The Daily Mail gave one of the more extreme interpretations of the research: “Call for U-turn on when to wean baby after warnings that exclusively breast-feeding for six months 'causes allergies'”.
But the short version of the BMJ paper as available on the web gives no such explicit warning about allergies, despite the Daily Mail’s (unattributed) phrase in quotation marks. Nevertheless, the BMJ paper does read as a carefully worded attempt to argue for a re-think in the World Health Organisation’s (WHO) recommendation “to exclusively breastfeed infants for the child's first six months”.The BMJ article was quickly attacked by pro-breastfeeding groups. One of the first attacks came from 'Baby Milk Action' under the headline “WHO breastfeeding recommendations under attack from industry-funded scientists”. Baby Milk Action is one of a global network of organisations whose aim is to “strengthen independent, transparent and effective controls on the marketing of the baby feeding industry”. The attack is quite well aimed. While the BMJ paper is called “new research” by some media accounts (see for example suite101.com ), Baby Milk Action points out that “In fact this is not a new scientific study nor a systematic review, but the authors review of selected past research, published in the 'Analysis' section of the BMJ.” It adds that “Three of the four authors of the piece, Mary Fewtrell, Alan Lucas and David Wilson, receive funding from the baby food industry.” Indeed the BMJ authors declare this funding.
The BMJ itself has published several comments on the controversial paper. A short but sharp comment comes from Yayuk and Yodi Mahendradhata. They echo other BMJ comments that “Fewtrell et al offered a highly biased 'review' of the evidences, despite making a plea for an independent scientific review”. And they predict that the mass media in developing countries will highlight “only the provocative points, leaving out counter arguments and other complex details. Unfortunately, there is limited capacity in developing countries to scrutinize such an eloquently written and high-profile article published in a highly respected international medical journal.”
So what of the paper itself? A box in the paper highlights three “areas of clinical concern”: iron deficiency; food allergies; risk of celiac disease. With regard to iron deficiency in breastfed infants, the text of the paper notes that risk of iron deficiency “might be reduced by improving iron status in pregnancy, delaying umbilical cord clamping, and supplementing infants at risk”. Pro-breastfeeding groups argue that supplementing the mother would be just as effective as supplementing the infant but the authors do not include this as an option.
In their look at the risk of food allergy and celiac disease, the authors declare that “important new data are now emerging with implications for practice”. The evidence here comes from two papers that seem to stem from a single study, and is interesting. The authors describe a finding of a 2005 JAMA paper on 1,560 children at risk for celiac disease as follows: ”introduction of gluten before three months and after six months was associated with increased risk of biopsy proved coeliac disease”. In the original paper this result comes from a second analysis, where the results in the full population (including those without biopsy) were inconclusive. The idea that both earlier and later exclusive breastfeeding have higher risk than that associated with exclusive breastfeeding up to 4-6 months seems counterintuitive, and would seem to warrant further research, especially given that the conclusion comes from a subset of the population of children in the study (albeit a subset with better clinical data).
A second paper from 2006 stemming from the same study is also referenced, which looks specifically at food allergy, and also concludes that there is a higher risk of wheat allergy in those exclusively breastfed after six months – the 95% confidence interval for the odds ratio is 1.18 – 12.28. The authors declare that they have no financial conflict of interest.
The WHO recommendation for exclusive breastfeeding up to 6 months was based on a Cochrane review by Kramer and Kakuma published in 2002. Kramer and Kakuma published an updated review in 2009 of breastfeeding up to 3-7 months. This includes results that seem to go against those quoted by the BMJ paper. Out of eleven meta-analyses of allergy signs and symptoms in the updated Cochrane Review, none give any evidence of extra risk for children exclusively breastfed up to 3-7 months and in all cases the estimate of risk of allergy favours the group exclusively breastfed up to 3-7 months (though in some cases only just). The strongest result in favour of breastfeeding up to 3-7 months gives an odds ratio for food allergy at 1 year of 0.08 - 0.48 in favour of exclusive breastfeeding up to 3-7 months, though of course one would have to apply an adjustment for the multiple comparisons here. The BMJ authors do not refer to the updated Cochrane review in the web version of their paper.
The two results from that single study that the BMJ authors quote regarding food allergy and celiac disease are interesting. But perhaps they could have given a more rounded picture of the risks and benefits of exclusive breastfeeding. Perhaps also they should have referred to the updated Cochrane Review, published over a year before their piece appeared in the BMJ.source: www.significancemagazine.org
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