19 May 2014 4:00-6:00 PM Presented by Amanda Rosenberg
Extended Breast Feeding: Breast Feeding In the Second Year of Life and Beyond
Objectives: 1. Outline current breast feeding recommendations. 2. Explain changes in macronutrients in breast milk after 12 months of lactation. 3. Describe the potential relationship between malnutrition and extended breast feeding. The American Academy of Pediatrics (AAP) recommends exclusive breast feeding for the first six months of life, followed by continued breast feeding as complementary foods are introduced, with the continuation of breast feeding for one year or longer, as mutually desired by mother and infant (1,2). The World Health Organization (WHO) recommends exclusive breast feeding for six months of life and after six months receive complementary foods with continued breast feeding until age two or beyond (3,5). This recommendation is based on the increased intake of family foods and decrease risk of disease (3). This is a controversial topic due to the changes in nutrient composition and the association of malnutrition with extended breast feeding (6,7,8,9). Most of the literature has shown the most drastic changes in macronutrient composition of breast milk occur in its protein content (4). At three months of lactation, the protein content is 0.4 g/oz, which decreases to 0.3 g/oz at six months of lactation (4). Protein content increases again at 12 months of lactation to 0.4 g/oz. Regardless of length of breast feeding, protein content is 0.6 mg/oz during weaning, when breast milk volume is less than 10 oz/day (4). Although protein content of breast milk is consistent in research, fat content has mixed results. One study found that fat content of breast milk between 2-6 months of lactation was 4.7-10% and lactation longer than one year had fat content of 5.6-15.7% (4). Other studies report no change in fat composition at three months of lactation compared to the milk of mothers lactating for longer than one year (4). The wide variability of fat content in breast milk is due to the variations of the methods of sample collections as well as the wide variation in milk composition between lactating mothers (4). Carbohydrate, specifically lactose, composition stayed constant at 2.7 g/oz regardless of lactation duration (4). The literature on breast feeding in the second year of life allude to a relationship between extended breast feeding and risk of malnutrition. Breast feeding beyond 12 months is associated with a decreased height for age, weight for age, and weight for height (6,7,8). This decrease is dependent on what growth charts are used. For example, the use of the older National Center for Health Statistics growth chart is associated with lower weight for age in infants breastfed past one year due to the charts accommodation for a high number of formula fed infants (9). Confounding factors of malnutrition in extended breast feeding include inadequate complementary foods and the inability to establish a direct cause and effect of breast feeding on malnutrition (10). Other evidence suggests that extended breast feeding is beneficial for children with low dietary intake of complementary foods, high incidence of diarrhea, not thriving, poor hygiene and those in poor living conditions (11). In summary extended breast feeding by itself is insufficient to meet the calorie and nutrient needs for the growing toddler but does offer a valuable supplementary source of protein, fat and micronutrients (7). References 1. Policy Statement: Breastfeeding and the Use of Human Milk. American Academy of Pediatrics. 2012; 129 (3): 827-841. 2. Weinstein, M.; Oleske, J.; Bogden, J. A Selected Review of Breast-Feeding Recommendations. Nutrition Research. 2006; 26: 379-384. 3. Infant and Young Child Feeding Fact Sheet. World Health Organization. 2014. http://www.who.int/mediacentre/factsheets/fs342/en/ 4. Tigchelaar-Perrin, M.; Fogleman, A.; Allen, J. The Nutritive and Immunoprotective Quality of Human Milk beyond 1 Year Postpartum: Are Lactation-Duration-Based Donor Exclusions Justified? Journal of Human Lactation. 2013; 29(3): 341-349. 5. Haschke, F.; Haiden, N.; Detzel, P.; Yarnoff, B.; Allaire, B.; Haschke-Becher, E. Feeding Patterns During the First 2 Years and Health Outcomes. Annals of Nutrition & Metabolism. 2013; 62(3): 16-25. 6. Victora, C.; Vaughan, J.; Martines, J.; Barcelos, L. Is Prolonged Breast-feeding Associated with Malnutrition? American Journal of Clinical Nutrition. February 1983; 39: 307-341. 7. Taren, D.; Chen, J. A Positive Association Between Extended Breast-Feeding and Nutritional Status in Rural Hubei Province, Peoples Republic of China. American Journal of Clinical Nutrition. 1993; 58: 862-867. 8. Buckley, K. Long-Term Breastfeeding: Nourishment or Nurturance? Journal of Human Lactation. 2001; 17(4): 304-312. 9. Grummer-Strawn, L. Does Breast-feeding Impair Child Growth? A Critical Review. Pediatrics. Apr 1993; 91(4):766-71. 10. Piovanetti, Y. Breastfeeding Beyond 12 Months: An Historical Perspective. Pediatric Clinics of North America. February 2001; 48(1): 199-205. 11. Karra, M.; Udipi, S.; Kirksey, A.; Roepke, J. Changes in Specific Nutrients in Breast Milk During Extended Lactation. American Journal of Clinical Nutrition. 1986; 43: 495-503.