Exclusive breastfeeding and developmental and behavioral status in early childhood

Preterm Infants on Early Solid Foods and Neurodevelopmental Outcome-A Secondary Outcome Analysis of a Randomized Controlled Trial

There are no evidence-based recommendations regarding the introduction of solid foods in preterm infants. The objective of this study was to investigate whether age at the introduction of solid foods affects neurodevelopmental outcomes. This study focuses on analyzing secondary outcomes from a prospective trial involving very low birth weight infants who were randomly assigned to either an early (10-12th week corrected age) or a late (16-18th week corrected age) complementary feeding group. The study evaluated neurodevelopmental outcomes at one and two years of corrected age, as well as at three years and four months of uncorrected age by utilizing Bayley scales. In total, 89 infants were assigned to the early and 88 infants to the late group, all with a mean gestational age of 27 + 1 weeks. A linear mixed-effects model was used to compare neurodevelopmental outcomes across the study groups, taking into account variables such as gestational age at birth, sex, nutrition at discharge, parents' highest education level, and high-grade intraventricular hemorrhage. The analysis did not reveal any significant differences between the groups. The timepoint of the introduction of solid foods had no impact on neurodevelopmental outcomes at one and two years of corrected age, and at three years and four months of uncorrected age.

Junk food use and neurodevelopmental and growth outcomes in infants in low-resource settings

Introduction

Feeding infants a sub-optimal diet deprives them of critical nutrients for their physical and cognitive development. The objective of this study is to describe the intake of foods of low nutritional value (junk foods) and identify the association with growth and developmental outcomes in infants up to 18 months in low-resource settings.

Methods

This is a secondary analysis of data from an iron-rich complementary foods (meat versus fortified cereal) randomized clinical trial on nutrition conducted in low-resource settings in four low- and middle-income countries (Democratic Republic of the Congo, Guatemala, Pakistan, and Zambia). Mothers in both study arms received nutritional messages on the importance of exclusive breastfeeding up to 6 months with continued breastfeeding up to at least 12 months. This study was designed to identify the socio-demographic predictors of feeding infants' complementary foods of low nutritional value (junk foods) and to assess the associations between prevalence of junk food use with neurodevelopment (assessed with the Bayley Scales of Infant Development II) and growth at 18 months.

Results

1,231 infants were enrolled, and 1,062 (86%) completed the study. Junk food feeding was more common in Guatemala, Pakistan, and Zambia than in the Democratic Republic of Congo. 7% of the infants were fed junk foods at 6 months which increased to 70% at 12 months. Non-exclusive breastfeeding at 6 months, higher maternal body mass index, more years of maternal and paternal education, and higher socioeconomic status were associated with feeding junk food. Prevalence of junk foods use was not associated with adverse neurodevelopmental or growth outcomes.

Conclusion

The frequency of consumption of junk food was high in these low-resource settings but was not associated with adverse neurodevelopment or growth over the study period.

Predicting child development and school readiness, at age 5, for Aboriginal and non-Aboriginal children in Australia's Northern Territory

BACKGROUND

Positive early development is critical in shaping children's lifelong health and wellbeing. Identifying children at risk of poor development is important in targeting early interventions to children and families most in need of support. We aimed to develop a predictive model that could inform early support for vulnerable children.

METHODS

We analysed linked administrative records for a birth cohort of 2,380 Northern Territory children (including 1,222 Aboriginal children) who were in their first year of school in 2015 and had a completed record from the Australian Early Development Census (AEDC). The AEDC measures early child development (school readiness) across five domains of development. We fitted prediction models, for AEDC weighted summary scores, using a Partial Least Square Structural Equation Model (PLS-SEM) considering four groups of factors-pre-pregnancy, pregnancy, known at birth, and child-related factors. We first assessed the models' internal validity and then the out-of-sample predictive power (external validity) using the PLSpredict procedure.

RESULT

We identified separate predictive models, with a good fit, for Aboriginal and non-Aboriginal children. For Aboriginal children, a significant pre-pregnancy predictor of better outcomes was higher socioeconomic status (direct, β = 0.22 and indirect, β = 0.16). Pregnancy factors (gestational diabetes and maternal smoking (indirect, β = -0.09) and child-related factors (English as a second language and not attending preschool (direct, β = -0.28) predicted poorer outcomes. Further, pregnancy and child-related factors partially mediated the effects of pre-pregnancy factors; and child-related factors fully mediated the effects of pregnancy factors on AEDC weighted scores. For non-Aboriginal children, pre-pregnancy factors (increasing maternal age, socioeconomic status, parity, and occupation of the primary carer) directly predicted better outcomes (β = 0.29). A technical observation was that variance in AEDC weighted scores was not equally captured across all five AEDC domains; for Aboriginal children results were based on only three domains (emotional maturity; social competence, and language and cognitive skills (school-based)) and for non-Aboriginal children, on a single domain (language and cognitive skills (school-based)).

CONCLUSION

The models give insight into the interplay of multiple factors at different stages of a child's development and inform service and policy responses. Recruiting children and their families for early support programs should consider both the direct effects of the predictors and their interactions. The content and application of the AEDC measurement need to be strengthened to ensure all domains of a child's development are captured equally.

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis

CONTEXT

The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.

OBJECTIVE

This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.

DATA SOURCES

Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.

DATA EXTRACTION

Two investigators independently extracted data from the included studies on a standardized data-extraction form.

DATA ANALYSIS

Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score.

CONCLUSION

Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020218517.

Breast feeding and infant development in a cohort with sibling pair analysis: the Japan Environment and Children's Study

OBJECTIVES

To investigate the association between breast feeding and infant development during the first year of life using sibling comparison.

DESIGN

Nationwide prospective birth cohort study with sibling pair analysis.

SETTING

15 regional centres that participated in the Japan Environment and Children's Study.

PARTICIPANTS

This study included 77 119 children (singleton, term birth and no malformation/severe diseases) whose mothers were registered between January 2011 and March 2014, including 3521 duos or trios of siblings.

PRIMARY OUTCOME MEASURES

The primary outcome was developmental delay at 6 and 12 months of age, assessed using the Japanese translation of the Ages and Stages Questionnaires, third edition. Multivariable regression analyses adjusted for confounders were performed to estimate the risk ratios of delay associated with any or exclusive breast feeding. Pairs of siblings discordant for statuses were selected, and conditional regression analyses were conducted with a matched cohort design.

RESULTS

Developmental delay was identified in 6162 (8.4%) and 10 442 (14.6%) children at 6 and 12 months of age, respectively. Any breast feeding continued until 6 months or 12 months old was associated with reduced developmental delay at 12 months of age (adjusted risk ratio (95% CI): 0.81 (0.77 to 0.85) and 0.81 (0.78 to 0.84), respectively). Furthermore, exclusive breast feeding until 3 months was associated with reduced developmental delay at 12 months of age (adjusted risk ratio, 0.86 (95% CI 0.83 to 0.90)). In sibling pair analysis, the association between any breast feeding until 12 months and reduced developmental delay at 12 months of age persisted (adjusted risk ratio, 0.64 (95% CI 0.43 to 0.93)).

CONCLUSIONS

The present study demonstrated the association of continuous breast feeding with reduced developmental delay at 1 year of age using sibling pair analysis, in which unmeasured confounding factors are still present but less included. This may provide an argument to promote breastfeeding continuation.

Appropriate age range for introduction of complementary feeding into an infant's diet

Following a request from the European Commission, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) revised its 2009 Opinion on the appropriate age for introduction of complementary feeding of infants. This age has been evaluated considering the effects on health outcomes, nutritional aspects and infant development, and depends on the individual's characteristics and development. As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age. Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping (< 1 min after birth), or born preterm, or born small-for-gestational age or with high growth velocity) may benefit from earlier introduction of CFs that are a source of iron. The earliest developmental skills relevant for consuming pureed CFs can be observed between 3 and 4 months of age. Skills for consuming finger foods can be observed in some infants at 4 months, but more commonly at 5-7 months. The fact that an infant may be ready from a neurodevelopmental perspective to progress to a more diversified diet before 6 months of age does not imply that there is a need to introduce CFs. There is no reason to postpone the introduction of potentially allergenic foods (egg, cereals, fish and peanut) to a later age than that of other CFs as far as the risk of developing atopic diseases is concerned. Regarding the risk of coeliac disease, gluten can be introduced with other CFs.

Is breast feeding associated with offspring IQ at age 5? Findings from prospective cohort: Lifestyle During Pregnancy Study

OBJECTIVES

Breast feeding is associated with health benefits for both mother and child, but many studies focusing on neurodevelopment have lacked information on important confounders and few randomised trials exist. Our objective was to examine the influence of breast feeding on child IQ at 5 years of age while taking maternal IQ and other relevant factors into account.

DESIGN

Prospective observational study.

SETTING

Population-based birth cohort in Denmark.

PARTICIPANTS

We used data from The Lifestyle During Pregnancy Study 1782 mother-child pairs sampled from the Danish National Birth Cohort (n=101 042).

OUTCOME MEASURES

Child IQ was assessed at age 5 years by the Wechsler Primary and Preschool Scales of Intelligence-Revised. On the same occasion maternal intelligence was assessed by Wechsler Adult Intelligence Scale and Raven's Standard Progressive Matrices. Exposure data on duration of breast feeding (n=1385) were extracted from telephone interviews conducted when the child was 6 and 18 months, and analyses were weighted by relevant sampling fractions.

RESULTS

In multivariable linear regression analyses adjusted for potential confounders breast feeding was associated with child IQ at 5 years (categorical χ2 test for overall association p=0.03). Compared with children who were breast fed ≤1 month, children breast fed for 2-3, 4-6, 7-9 and 10 or more months had 3.06 (95% CI 0.39 to 5.72), 2.03 (95% CI -0.38 to 4.44), 3.53 (95% CI 1.18 to 5.87) and 3.28 (95% CI 0.88 to 5.67) points higher IQ after adjustment for core confounders, respectively. There was no dose-response relation and further analyses indicated that the main difference in IQ was between breast feeding ≤1 month versus >1 month.

CONCLUSIONS

Breastfeeding duration of 1 month or shorter compared with longer periods was associated with approximately three points lower IQ, but there was no evidence of a dose-response relation in this prospective birth cohort, where we were able to adjust for some of the most critical confounders, including maternal intelligence.

Complementary feeding and developmental milestones: a systematic review

BACKGROUND

Systematic reviews were conducted as part of the USDA and the US Department of Health and Human Services Pregnancy and Birth to 24 Months Project to examine the relation between complementary feeding and developmental milestones.

OBJECTIVES

The aim of this study was to describe systematic reviews examining the relationship between timing of introduction of complementary foods and beverages (CFB), and the types and amounts of CFB consumed, and developmental milestones.

METHODS

The literature was searched using 4 databases (PubMed, Cochrane, Embase, and CINAHL) to identify articles that met predetermined criteria for inclusion. Data extraction and risk of bias assessment were conducted for each included study. The body of evidence for each systematic review was qualitatively synthesized to develop a conclusion statement, and the strength of evidence was graded.

RESULTS

Three included articles (1 randomized controlled trial; 2 observational studies) examined timing of introduction of CFB. Eight included articles (3 randomized controlled trials; 5 observational studies) examined types and amounts of CFB. There was insufficient evidence to draw conclusions about the relation between either timing of CFB introduction or types and amounts of CFB, and developmental milestones.

CONCLUSIONS

The ability to draw conclusions about the relationship between complementary feeding and developmental milestones was restricted by an inadequate amount of evidence with potential for issues with reverse causality and wide variation in design, type/age of outcome assessment, exposure assessment, and reported results. Additional research to address these gaps and limitations would be useful.

Timing of introduction of complementary foods and beverages and growth, size, and body composition: a systematic review

BACKGROUND

The systematic review described in this article was conducted as part of the USDA and Department of Health and Human Services Pregnancy and Birth to 24 Months Project.

OBJECTIVES

The aim was to describe the relationship between timing of introduction of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes across the life span.

METHODS

The literature was searched and selected using predetermined criteria. Data were extracted and risk of bias assessed for each included study. Evidence was qualitatively synthesized, conclusion statements were developed, and the strength of the evidence was graded.

RESULTS

Eighty-one articles were included in this systematic review that addressed timing of CFB introduction relative to growth, size, and body-composition outcomes from infancy through adulthood. Moderate evidence suggests that introduction of CFBs between the ages of 4 and 5 mo compared with ∼6 mo is not associated with weight status, body composition, body circumferences, weight, or length among generally healthy, full-term infants. Limited evidence suggests that introduction of CFBs before age 4 mo may be associated with higher odds of overweight/obesity. Insufficient evidence exists regarding introduction at age ≥7 mo.

CONCLUSIONS

Although several conclusions were drawn in this systematic review, additional research is needed to address gaps and limitations in the evidence on timing of introduction of CFBs and growth, size, and body composition, such as randomized controlled trials that examine multiple outcomes and/or CFB introduction between the ages of 4 and 6 mo, and research that accounts for potential confounders such as feeding practices and baseline growth status and considers issues of reverse causality.

Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition

This position paper considers different aspects of complementary feeding (CF), focussing on healthy term infants in Europe. After reviewing current knowledge and practices, we have formulated these recommendations: Timing: Exclusive or full breast-feeding should be promoted for at least 4 months (17 weeks, beginning of the 5th month of life) and exclusive or predominant breast-feeding for approximately 6 months (26 weeks, beginning of the 7th month) is a desirable goal. Complementary foods (solids and liquids other than breast milk or infant formula) should not be introduced before 4 months but should not be delayed beyond 6 months.

CONTENT

Infants should be offered foods with a variety of flavours and textures including bitter tasting green vegetables. Continued breast-feeding is recommended alongside CF. Whole cows' milk should not be used as the main drink before 12 months of age. Allergenic foods may be introduced when CF is commenced any time after 4 months. Infants at high risk of peanut allergy (those with severe eczema, egg allergy, or both) should have peanut introduced between 4 and 11 months, following evaluation by an appropriately trained specialist. Gluten may be introduced between 4 and 12 months, but consumption of large quantities should be avoided during the first weeks after gluten introduction and later during infancy. All infants should receive iron-rich CF including meat products and/or iron-fortified foods. No sugar or salt should be added to CF and fruit juices or sugar-sweetened beverages should be avoided. Vegan diets should only be used under appropriate medical or dietetic supervision and parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet.

METHOD

Parents should be encouraged to respond to their infant's hunger and satiety queues and to avoid feeding to comfort or as a reward.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Health organisations recommend exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries. Recently, research has suggested that introducing solid food at around four months of age while the baby continues to breastfeed is more protective against developing food allergies compared to exclusive breastfeeding for six months. Other studies have shown that the risks associated with non-exclusive breastfeeding are dependent on the type of additional food or fluid given. Given this background we felt it was important to update the previous version of this review to incorporate the latest findings from studies examining exclusive compared to non-exclusive breastfeeding.

OBJECTIVES

To assess the benefits and harms of additional food or fluid for full-term healthy breastfeeding infants and to examine the timing and type of additional food or fluid.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2016) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 trials (2542 randomised infants/mothers). Nine trials (2226 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one primary (breastfeeding duration) and one secondary (weight change) outcome. None of the trials reported on physiological jaundice. Infant mortality was only reported in one trial.For the majority of older trials, the description of study methods was inadequate to assess the risk of bias. Most studies that we could assess showed a high risk of other biases and over half were at high risk of selection bias.Providing breastfeeding infants with artifical milk, compared to exclusive breastfeeding, did not affect rates of breastfeeding at hospital discharge (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.97 to 1.08; one trial, 100 infants; low-quality evidence). At three months, breastfeeding infants who were provided with artificial milk had higher rates of any breastfeeding compared to exclusively breastfeeding infants (RR 1.21, 95% CI 1.05 to 1.41; two trials, 137 infants; low-quality evidence). Infants who were given artifical milk in the first few days after birth before breastfeeding, had less "obvious or probable symptoms" of allergy compared to exclusively breastfeeding infants (RR 0.56, 95% CI 0.35 to 0.91; one trial, 207 infants; very low-quality evidence). No difference was found in maternal confidence when comparing non-exclusive breastfeeding infants who were provided with artificial milk with exclusive breastfeeding infants (mean difference (MD) 0.10, 95% CI -0.34 to 0.54; one study, 39 infants; low-quality evidence). Rates of breastfeeding were lower in the non-exclusive breastfeeding group compared to the exclusive breastfeeding group at four, eight, 12 (RR 0.68, 95% CI 0.53 to 0.87; one trial, 170 infants; low-quality evidence), 16 and 20 weeks.The addition of glucose water resulted in fewer episodes of hypoglycaemia (below 2.2 mmol/L) compared to the exclusive breastfeeding group, reported at 12 hours (RR 0.07, 95% CI 0.00 to 1.20; one trial, 170 infants; very low-quality evidence), but no significant difference at 24 hours (RR 1.57, 95% CI 0.27 to 9.17; one trial, 170 infants; very low-quality evidence). Weight loss was lower for infants who received additional glucose water (one trial, 170 infants) at six, 12, 24 and 48 hours of life (MD -32.50 g, 95% CI -52.09 to -12.91; low-quality evidence) compared to the exclusively breastfeeding infants but no difference between groups was observed at 72 hours of life (MD 3.00 g, 95% CI -20.83 to 26.83; very low-quality evidence). In another trial with the water and glucose water arms combined (one trial, 47 infants), we found no significant difference in weight loss between the additional fluid group and the exclusively breastfeeding group on either day three or day five (MD -1.03%, 95% CI -2.24 to 0.18; very low-quality evidence) and (MD -0.20%, 95% CI -0.86 to 0.46; very low-quality evidence).Infant mortality was reported in one trial with no deaths occurring in either group (1162 infants). The early introduction of potentially allergenic foods, compared to exclusively breastfeeding, did not reduce the risk of "food allergy" to one or more of these foods between one to three years of age (RR 0.80, 95% CI 0.51 to 1.25; 1162 children), visible eczema at 12 months stratified by visible eczema at enrolment (RR 0.86, 95% CI 0.51 to 1.44; 284 children), or food protein-induced enterocolitis syndrome reactions (RR 2.00, 95% CI 0.18 to 22.04; 1303 children) (all moderate-quality evidence). Breastfeeding infants receiving additional foods from four months showed no difference in infant weight gain (g) from 16 to 26 weeks compared to exclusive breastfeeding to six months (MD -39.48, 95% CI -128.43 to 49.48; two trials, 260 children; low-quality evidence) or weight z-scores (MD -0.01, 95% CI -0.15 to 0.13; one trial, 100 children; moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found no evidence of benefit to newborn infants on the duration of breastfeeding from the brief use of additional water or glucose water. The quality of the evidence on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. The majority of studies showed high risk of other bias and most outcomes were based on low-quality evidence which meant that we were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence to disagree with the current international recommendation that healthy infants exclusively breastfeed for the first six months.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2014) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted data and assessed risk of bias.

MAIN RESULTS

We included eight trials (984 randomised infants/mothers). Six trials (n = 613 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one secondary outcome (weight change). The trials that provided outcome data compared exclusively breastfed infants with breastfed infants who were allowed additional nutrients in the form of artificial milk, glucose, water or solid foods.In relation to the majority of the older trials, the description of study methods was inadequate to assess the risk of bias. The two more recent trials, were found to be at low risk of bias for selection and detection bias. The overall quality of the evidence for the main comparison was low.In one trial (170 infants) comparing exclusively breastfeeding infants with infants who were allowed additional glucose water, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), with more infants in the exclusive breastfed group still exclusively breastfeeding. Conversely in one small trial (39 infants) comparing exclusive breastfed infants with non-exclusive breastfed infants who were provided with artificial milk, fewer infants in the exclusive breastfed group were exclusively breastfeeding at one week (RR 0.58, 95% CI 0.37 to 0.92) and at three months (RR 0.44, 95% CI 0.26 to 0.76) and there was no significant difference in the proportion of infants continuing any breastfeeding at three months between groups (RR 0.76, 95% CI 0.56 to 1.03).For infant morbidity (six trials), one newborn trial (170 infants) found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference (MD) 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24 mmol/L, 95% CI -0.51 to 0.03). Weight loss was also higher (grams) in infants at six, 12, 24 and 48 hours of life in the exclusively breastfed infants compared to those who received additional glucose water (MD 7.00 g, 95% CI 0.76 to 13.24; MD 11.50 g, 95% CI 1.71 to 21.29; MD 13.40 g, 95% CI 0.43 to 26.37; MD 32.50 g, 95% CI 12.91 to 52.09), but no difference between groups was observed at 72 hours of life. In another trial (47 infants analysed), we found no significant difference in weight loss between the exclusively breastfeeding group and the group allowed either water or glucose water on either day three or day five (MD 1.03%, 95% CI -0.18 to 2.24) and (MD 0.20%, 95% CI -1.18 to 1.58).Three trials with four- to six-month-old infants provided no evidence to support any benefit from the addition of complementary foods at four months versus exclusive breastfeeding to six months nor any risks related either morbidity or weight change (or both).None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence of benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water, and the quality of the evidence from a small pilot study on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer-term effects on infants and mothers, though randomising infants to receive supplements without medical need may be problematic.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.