What is the Definition of Breastfeeding
Mirriam Labbok, MD, MPH, IBCLC
from BREASTFEEDING ABSTRACTS,
February 2000, Volume 19, Number 3, pp. 19-21.
What is the definition of
breastfeeding, and why is this an issue? Does this seem like a silly
question? In fact, for many years, there were no agreed-upon definitions
for breastfeeding. What was meant by the word breastfeeding depended
on who was speaking. This has led to much confusion in interpretation
of research and program experience. Unfortunately, many journals still
accept papers without definition of their terms.
Perhaps the most generally
used definition of breastfeeding in the 1960s and 1970s was that of
the formula industry. The term "exclusive breastfeeding" meant
that breastfeeding was the infant’s only source of milk, but other
foods might be given in addition to breast milk. Unfortunately, this
definition continues to be used by the occasional researcher or program
planner who has not reviewed recent discussion. Clearly, this definition,
which views breastfeeding only as a substitute for formula, not as a
maternal or child health issue, is to be avoided and soon forgotten.
More recently WIC, the U.S. Department of Agriculture’s supplemental
food program for mothers and infants, defined a mother/infant pair as
“breastfeeding” if they ever breastfed at all or breastfed
during a specified time period. This definition has now been modified
to be more reflective of a better understanding of breastfeeding.
International Definitions
Two newer sets of internationally
recognized definitions of various breastfeeding terms predominate today
in research and program design. One addresses the maternal/infant parameters
that affect so many of the health outcomes and management issues associated
with breastfeeding, while the second deals primarily with infant nutritional
intake.
IGAB Consortium Definitions
On April 28, 1988, a meeting
was held on definitions related to breastfeeding. The meeting was sponsored
by the Interagency Group for Action on Breastfeeding (IGAB), an ad hoc
working group of representatives from UNICEF, United States Agency for
International Development (USAID), SIDA, and WHO. In addition to these
organizations, the meeting was attended by or input and review were
received from the International Lactation Consultants Association (ILCA),
LLLI, the Population Council, the International Baby Food Action Network
(IBFAN), Johns Hopkins School of Hygiene and Public Health, Wellstart
International, Family Health International, and the technical secretariat,
Georgetown IRH/Breastfeeding Division. The completed definitions were
then reviewed and modified according to input from more than 50 other
breastfeeding research and program experts from developed and developing
countries, including Drs. Derrick Jelliffe, Margaret Kyenkya-Isabirye,
Ted Greiner, and other individuals and organizations. The final report
was completed and submitted for publication in October, 1989.1 This
set of definitions is now suggested to authors by several journals,
including the Journal of Human Lactation.
The purpose of bringing
together this breadth and depth of experts was to ensure that any agreed-upon
definition of breastfeeding would serve research and program needs,
as well as be useful in physiological research on the mother or the
child. The parameters agreed upon for a definition include:
• A definition
only applies to a single point in time, perhaps a 24-hour recall.
•It defines only breastfeeding and does not define other forms
of feeding.
•It differentiates breastfeeding from breast-milk feeding.
•It encourages further description when the basic definitions
are used.
The agreed-upon definitions
are:
Exclusive breastfeeding:
No other liquid or solid from any other source enters the infant ’s
mouth.
Almost exclusive: Allows
occasional tastes of other liquids, traditional foods, vitamins, medicines,
etc.
Full breastfeeding:
Includes exclusive and almost exclusive.
Full breast milk feeding
(or fully breast milk fed): The infant receives expressed breast milk
in addition to breastfeeding.
Partial: Mixed feeding,
designated at high, medium, or low. Methods for classification suggested
include percentage of calories from breastfeeding, percentage of feeds
that are breastfeeds, etc. Any feeding of expressed breast milk would
fall under this category.
Token: Minimal, occasional
breastfeeds (for comfort or with less than 10 percent of the nutrition
thereby provided.)
Figure 1 illustrates a
schema and framework for breastfeeding definitions. The schema also
suggests that researchers and program planners differentiate if there
is use of expressed milk, how other milks are given, if there is pacifier
use allowed, and, where applicable, the type, timing, and amount of
other feeds.
WHO Breastfeeding Definitions
One year later, a related
set of definitions of breastfeeding was developed by WHO/UNICEF2 which,
in principle, built upon the earlier set of definitions. (See Figure
2, above.) However, one might interpret the WHO/UNICEF definitions as
designed to study only what enters the infant’s mouth, geared
to the study of infant nutrition. This newer set of definitions does
not take into account:
•Impact of direct
breastfeeding compared to indirect breast-milk feeding on maternal
physiology and maintenance of milk supply
•The contrasting definitions used in research studies cited
•The immunological and other differences for the infant between
breastfeeding and breast milk feeding.
The WHO/UNICEF definitions
are:
Breastfeeding: The child
has received breast milk direct from the breast or expressed.
Exclusive breastfeeding:
The infant has received only breast milk from the mother or a wet
nurse, or expressed breast milk, and no other liquids or solids with
the exception of drops or syrups consisting of vitamins, mineral supplements,
or medicines.
Predominant breastfeeding
:The infant ’s predominant source of nourishment has been breast
milk. However, the infant may also have received water and water-based
drinks (sweetened and flavored water, teas, infusions, etc.), fruit
juice; oral rehydration salts solution (ORS), drop and syrup forms
of vitamins, minerals and medicines, and ritual fluids (in limited
quantities). With the exception of fruit juice and sugar water, no
food-based fluid is allowed under this definition.
Full breastfeeding:
Exclusive breastfeeding and predominant breastfeeding together constitute
full breastfeeding.
Complementary feeding:
The child has received both breast milk and solid or semi-solid food.
Bottle-feeding: The
child has received liquid or semi-solid food from a bottle with a
nipple/teat.
Does it Make any Difference
if Definitions Vary?
Variance between definitions
of the same words makes it more difficult to interpret breastfeeding
research and to apply evidence-based thinking to the understanding of
breastfeeding ’s impact on the health of mother and child. The
interpretation of breastfeeding research is further complicated
by issues in selection of sampling frames, sample size, selection bias
in selection of cases, lack of or inappropriate controls, confounding,
analytic techniques used, selective presentation of findings due to
journal space limits, misinterpretation, or confused conclusions.4
In addition, one encounters conviction-based reasons for misinterpretation,
including selected presentation of findings based on preferred outcomes,
the decision not to publish findings that disprove the author’s
beliefs and hypotheses, and the inclusion of statements in discussion
and conclusion sections that overstate or reinterpret what the findings
show.
Conclusions
While this author prefers
definitions that allow a more complete description of any potential
obstacle to the maternal/child interactive physiology of breastfeeding,
it is clear that other definitions remain. It then becomes our duty,
each one of us, whether researcher or lactation consultant, program
planner or health care provider, mother or supporter, to be cognizant
of the variety of definitions used by writers and researchers. When
we make decisions concerning breastfeeding, we must be diligent to ensure
that our decisions are evidence-based and that our understanding reflects
the definitions of breastfeeding used in the research. Policy-makers
and health care providers must be very clear concerning what patterns
of feeding we recommend based on the definition used in the articles
that convinced us.
So, what is the “exclusive
breastfeeding ” that so many organizations recommend for the first
six months? Do they know? Do you?
Miriam Labbok is Medical
Officer, Supervisory Public Health Advisor, and Chief of the Nutrition
and Maternal/Infant Health Division of the United States Agency for
International Development. Dr. Labbok serves on the Health Advisory
Council of La Leche League International, the Health Advisory Board
of the International Lactation Consultants Association, and the International
Board of Lactation Consultant Examiners. She is a founding member of
the Academy of Breastfeeding Medicine.
REFERENCES
1. Labbok, M. H. and Krasovec,
K. Towards Consistency in breastfeeding definitions. Stud Fam Plan
1990; 21(4):226-30.
2. Indicators for assessing
breastfeeding practices. Report of an informal meeting in June 1991,
Geneva. World Health Organization, Geneva.
3. WHO Global Data Bank
on Breastfeeding. World Health Organization, Geneva, 1996.
4. Labbok M. H. Health
sequelae of breastfeeding for the mother. Clin Perinatol 1999;
26(2):491-503, viii-ix.
Page last edited Sun Oct 14 09:32:41 UTC 2007.
