Assessing the impact of exclusive breastfeeding on child development

Definition of exclusive breastfeeding (EBF)

EBF refers to the practice of feeding an infant solely with breast milk, excluding any other liquids or solids, including water, for the first 6 months of life. This method of feeding is recognized as the optimal standard due to its vast benefits for both mother and child.^[1]

Importance of EBF for child development

• Nutritional sufficiency: EBF offers an ideal balance of proteins, fats, vitamins, and minerals essential for the infant’s growth and development.^[2]

• Enhanced immune protection: Breast milk contains antibodies and immune-supporting components that bolster the infant’s defense against infections, including respiratory illnesses and gastrointestinal issues.^[3]

• Cognitive growth: Research indicates a strong association between EBF and improved cognitive outcomes, potentially influencing learning abilities and intelligence both in early childhood and later life.^[4]

• Improved digestive health: Breast milk is easier to digest compared to formula, promoting healthier gut development and reducing the likelihood of digestive problems such as constipation.^[5]

• Mother-child emotional bond: The physical closeness during breastfeeding enhances emotional bonding, fostering the infant’s emotional well-being and sense of security.^[6]

• Optimal physical growth: EBF ensures appropriate weight gain without the risk of excessive weight gain, contributing to the child’s overall physical development.^[7]

• Reduced allergy risk: Breastfeeding has been shown to reduce the likelihood of developing allergies and allergic reactions, as breast milk contains protective factors against allergens.^[8]

• Thermoregulation: Breast milk adjusts to the baby’s needs, helping regulate body temperature, which is critical for newborns who have not fully developed temperature regulation mechanisms.^[9]

• Economic and environmental benefits: Breastfeeding is cost-effective, compared to formula feeding, and has minimal environmental impact as it requires no packaging or transportation.^[10]

Factors influencing practice

• Workplace constraints: Returning to work early and inadequate maternity leave can interfere with breastfeeding, making it difficult to maintain EBF.^[11]

• Lack of social support: Insufficient encouragement and help from family, friends, or the community may hinder a mother’s ability to continue breastfeeding.^[12]

• Maternal health challenges: Conditions such as mastitis, inadequate milk supply, or postpartum depression can make it difficult for mothers to sustain EBF.^[13]

• Cultural influences: Cultural beliefs and societal norms may discourage or promote breastfeeding practices, depending on the community’s attitudes.^[14]

• Perceived milk insufficiency: Some mothers may wrongly believe that they are not producing enough milk, leading them to introduce formula or other foods too early.^[15]

• Aggressive marketing of formula: The aggressive promotion of infant formula by companies can sway mothers away from EBF.^[16]

• Lack of education: Inadequate knowledge about the advantages of EBF and proper breastfeeding techniques can lead to premature weaning.^[17]

• Hospital practices: Certain hospital policies, such as separating infants from mothers or unnecessary formula supplementation, can discourage breastfeeding.^[18]

• Infant health issues: Infants with conditions like difficulty latching or tongue-tie may struggle with breastfeeding, complicating efforts to exclusively breastfeed.^[19]

• Influence of alcohol and tobacco use by the mother: Maternal consumption of alcohol and tobacco during the breastfeeding period is a significant barrier to EBF. Alcohol can alter the flavor of breast milk, potentially leading to infant refusal and disrupted feeding patterns. More critically, alcohol passes into breast milk and may affect infant development, particularly neurological growth and sleep patterns.^[20]

• Improper breastfeeding posture and musculoskeletal discomfort: The physical positioning of the mother during breastfeeding plays a crucial role in sustaining EBF. Poor posture while nursing, especially over long periods, can lead to musculoskeletal problems such as back pain, neck strain, and shoulder discomfort. These physical discomforts may discourage mothers from maintaining regular breastfeeding sessions, subsequently affecting milk supply and feeding frequency.^[21]

Consequences of not exclusively breastfeeding

• Higher infection risk: Babies who are not exclusively breastfed are more vulnerable to infections such as ear and respiratory infections and gastrointestinal illnesses.^[22]

• Nutritional deficiencies: Formula or early introduction of solid foods may not offer the same balance of nutrients as breast milk, potentially leading to nutritional gaps.^[23]

• Weakened immune system: Infants who are not exclusively breastfed may have weaker immune systems, making them more susceptible to illnesses.^[24]

• Increased allergy risk: Not being exclusively breastfed may increase the risk of allergies, as breast milk provides protective factors against allergens.^[8]

• Potential cognitive impairment: Studies indicate that non-EBF infants may experience suboptimal cognitive development, which could affect their learning and intelligence later in life.^[25]

• Higher risk of digestive issues: Non-EBF infants are more prone to digestive problems, including constipation and diarrhea, as breast milk is easier to digest than formula or solid foods.^[26]

• Greater likelihood of chronic diseases: Infants who are not exclusively breastfed are more likely to develop chronic conditions such as obesity, diabetes, and heart diseases later in life.^[27]

• Weaker emotional bond: Non-EBF infants may miss out on the emotional bonding that comes with breastfeeding, potentially affecting their emotional development.^[6]

• Economic and environmental costs: Formula feeding is more expensive and has a larger environmental footprint compared to breastfeeding, which is natural and sustainable.^[28]

• Increased healthcare costs: Non-EBF infants are more likely to experience health issues, leading to higher medical expenses for their families.^[10]

World Health Organization (WHO) and global recommendations on breastfeeding

The WHO provides comprehensive guidelines on EBF to promote child development. The key recommendations are as follows:^[29]

• Early initiation of breastfeeding: WHO recommends initiating breastfeeding within the 1^st h of life. This early start allows the newborn to receive colostrum, which is rich in nutrients and antibodies, crucial for building the baby’s immune system.

• EBF for 6 months: EBF is recommended for the first 6 months of life. During this period, the infant should receive only breast milk, with no additional liquids, foods, or formula.

• Introduction of complementary foods: After 6 months, appropriate complementary foods should be introduced while continuing breastfeeding up to 2 years of age or beyond. Complementary foods must be nutritious, safe, and age-appropriate.

• Responsive feeding: Caregivers are encouraged to recognize and respond to an infant’s hunger and fullness cues, ensuring feeding on demand rather than on a strict schedule.

• Avoidance of bottles and pacifiers: Use of bottles and pacifiers should not be used in the early months to avoid nipple confusion and promote effective breastfeeding.

• Skin-to-skin contact: Encouraging skin-to-skin contact between the mother and infant, especially in the early days, helps promote bonding and breastfeeding success.

• Support for working mothers: Supportive workplace policies are recommended such as flexible hours and dedicated spaces for breastfeeding or expressing milk to assist employed mothers in continuing breastfeeding.

• Health worker training: Importance of training healthcare providers is emphasized so as to offer proper breastfeeding guidance, address challenges, and encourage sustained breastfeeding.

• Community education and support: WHO stresses the need for educating communities, families, and healthcare professionals about breastfeeding to create an enabling environment for mothers.

EBF on the global stage

According to global data, over 95% of babies are breastfed at some point, but significant disparities exist between high-income and low-income countries. In low- and middle-income countries, 96% of infants receive breast milk, while 21% of babies in high-income countries, or one in five, never breastfeed.^[30]

Breastfeeding rates among high-income countries vary significantly. Nearly all babies in countries such as Oman, Sweden, and Uruguay are breastfed, whereas in Ireland and the United States, only 55% and 74% of infants, respectively, receive breast milk.^[31]

In contrast, low- and middle-income countries maintain high breastfeeding rates across socioeconomic groups. However, breastfeeding duration differs by economic status. In high-income countries, lower-income mothers are less likely to breastfeed, while in low- and middle-income countries, higher-income mothers are less likely to do so.^[32]

UNICEF data reveal that only 41% of wealthier families in low- and middle-income countries breastfeed until the recommended 2 years, compared to 64% of poorer households. West and Central Africa show the highest disparity, where 63% of infants from low-income families continue breastfeeding at 2 years, compared to just 26% from wealthier families.^[33]

EBF in Nigeria: A contemporary overview

According to the National Population Commission (2013), while breastfeeding is almost universal in Nigeria, the practice of EBF is far less common, with only 17% of children under 6 months being exclusively breastfed. The need to promote, protect, and support breastfeeding in Nigerian communities has become widely recognized. A study conducted in Kwara State on mothers’ knowledge and practice of EBF revealed that only 31% of the mothers had adequate knowledge, and just 53% initiated breastfeeding immediately after birth. Only 31% of these mothers practiced EBF. Of the 53 mothers who stopped breastfeeding, 85% ceased between 16 and 20 months.^[34]

In another community-based cross-sectional study in two Local Government Areas of Lagos State, 600 mothers were interviewed using structured questionnaires. The majority (91.8%) of respondents breastfed their babies, with 59.2% initiating breastfeeding within 1 h of delivery. Although 82% of respondents initiated EBF, only 52.9% sustained it for the recommended 6 months.^[35]

In addition, a study in Ogun State found that out of 340 women, 93.8% breastfed their babies, with the median duration of breastfeeding being 15 months. About 38.8% of mothers initiated breastfeeding within 30 min of delivery, and 58.8% practiced EBF for 6 months. The study also found that women who received breastfeeding information from mass media were more likely to practice EBF compared to those informed through other means.^[36]

Cognitive development

• Early stages (0–6 months): Nutrients in breast milk support brain development, enhancing memory and learning capabilities during this critical period.^[37]

• Later stages (6+ months): EBF in early months correlates with improved cognitive outcomes, while continued breastfeeding supports ongoing brain development.

Physical development

• Early stages (0–6 months): Breast milk provides an ideal balance of nutrients necessary for growth and weight gain.^[11]

• Later stages (6+ months): Continuing breastfeeding bolsters immune system development, reducing the risk of infections and promoting overall health.

Mental development

• Early stages (0–6 months): The emotional bond formed through breastfeeding fosters a sense of security and contributes positively to mental well-being.^[38]

• Later stages (6+ months): Breastfeeding continues to provide emotional comfort, supporting mental and emotional stability.

Social development

• Early stages (0–6 months): Close physical contact during breastfeeding encourages bonding and attachment, essential for healthy social development.^[6]

• Later stages (6+ months): Breastfeeding interactions offer opportunities for communication and social learning.

Immune system development

• Early stages (0–6 months): Breast milk contains antibodies that protect against infections and diseases.^[3]

• Later stages (6+ months): Continued breastfeeding contributes to immune health, reducing illness risks.

Nutritional foundation

• Early stages (0–6 months): EBF provides complete, digestible nutrition, essential for the newborn’s growth and development.^[39]

• Later stages (6+ months): While complementary foods are introduced, breastfeeding continues to provide vital nutrients, ensuring a strong foundation for healthy growth.