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Millennium Development Goal 4 must and will be achieved in time, but only if policies and actions are rational, appropriate, effective, and soundly based. Over the last few years, plenty of evidence has accumulated on what are the best interventions and enacted policies to improve child health and survival. Among these, breastfeeding is the most rational and effective. But while international agencies and national governments have attempted to include breastfeeding in health and nutrition programmes, no concrete effort has been made to make this salutary policy operational. Political will is still missing.

The evidence is conclusive

The evidence that breastfeeding is crucial to child health and survival, is conclusive. In 2009 The World Health Statistics Report recognised that poor infant feeding – meaning, not being exclusively breastfed for the first 6 months of life – increases the risk of child mortality (1). In 2003 the Lancet series on child survival (2), in 2005 the Lancet series on neonatal survival (3), and in 2008 the Lancet series on maternal and child undernutrition(4), all emphasised the crucial importance of exclusive breastfeeding for the first 6 months, stating that this one practice alone will save more lives than any intervention, and also will enhance nutritional status.

In 2003 (2) it was stated that universalised exclusive breastfeeding would save 13 per cent of all under 5 deaths, amounting to 1.3 million a year in the 42 high mortality countries. Further analysis in 2008 (4) shows that suboptimal breastfeeding in the first 6 months of life is causally associated with 77 per cent of all child deaths. One Lancet commentary states that breastfeeding counselling stands the test of 'admissible evidence' as one of the top three nutritional interventions, as well as saving lives (5).

The World Health Organization's fact sheet on diarrhoeal disease (6) gives detailed information about diarrhoea, its causes, the magnitude of the problem, and solutions, and cites exclusive breastfeeding as a key preventive measure. A review article in the WHO Bulletin identifies 'non-exclusive breastfeeding' (during the first 4 months of life) as a predisposing cause of childhood pneumonia (7). Other review articles in the same publication emphasise the vital importance of enacted nutritional policies, including breastfeeding promotion, to reduce morbidity and mortality from childhood pneumonia (8).

Breastfeeding must have top priority

In the last few decades little has been done to give greater priority to increasing the rates of exclusive breastfeeding, despite repeated and emphatic agreement of its benefits. A recent commentary in The Lancet (9) argues clearly in favour of increased investments in breastfeeding and complementary feeding. It also notes that nutrition has received little international funding, especially when compared with what are large investments for the control of other diseases: 'The limited funding for combating undernutrition is dominated by programmes for food aid and micronutrient supplementation. While such programmes have a role in some circumstances, there is urgent need for strengthening investments for community-based approaches to early life nutrition'. The commentary stresses the importance of promoting exclusive breastfeeding.

In 2009 The World Health Statistics Report (1) says that exclusive breastfeeding among children under 6 months of age has increased in recent years, reaching nearly 40 per cent in low-income countries. But 40 per cent is not an adequate figure, when all infants benefit from optimal breastfeeding.

Ensuring exclusive breastfeeding during the first 6 months of life, and continued breastfeeding thereafter, requires substantial investment in multisectoral interventions. These need to be designed to support women to breastfeed successfully. As one example, individual or group counselling by a trained worker is essential (9,10,11). Improving maternity benefits (12), encouraging breastfeeding and crèches at work (13), and protection of breastfeeding from pernicious commercial influence (14), are also all needed. All require financial, material and human resources.

A UNICEF team recently reckoned that the number of annual child deaths is around 8.8 million (15), and call for the scaling up of rotaviral and pneumococcal vaccines, to rapidly reduce child deaths. But the commentary does not mention nutrition interventions! The advice of WHO and UNICEF should stay in line with the emphasis on exclusive breastfeeding in the available scientific literature, and indeed the repeated resolutions and formal statements made by these agencies. Emphasis on vaccines is misplaced. Technology-driven solutions do not address the fundamental value of sound childhood nutrition, beginning with breastfeeding.

The time to act is now

Breastfeeding is and must be a top public health priority. It requires social, political, legal and financial investment. It is now time to stop the omission of breastfeeding when resources are allocated.

Breastfeeding is the single most effective way to protect the health and to save the lives of babies and young children. Nobody seriously doubts this. Exclusive breastfeeding is essential for the child at the time and also protects the health of the mother and of the child in later life (16). It makes substantial contributions to the local economy and poverty reduction (17).

The WHO World Health Assembly should adopt a Resolution calling for specific needed actions and international funding to assure the rights of all children to be nourished properly at the breast, so that all nations could achieve this essential health measure in a specified time period, to be monitored regularly. Meanwhile UN agencies and government ministries of health should review their programmes and priorities and put breastfeeding first. We and many colleagues stand ready to support this essential work which, as we affirm, will do more to protect the health and save the lives of children around the world than any other intervention or enacted policy.

References:

1. WHO. World Health Statistics 2009. Available at http://www.who.int/whosis/whostat/2009/en/index.html Accessed on 24 May 2011.
2. Jones G, Steketee R, Black R, Bhutta Z, Morris S, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? The Lancet 2003; 362: 65-71.
3. Darmstadt GL, Bhutta Z, Cousens S, Adam T, Walker N. Evidence-based, cost-effective interventions: how many newborn babies can we save? The Lancet 2005; 365: 977–988.
4. Bhutta Z, Ahmed T, Black RE, Dewey S, Giugliani E, Haider B, et al. What works? Interventions for maternal and child undernutrition and survival. The Lancet 2008; 371(9610):417-40.
5. Horton R. Maternal and child undernutrition: an urgent opportunity. The Lancet 2008; 371 (9608): 179.
6. WHO. Diarroheal disease. Fact sheet no. 330, August 2009. Available at: http://www.who.int/mediacentre/factsheets/fs330/en/index.html Accessed 24 May 2011.
7. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bulletin of the World Health Organization 2008; 86(5):408-16.
8. Roth D, Caulfield L, Ezzati M, Black R. Acute lower respiratory infections in childhood: opportunities for reducing the global burden through nutritional interventions. Bulletin of the World Health Organization 2008; 86 (5):356-64.
9. Victora C. Nutrition in early life: a global priority. The Lancet 2009; 374 (9696):1123-1125.
10. Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.pub3
11. WHO multicentre growth reference study group. Breastfeeding in the WHO multicentre growth reference study. Acta Pædiatrica 2006; Suppl 450: 16-26.
12. Agostoni C, Braegger C, Decsi T, Kolacek S, Koletzko B et al. Breasfeeding: A commentary by the ESPGHAN Committee on Nutrition. Journal of Pediatric Gastroenterology 2009; 49(1):112-25.
13. Gupta A, Patnaik B, Singh D, Sinha D, Drèze J, Holla R et al. Strategies for Children Under Six - report prepared for the Planning Commission. Economic and Political Weekly 2007; 87-101.
14. World Health Organization. International Code of Marketing of Breast-milk Substitutes. Geneva: WHO, 1981.
15. You D, Wardlaw T, Salama P, Jones G. Levels and trends in under-5 mortality, 1990-2008. The Lancet 2010; 375 (9709):100-3.
16. Horta BL, Bahl R, Martines J, Victora C (eds). Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analysis. Geneva: WHO, 2007.
17. Gupta A, Rohde J. Economic value of breast-feeding in India. Economic and Political Weekly 1993; pp. 1390-1393. Available at: http://www.jstor.org/stable/4399902. Accessed 24 May 2011.

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Please cite as: Rohde J, Gupta A, Dadhich JP. Breastfeeding. The first priority for children.[Short communication]. World Nutrition, Octoberr 2011, 2, 9 491-495. Obtainable at www.wphna.org

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