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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.

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