides across her own gut barrier into her milk, provoking AD 44.
b. Acute Otitis Media:
Acute Otitis Media (AOM) is a common childhood infection which arises from an upper respiratory
tract infection. There are many studies which have demonstrated that breastfeeding protects against
several infections including AOM whereby breast milk which contains immunoglobulins with antibody
activity against common bacteria such as Haemophilus influenzae and Streptococcus pneumonia.
c. Gastrointestinal infections:
Gastrointestinal infections are very common among infants and many studies have shown that
breastfeeding protects against the risk of diarrhea morbidity which is more commonly present in infants
who were not breast fed. It is suggested that factors such as immunoglobulin (IgA) oligosaccharides,
lactoferrin and other nutrients available in breast milk may protect the infant from various infections
through passive immunity.
d. Lower respiratory tract diseases:
There are many infants who are hospitalized with moderate to severe respiratory infection which is
caused by respiratory syncytial virus (RSV) infection. It has been reported that severe lower respiratory
tract diseases may eventually leads to childhood asthma. And this risk can be reduced in infants of
less than 1 year of age if they were breastfed exclusively for 4 months or more unlike those who are
formula fed.
e. Asthma:
Studies regarding the effect of breastfeeding on asthma are controversial whereby it has been
shown that there is a greater reduction in the risk of asthma in infants under 10 years of age who
were breastfed for 3 months and had a family history of asthma. While the association was weaker
in subjects without a family history of asthma and who were breastfed for 3 months. Moreover, it was
also shown that formula fed infants regardless of having a family history of asthma were more likely
to suffer from the bronchial disorder. Nevertheless, the author reported that it is still to be confirmed
if this association changes for older children.
f. Cognitive development:
Several studies have shown little or no evidence for an association between cognitive development
and breastfeeding in infancy.
 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014) 60

g. Obesity:
It has been stated that relationship between the types of postnatal feeding and the subsequent
development of fat and fat-free mass are quite complex and depends on several factors including
differences in food composition (human milk versus formula), food delivery (breast versus bottle), food
“lifestyle” (breastfeeding versus formula feeding) and food behavior (self-regulation and feeding on
demand versus set schedules of feeding of predetermined amounts). It is worth noting that the kinetics
of breast fed infants differs from that of formula fed infants whereby the latter exhibit a higher weight
and lengths gains unlike breast fed children. Furthermore, it has been stated that breast fed infants
have a different suckling pattern and appeared to have a better control on meal sizes and feeding
intervals unlike formula-fed infants. Moreover, anthropometric and behavioral differences between
breast fed and formula- fed infants may arise due to diet related differences in the circulating levels
of biochemical markers (such as leptin, ghrelin, insulin-like growth factors, and other compounds)
which are used in energy metabolism during infancy. Overall, it can be concluded that there is a strong
association between breastfeeding during infancy and a reduction in the risk of being overweight or
obese in adolescent and adult life.
h. Risk of cardiovascular diseases:
While some studies have shown significant reductions in blood pressure and amount of serum
LDL, others have found little or no evidence that breastfeeding protects against the development
of cardiovascular diseases. Thus, further investigation is required to prove the association of
breastfeeding and the risk of developing heart diseases.
i. Type I Diabetes:
Several studies have shown a positive association between breastfeeding and reduction in type
I diabetes through passive immunity conferred by breast milk which is enriched with secretory
immunoglobulin A antibodies. Also, breast milk promotes an increased â cell proliferation or delayed
exposure to foreign food antigens especially in those infants who were exclusively breastfed. On the
other hand, cow’s milk has been associated with diabetogenecity whereby â-lactoglobulin which is a
specific milk protein found in cow’s milk causes a defect in the immune system of the infant leading
to type I diabetes.
j. Type 2 Diabetes:
There is a rising concern about type 2 diabetes which is increasing especially among children and
adolescents. Type 2 diabetes is developed when the body develops a resistance to insulin and no
longer uses insulin properly. One of the meta-analysis performed have shown that those infants who
were breastfed have a lesser risk of developing type 2 diabetes in later life as compared to those
who were not breast fed.
k. Childhood Leukemia:
Leukemia is one of the most commonly found cancers among children .It has been reported that
the common cause of leukemia are viruses, but the majority of human leukemias and lymphomas
do not have a specific etiology. Since breastfeeding confers passive immunity, studies have shown
that breastfeeding is implicated in reducing the risk of leukemia in infants especially in those children
who were breast fed for at least 6 months.
l. Infant Mortality:
Infant mortality is decreasing in both developed and developing countries. For instance according to
Statistics Mauritius 45, infant mortality rate in Mauritius was decreased by 8.8% in 2010. It has been
demonstrated that breastfeeding eventually reduces the rate of infant mortality by decreasing the
risk of infectious diarrhea and respiratory diseases which are the leading cause of infant mortality.
However, it is less clear if breastfeeding prevents infant deaths in developed countries.
61 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014)

Composition of breast milk Characteristics of breast milk

Human milk is species-specific and is “Breast milk is unique in its physical
superior to any other breast milk substitute 32 and it structure and types and concentrations of protein,
is also assumed to the ideal food for infant during fat, carbohydrate, vitamins and minerals, enzymes,
the first 4-6 months, ensuring proper growth and hormones, growth factors, host resistance factors,
development 33. Human milk which is the most inducers and modulators of the immune system,
natural food available for infant is unique whereby its and anti-inflammatory agents” 12. There are three
nutritional composition varies from mother to mother, phases of milk namely, colostrum, transitional milk
from day to day, during the day and during a feed and mature milk each with distinct characteristics.
34, 35
. Human milk contains several factors such as
immunoglobulin, T lymphocytes, enzymes such as Infant’s first milk:
lysozymes, phagocytes among others which are not The first milk that is synthesized by the
present in breast milk substitute 36. A comparison of breast for the baby right after birth is thick, yellow-
composition of human colostrum, human mature coloured fluid called colostrum. The yellow color is
milk, cow’s milk and standard formula is depicted in owing to the high concentration of beta-carotene,
Table 2.1. a precursor of vitamin A which is required for the

Table. 3: Benefits of breastfeeding for mothers37

a. Breastfeeding promotes bonding between mother and baby.

This is achieved through the release of oxytocin which stimulates uterine contractions and milk
ejection and enhance maternal behavior and bonding between mother and child 37.
b. Breastfeeding and the risk of breast cancer:
There is limited and inconsistent evidence in favour of a positive association of breastfeeding with
breast cancer 47. According to Bernier et al. 48, there is a slight but significant decreased risk in those
who breastfed their children compared to those who did not breastfeed.
c. Breastfeeding and Post-partum Hemorrhage:
Many studies have shown that breastfeeding increases the level of oxytocin which expel the
placenta and help the uterus to shrink back to pre-pregnancy size by stimulating contractions.
Lactational amenorrhea causes less menstrual blood loss over the months after delivery 49.
d. Breastfeeding and insulin requirements in diabetic mothers:
According to Davies et al. 50, breastfeeding mothers suffering from type I diabetes require a smaller
dose of insulin as compared to those who are not breastfeeding.
e. Breastfeeding and the risk of ovarian cancer:
It has been demonstrated that mothers who breastfed their infants for 18 months or more had a lower
risk to suffer from epithelial ovarian cancer 51.
f. Breastfeeding and endometrial cancer:
Studies have shown that there is a linear inverse association between breastfeeding and the risk of
endometrial cancer. That is, the longer the duration of lactation, the smaller is the risk for the mother
to develop endometrial cancer 52.
g. Breastfeeding and osteoporosis:
According to La Leche League International 53, breastfeeding helps to prevent osteoporosis and hip
fracture in later life.
h. Breastfeeding and birth spacing:
Breastfeeding enhances child spacing as it is associated with a decrease in fertility 54.
a. Sudden Infant Death Syndrome (SIDS):
This is one among the leading cause of infant death among infants aged 1 to 12 months in the US.
Results from multiple meta-analysis have shown that breastfed infants are less likely to encounter
SIDS as compared to those who were not breastfed.
 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014) 62

protection against infection and for early retinal colostrum also contains white cells which help to
development 38. It has also been stated that the prevent infection in the infant and it also consists
amount of colostrum obtained is limited but it rich in of lactose which prevents hypoglycemia and at the
nutrients and substances that the infant needs in the same time helps the newborn to pass meconium 38.
first days of life 12. The “liquid gold” is rich in proteins, This in turn, promotes the excretion of bilirubin.
fat-soluble vitamins, minerals, and immunoglobulins
A- sIgA33. It should be noted that IgA protects Transitional milk:
the infant’s immune system by identifying and Transitional milk is used to describe the
destroying foreign objects such as bacteria and postcolostral period (7 to 21 days post partum) when
viruses12. Another advantage of colostrum is that the composition of the milk changes more slowly
the mother will have less blood loss because the than in the first few days following parturition39. The
uterine contracts as the baby suckle. Furthermore, content of transitional milk includes high levels of

Table. 4: Types of Infant formula12

1. Milk-based infant formula:

This is commonly consumed by infants and it is made from modified cow’s milk with added
carbohydrate, (usually lactose), vegetable oils, and vitamins and minerals.
2. Iron-Fortified Infant Formula:
This type of milk is usually recommended by the American Academy of Pediatrics (AAP), as the
most appropriate milk from birth to 12 months for infants who are not receiving breast milk or who
are partially receiving breast milk. It ensures that formula-fed infants receive an adequate amount
of iron which is important during the first year so as to lower the risk of iron deficiency anemia as
shown by some studies.
3. Low Iron Infant Formula:
This type of infant formula contains approximately 5 milligrams of iron per quart of formula. And some
parents opt for low iron infant formula for their infants because they believe that iron enriched formula
milk causes gastrointestinal problems, such as colic, constipation, diarrhea, or vomiting owing to the
iron. Nevertheless, it has been shown that gastrointestinal problems are no more frequent in infants
consuming iron-fortified than low-iron infant formula. It should be noted that AAP discourages the
use of this type of milk because a proper amount of iron is required for normal infant growth and
cognitive development 32.
4. Soy-Based Infant Formula:
This type of formula milk has been developed for infants who cannot tolerate modified cow’s milk.
It consists of soy protein isolate made from soybean solids as the protein source, vegetable oils as
the fat source, added carbohydrate (usually sucrose and/ or corn syrup solids), and vitamins and
minerals.AAP stated that this type of milk is safe and effective but has no advantage over modified
cow’s milk.
5. Hydrolysed Formulas (hypoallergenic formulas):
These are also known as “predigested” milk whereby the protein content has been broken into smaller
proteins that can be easily digested. A study done by concluded that extensively hydrolysed casein
formula reduced the incidence of atopic dermatitis but not that of asthma. On the other hand, Fisher
64
stated that prolonged supplementation with hydrolysed formula as opposed to cow’s formula or
exclusive breastfeeding, does not reduce the risk of allergy. It should be noted that hypoallergenic
formulas cost more than regular formulas.
6. Lactose-Free Formulas:
These are formulas developed for infants with secondary lactose intolerance (the transitory lactose
intolerance that occurs infrequently after gastroenteritis) or primary lactose intolerance (which occurs
rarely among infants) 63.
63 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014)

fat, lactose, water-soluble vitamins, and contains Mature milk:

more calories than colostrum but lower levels of Mature milk (21 days post partum) also
immunoglobulins 33. varies but to a lesser extent than in early lactation
39
. Mature milk looks thinner, paler and is more

Table. 5: Types of weaning

Types of weaning Definition

a. Child-led/natural weaning This occurs when the children wean themselves from the breast by
becoming less interested in breast milk 18.
b. Mother-led weaning This is also known as planned weaning whereby the mother
starts to give complementary foods without receiving cues from
the infant that he is ready to stop breastfeeding. There are different
factors that encourage this type of weaning such as employment,
insufficient milk, painful feedings, medical complications among
others.
c. Sudden/ Abrupt weaning This occasionally occurs when there is a prolonged unplanned
separation of the mother and infant or severe maternal illness.
d. Gradual weaning This means that mothers can gradually substitute other kinds of
nutrition, affection and attention to compensate for the loss of
nursing 18.
e. Partial weaning This occurs when the baby still receives breast milk 1 or 2 times
per day depending on the convenience of the mother while
receiving complementary foods 73.

Table. 6: Infant feeding problems

a. Food sensitivities and allergies:

Many children experience food intolerance which is characterised by reproducible symptoms when
exposed to the offending food or the child may develop an abnormal immunologic reaction to food.
Some foods that are associated with allergic reactions in infants are: cow’s milk, eggs, soy and wheat
32
.
b. Frequent spitting up or vomiting:
Both conditions are classified as gastroesophageal reflux which is harmless to the infant. Spitting up
occurs when milk is ingested too quickly or because of overfeeding. And vomiting (emesis) occurs
owing to transient physiologic episodes of lowered esophageal sphincter tone with efflux of gastric
contents into the esophagus 32.
c. Poor appetite:
According to Berall76, this one of the most common problems that parents
complain of because of:·
฀ •฀ An฀ organic฀ disorder฀ (dysphagia,฀ regurgitation฀ or฀ chronic฀ vomiting;฀ diarrhea฀ or฀ blood฀ in฀ stool;฀
neurodevelopmental anomalies among others)·
฀ •Parental฀misperception·
฀ •Vigorous฀behaviour฀of฀the฀child·฀
฀ •฀The฀child฀is฀apathetic฀or฀withdrawn.
d. Refusal to take food:
Some reasons why this problem occurs are that the child displays highly selective behaviours, suffers
from colic which in turn interferes with feeding or the infant is gets afraid at the sight of food or drinks
 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014) 64

watery than colostrum 33. Additionally, it consists of Hind-milk:

90% water which is required to maintain hydration Hind- milk is the richer milk, containing
of the infant and the remaining 10% consists of more fat which occurs after the initial release of milk
carbohydrates, proteins and fats which are important and is more opaque and creamy white in colour40.
for both growth and to meet energy needs of the This type of milk induces a feeling of satiety in the
baby. There are two types of mature milk: Foremilk infant as well as making the latter feels sleepy 12.
and hind- milk.
Therefore, both foremilk and hind-milk are
Foremilk: necessary for the baby to receive optimum nutrition
Foremilk is the first milk available in large in order to grow and develop well.
amount at the beginning of a feeding which is watery
thus, providing all the water the baby needs from it. Advantages of breastfeeding
Therefore, no other drinks such as water or juice Breast feeding is universally endorsed by
are required before 4-6 months, even in hot climate the world’s health and scientific organizations as
40
. Foremilk is rich in proteins, lactose and other the best way of feeding infants41. Many studies have
essential nutrients but contains less fat 33. been carried out and have highlighted innumerable

Figure 2.1: Reasons why mothers express breast milk30

Fig. 2.2: Disadvantages of Fig. 2.3: Avoiding breast engorgement 54

expressed breast milk31
65 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014)

benefits of breastfeeding for infants, for mothers and breastfeeding and very few contraindications.
the society. Some of them include lowered risk of otitis Breastfeeding is contraindicated due to the
media, gastroenteritis, respiratory illness, sudden following:
infant death syndrome, necrotisingenterocolitis, Ø In infants who have special health problems
obesity, hypertension among others in infants 42 such as galactosemia, maple syrup urine disease
(Table 2.2). Maternal outcomes include reduced risk and phenylketonuria 38.
of breast and ovarian cancer, Type 2 diabetes, and Ø In cases where mothers have active
postpartum depression (Table 2.3) while societal untreated tuberculosis disease or are human
benefits include decrease health care related cost T-cell lymphotropic virus type I– or II–positive 32.
and fewer absences from work. Breastfeeding may not be in the best interest of
the baby when breastfeeding mothers have herpes
Concerns, controversies and contraindications simplex lesions on a breast (infant may feed from
to breastfeeding: other breast if it is free from any lesions)32.
Although breastfeeding is optimal for Ø In situations where the mother is using
infants, there are some controversies surrounding drugs of abuse 55

Figure 2.4: Causes of sore nipple 56

 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014) 66

Ø In certain circumstances where mothers Additionally, more and more studies are
are receiving diagnostic or therapeutic radioactive supporting the fact that if an HIV infected mother
isotopes, antimetabolites or chemotherapeutic choose to or must breastfeed, it is essential to
agents, small number of other medications or who breastfeed exclusively for the first six months to
had been exposed to radioactive materials 32. They reduce the risk of contaminants that may come with
should not breastfeed until these substances are formula and other foods and cause gut inflammation
cleared from the breast milk 54. allowing HIV organisms to reach the submucosal
Ø In infants born to mothers who are HIV tissue 38. Furthermore, antiretroviral drugs can
infected, breastfeeding is discouraged owing to reduce the risk of HIV infection to the infant through
the risk of transmission of HIV to the infant through breast milk.
human milk54. Naylor &Wester38 highlighted that
WHO recommends replacement feeding if it is Problems with breastfeeding:
acceptable, feasible, affordable, sustainable and Among mammals, the only species in which
safe (AFASS). breastfeeding and weaning have to be learned and

Fig. 2.5: Problems associated with infant formulas

Figure 2.6: Reasons for introducing solid foods 14

67 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014)

are not governed by instinct are the Homo sapiens56 the lactation process, prevention and treatment is
and breastfeeding problems are very common, but recommended.
last for a short time and are preventable 38. According
to Giugliani56, many mothers are facing breastfeeding Breast engorgement:
problems as their traditional source of learning was Breast engorgement is mainly caused by
lost as extended families are being replaced by infrequent or ineffective milk removal 38. The breasts
nuclear families. This provides few opportunities for become engorged 3-5 days postpartum 57. The
the mothers to learn about breastfeeding. Therefore, breasts become full, warm and at the time when the
to enable a mother to start or continue enjoying “milk comes in” at 3-5 days after delivery, there is

Fig. 2.7: Appropriate complementary feeding72

Fig. 2.8: Foods with which weaning can be started 74

 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014) 68

a rapid increase in milk volume that cause vascular Formula feeding practices:
congestion which is followed by oedema38. Excessive According to the National Academy of
engorgement with pain and oedema can be avoided Sciences 61, multiple health organisations endorse
by adopting the practices as shown in Figure 2.3. breastfeeding as the optimal form of nutrition for
infants for the first year of life. However, not all
Sore nipples/ nipple trauma: mothers are able to breastfeed either temporarily
One of the reasons why mothers discontinue or permanently, owing to a small number of health
breastfeeding and opt for early weaning is owing to conditions of the infant or the mother 62. Hence,
sore nipples 54. This usually occurs while the baby is many infants who were unable to be breastfed were
latching during the first week or two and it eventually wet-nursed (given breast milk by a woman other
makes the women feel a mild pain and discomfort. than the child’s mother) while others, who were
According to Giugliani56, the causes of pain during unfortunate were “dry-nursed”. Dry nursing refers to
breastfeeding are shown in Figure 2.4. home prepared mixture which consisted of a liquid,
either water or milk mixed with finely ground grains.
Sore nipples can be prevented by teaching Over time, cow’s milk was modified to feed infants
proper techniques on the initiation of breastfeeding 58. who were unable to breastfeed.
Additionally, the breast should be allowed to air-dry
for some minutes after a feeding and nursing pads Infant formulas are food products designed
should be changed regularly to prevent milk flow 56, to provide for the nutritional needs of infants under
57
. Other precautions include expressing breast milk if 1 year old63. They include powders, concentrated
the breasts are engorged and avoiding use of soap, liquids, or ready-to-use forms. The first commercial
alcohol and extra water on the breast 57. infant formula consisted of wheat flour, cows’ milk,
malt flour and potassium bicarbonate. Thereafter,
Insufficiency of milk: new kinds of formula milk were developed whereby
Another reason causing early termination certain modifications were needed to make it safe
of breastfeeding is insufficient breast milk 59. Most and palatable for human infants61. The birth of infant
women produce sufficient milk according to the formula industry became more apparent owing to
baby’s needs, however, the complaint of “insufficient the process of modifying cow milk for large-scale
milk” is not just owing to the wrong perception of production in the 1920s.
the mother but the latter lacks confidence on her
ability to breastfeed 56.Other reasons that make Currently, there are more than 40 formulas
mothers perceive that they are not producing for healthy term infants which are being sold 64
“sufficient milk” are ineffective suckling and/or and FDA monitors infant formula manufacturers to
infrequent feeding routines, conditions of the baby, ensure that the product provides the appropriate
such as illness or ankyloglossia, condition of the nutrition for all infants. Fisher 64 pointed out that
mother such as fatigue, stress, and use of certain each product has a unique and desirable feature
medications, psychological inhibition, pregnancy, for optimal development of the infant as explained
and smoking38. in Table 2.4.

Therefore, it is important to determine the

aetiology of the milk insufficiency in order to identify Problems with infant formula:
necessary interventions to resolve the problem 60. Formula feeding have some benefits such
as convenience, fewer feeding times and mothers
There are many other problems that many need not worry about their food or liquid intake being
mothers experience during the lactation process passed to the baby 65. However, infant formulas do
which include gigantomastia, plugged ducts, flat/ have drawbacks as shown in Figure 2.5.
inverted nipples, medical complications such as
mastitis, breast abscess among others 54. Complementary feeding:
Complementary feeding is the term used
for giving other foods and drinks in addition to
69 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014)

breastfeeding after the completion of the 6 months Nevertheless, it was affirmed there is no
exclusive breastfeeding period69. According to WHO evidence of harm even within populations that begin
7
, this process covers the period from 6-24 months weaning within a few days of birth14.
of age and is a critical period of growth during which
infants are at high risk of nutrient deficiencies and Late Weaning:
illnesses. A study by Kuo et al. 70 has shown that late
The importance of introducing solid foods weaning may cause deficiencies of zinc, protein, iron
in addition to the infant’s milk feed is shown in Figure and vitamins B and D that leads to the suppression of
2.6. growth and cause feeding problems. Iron deficiency
anaemia and rickets are also found to be more
The ideal age to begin weaning is 4 to prevalent among infants who are weaned after 6
6 months of age because besides filling the gap months 14.
between the total nutritional needs of a child and
the amounts provided by breast milk, it is the age Types of weaning:
when nerves and muscles in the mouth develop There are different ways by which weaning
sufficiently to let the baby munch, bite and chew 68. can happen. Table 2.5 shows the different types of
Nevertheless, following the WHO recommendations weaning.
in 2001 there has been considerable debate over the
ideal age to begin weaning in healthy term infants 26. Complementary foods:
It has been highlighted that gastroenteritis is common The best way to help a baby’s digestive
in developing countries and is associated with the system to get used to solid foods is by introducing
introduction of formula and complementary foods 14. It the foods gradually and one new food at a time so
is to be noted that the risks of gastroenteritis is lower that if the infant has had any allergy, it can be spotted
in developed countries, thus many are questioning easily 69. Starting new foods is a critical step for the
whether the WHO recommendation applies for the baby and it usually takes some time for infants to get
developed countries as well 69. Furthermore, it was used to this new way of eating. It is usually best to
highlighted 14 that the debate remains over whether start weaning (around 6 months) the infant with the
some infants who are not weaned until 6 months foods shown in Figure 2.8.
may be at risk of micronutrient deficiencies.
It is impor tant to note that good
Early and late introduction of complementary complementary foods should be rich in energy,
foods: protein and micronutrients (especially iron, zinc,
Timing of the first introduction of solid food calcium, vitamin A, vitamin C and folate) and should
during infancy may have potential effects on life-long be clean and safe (free from pathogens, chemicals,
health70. It can be seen that very often solid foods toxins, bones or hard bits) to ensure the proper
are either given too early or too late. According to growth and development of the child 68.
UNICEF 71, the frequency and amounts of food
that is given may be insufficient hence;hindering Common feeding difficulties in infants:
the normal growth of the child or their consistency Many parents have concerns and questions
or energy density may be incorrect in relation to about infant feeding and eating issues whereby the
the child’s needs. Therefore WHO72 stated that it most common feeding difficulties are colic, poor
is advisable for mothers to adopt an appropriate appetite, food refusal or selective eating 75. It is
complementary feeding as shown in Figure 2.7: important to treat feeding difficulties which can later
leads to failure to thrive, nutritional deficiencies,
Early weaning: impaired parent/child interactions and chronic
Some studies have shown that giving solid aversion with socially stigmatizing mealtime behavior
76
foods too early may lead to increased risk of chronic . According to Liu & Stein 77, feeding problems can
diseases such as islet autoimmunity (the pre-clinical be a result of medical disorders and inappropriate
condition leading to Type 1 diabetes), obesity, adult- food selection. Some common feeding problems are
onset celiac disease, and eczema 70. depicted in Table 2.6.
 MOTEE & JEEWON, Curr. Res. Nutr Food Sci Jour., Vol. 2(2), 56-72 (2014) 70

CONCLUSION the other hand, complementary foods in terms of

nutrient-dense are normally introduced around 4 to 6
Breastfeeding is the gold standard of infant months. Difficulties encountered during the weaning
feeding up to 6 months.It remains the most cost process are often refusal to eat followed by vomiting,
effective way for reducing the risk of diseases such colic, allergic reactions and diarrhoea. Given
as obesity, hypertension, eczema, type diabetes related problems associated with breastfeeding,
among others in later life as well as mortality. Breast it is highly likely that in the future, nutrigenomics
engorgement, sore nipples, milk insufficiency and (or nutrigenetics) based research will provide
availability of various infant formulas are the main opportunities towards personalized modification of
factors which influence breastfeeding practice in breast milk for optimum health of neonates78.
terms of initiation, exclusivity and duration. On

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