Optimal Duration of Exclusive Breastfeeding - Literature review Example

Optimal Duration of Exclusive Breastfeeding Your name Course name Course Instructor Date of Submission Abstract There has been an immense debate for the last decade between four and six months in regard to the length of elusive breastfeeding (EBF). Experts had divided opinion around what is referred to as weanling dilemma and safety or concern on milk substitute sanitation. In addition, it is also associated with the target community, whether they are third world or developed countries. Developing recommendation or national program on EBF for each country should be in regard to the strongest evidence found if possible from systematic review of randomized control trials. The beneficial value of using six compared to four months EBF from either developed or third world countries has been revealed in a review involving enough and proportional evidence. The review has a good objectivity considering its strengths and limitations. The applicability of the review in developing six months EBF recommendation for Indonesia population is viewed to be appropriate due to the outcomes of the review that are observed to be cheap and suitable with less harm and even protective against diarrhea. This is a critical appraisal of a systematic review written by Kramer and Kakuma (2002). Key words: exclusive breastfeeding (EBF), critical appraisal, systematic review Introduction It has been established that mothers’ breast milk is the best food needed for maintaining infants’ health, and support for their growth and development (whitney et al., 2002). Hence, breastfeeding is viewed as the perfect choice of feeding healthy infants (Szajewska et al., 2006). Nevertheless, the question of optimal duration of exclusive breastfeeding (EBF) has resulted to a broad debate and divided recommendations (Kramer and Kakuma, 2002). A period of 4.6 months was suggested in 1905 by the World Health Organization (WHO) while UNICEF and American Academy of Pediatrics used the wording at about 6 months in 1999 and 1997 respectively (Lutter, 2000). Currently, recommendation for EBF in Indonesia is still in accordance to the 1995 WHO recommendations. The current recommendation of EBF for six months is less probable to be accepted in Indonesia where malnutrition is still rampant due to the belief or so called weanlings dilemma’s that breast milk alone is not enough to satisfy the infant’s energy and micronutrients needs beyond four months of age (Coutsoudis and Bentley, 2004). In 2000, Kramer and Kakuma (2002) reviewed the evidence from the accessible studies in the light of this controversy to derive a comprehensive recommendation of optimal duration of EBF the outcomes of which were published in the Cochrane database of Systematic Reviews on January 21, 2002. The conclusion of this article cannot be taken for granted despite the fact that this article was published in a trustworthy peer-reviewed journal (Health Library, 2002). Hence, the present critical appraisal is carried out to evaluate the severity and quality of systematic review by Kramer and Kakuma (2002) on the optimal duration of EBF with specific application to Indonesia population using critical appraisal checklist for a systematic review by oxman, Cook and Guyatt (Oxman et al., 1994). Appropriateness of Background The systematic review by Kramer and Kakuma (2002) has adequate and balanced background knowledge to draw readers into the existing debate, divided opinions and recommendations for EBF. Reasons for 4.6 months period of EBF recommendation has been sufficiently supported by the discussion of such issue as: the growth faltering related to inadequacy of energy intake from breast milk alone after three or four months presented by FAO and WHO in 1974, and the weanling dilemma’s theory by Rowland (1978 and 1986). There is also a balance between literature presented in the background to include studies both from develop and developing countries up until the most recent one in 2000, before the review. Thus, the literature review presented is clear, comprehensive and provides up to date background to the review. The Clarity of Questions The objectives of the review were clearly defined with the primary objective being to compare the child health, growth and development as well as maternal health as a result of two different EBF exposures which include The Indonesian Journal of Public Health, Vol. 3, No. 1, July 2006: 1-4 to six months versus six months EBF. There is difficulty in giving a clear definition of EBF due to the fact that not all studies included in the review strictly adhered to WHO’s definition (Kramer and Kakuma, 2002). This is a common problem when making comparisons of different breastfeeding initiation and termination studies (Coutsoudis and Bentley, 2004). However, Kramer and Kakuma (2001) have acknowledged the various definitions in their effort to avoid misleading conclusions. Type of Studies Kramer and Kakuma (2002) selected the best available evidence they could find in their reviews in terms of the strength of evidence including randomized control trials (RCTs) and observational studies. Moreover, published studies in all languages were identified hence reducing the publication bias. Even though further unpublished studies and data were identified through further investigation from the reference lists of the relevant published studies; there is still a chance of unpublished studies that have not been identified to be included in the review, especially those studies from third world countries that have less opportunity for online publication. The outcomes of those unidentified studies might be different from studies included in Kramer and Kakuma’s review, hence, they might have had influenced the results, regardless of whether they would have underestimated or overestimated it. The restriction was imposed on the review. The review was limited to studies with internal comparison group with one group of infants who received EBF for three but seven less months and mixed breastfeeding (MBF) until six months or later and another group of infants who were exclusively breastfed for 6 months (Kramer and Kakuma, 2002). Studies with external comparison using reference data were excluded. The results of the studies with external comparison might differ from those with internal comparison, something that might have affected the results of the review. However, with the restriction, the comparison would give a more precise outcome because they compared the subjects in relatively similar populations. Moreover, Kramer and Kakuma (2002) argue in their review that the restriction was imposed to provide direct relevance to the clinical and public health decision context: whether infants who are exclusively breastfed for the first three to four months should continue EBF or should receive complementary foods in addition to breast milk (MBF). Identification of Studies In order to reduce selection bias in the review, two independent literature searches were conducted. In addition, Kramer and Kakuma (2002) also made an effort to contact the authors of all studies that qualified for inclusion in the review to obtain details of the methodology, clarify inconsistencies and obtain unpublished data. Consultations with experts in the field and further examination of the reference lists were performed so as to identify other potentially relevant published or unpublished studies. Overall, the identification of studies to be included in the review was by far thorough to cover relevant studies and to reduce potential publication bias. Assessment of the Included Studies To ensure objectivity and to reduce selection bias, evaluation of potentially relevant studies was carried out without consideration of the results of the studies (Kramer and Kakuma, 2002). In their efforts to assess the quality of the studies they have identified, Kramer and Kakuma used three tools as standard criteria. For assessing the quality of randomized controlled trials, Cochrane criteria for assessing controlled clinical trials and the five point Jadad scale (Jadad 1996 cited in Kramer and Kakuma, 2002) were used. For observational studies including cohort, case-control and cross sectional studies, assessment for control for confounding, losses to follow up, and outcome were conducted. The results of these assessments were presented in the Table of Included Studies in the methodological quality section of the review. Strength and limitations of the included studies were sufficiently discussed. For example, Kramer and Kakuma (2002) have discussed three limitations they have had identified from two Honduras studies by Cohen (1994) and Dewey (1999) while emphasizing the strength of the studies as the only experimental design studies to specifically address EBF recommendations controversy. These considerations are important to ensure objectivity of the review as well as to avoid misleading conclusion readers might perceived. Hence, the review that authors have done is enough to assess the quality of the included studies. The Results of the Review Argument of Kramer and Kakuma (2002) that there was no studies, either from controlled clinical trials or the observational studies, shows significant evidence of the so called weanling’s dilemma in the EBF duration for up to six moths. Moreover, in the two Honduras’ controlled trials, weight-forage, length-for-age and weight-for-length z-score at six months were slightly higher in the EBF group despite the fact that they were not statistically significant (Kramer and Kakuma, 2002). In contrast, observational studies of EBF versus MBF for three to seven months in third world countries’ setting show reduced weight and length gain from four to six months in the EBF group, but the results were not statistically significant (Kramer and Kakuma, 2002). In order to avoid misleading conclusions and overgeneralization in presenting these results, Kramer and Kakuma consider the limitation of observational Systematic Review-based Recommendation. Trias Mahmudiono studies design such as confounding due to differences in socioeconomic status, water and sanitation facilities, parental size and weight and length of the MBF group before the introduction of complementary food (Kramer and Kakuma, 2002). However, the results varied from study to study regarding to specific outcome. Thus, caution should be taken in the interpretation. For example, the two Honduras controlled trials differ in their results regarding the age at which the infants sat from lying position and walking by 12 months. Significant heterogeneity also observed in the results of four observational studies in developed countries. The slightly but significantly higher pooled weight and length gain between six to nine months were observed in the MBF group (Kramer and Kakuma, 2002). Six months EBF shows much more advantages than four to six months MBF in terms of the benefit outcomes. The review underlines several advantages of the six months EBF including significant reduction in risk of gastrointestinal infection (Kramer, 2000), delayed resumption of menses, prolonged amenorrhea, rapid maternal postpartum weight loss, and infants’ early development as indicated by significantly younger age of crawling (Cohen, 1994 and Dewey, 1999). The only drawback revealed was a lesser iron status in the six months EBF group in Honduras studies. However, Kramer and Kakuma (2002) argue that the improvement of iron status in the MBF can also be achieved by iron supplementation. Hence, there was no detrimental effect of the initiation of EBF for six months observed in the systematic review. Application of Results The populations which are represented in the review including Honduras (Cohen, 1994 and Dewey, 1999), Peru (Brown, 1991), the Philippines (Adair, 1993), and Senegal (Simondon, 1997), were quite similar to Indonesian population. The results of the review might be suitable to be applied in Indonesia because the systematic review by Kramer and Kakuma (2002) was sufficiently including studies from third world countries. The review also puts into consideration all significant outcomes both for infants’ growth and development as well as mothers’ health. Issues such as slightly but significantly lesser weight and length gain for six to nine months, and lesser iron status of infants with six months duration of EBF were sufficiently discussed, and possible explanations were stated. Therefore, implementation of the findings of the review to Indonesian population might already cover all probable outcomes with no such detrimental or surprising outcomes. However, the review by Kramer and Kakuma (2002) did not address the concept of cost-benefit or cost-effectiveness in implementing the results into particular settings. One of the most significant potential advantages of 6 months EBF in third world countries’ setting is the reduction of mortality from infectious diseases especially diarrhea. This phenomenon is likely associated with the introduction of breast milk substitutes, semi-solid or even worse solid food which not clean and safe than breast milk (Coutsoudis and Bentley, 2004). According to the Indonesia Demographic and Health Surveys (DHS) conducted in 1994 and 1997, the median duration of exclusive breastfeeding (EBF) in six provinces was less than 4 months (Latief et al., 2000). Moreover, the percentage of EBF for 0.3 months was only 54% in 1997 (Latief et al., 2000). At the same time, 3,134.2 thousand cases of diarrhea disease took place in 1998 and it could be hypothesized that at least some of them could be connected directly to the short period of EBF. The results of the meta-analysis conducted by the WHO based on developing countries’ data that mortality from infectious diseases, particularly diarrhea, is five or six times higher in infants who are not breastfed compared to those who are breastfed for the first two months of life is confirmed by these findings (Coutsoudis and Bentley, 2004). In Indonesia, diarrhea was ranked as the highest contributor for the loss of Disability Adjusted Life Years (DALY) and a leading cause of less than five morbidities, and second only to malnutrition (Latief et al., 2000). Hence, for Indonesian population, the advantages of the implementation of EBF for six months will ideally include the reduction of DALY and costs associated with morbidity from diarrhea. Such benefits that worth the harm and costs that might be coming from effort to improve iron status of infants that exclusively breastfed for six months like iron supplementation. Conclusion In summary, the advantages of EBF for six months to four to six months EBF are demonstrated clearly by the review by Kramer and Kakuma. There is no proof that has been observed in association to what is referred to as weanling’s dilemma (Kramer & Kakuma 2002). Supporting proofs from observational studies were sufficient for both developed and third world countries’ setting. Nevertheless, additional evidences were required through well-designed and conducted RCTs due to the fact that the only RCTs discovered in the review were carried out both in Honduras and having several methodological problems. Nevertheless, the review placed into consideration its strengths and weakness, thus, less probable to be ambiguous or bias. The outcomes of the review are considered to be cost effective and appropriate with less detrimental effects or harm in terms of applicability, especially for Indonesia population. References Bahl, R., Frost, C., & Kirkwood, B.R., 2005. Infant feeding patterns and risks of death and hospitalization in the first half of infancy: multi-centre cohort study. Bull World Health Organ. 83(6), p.418-26. Bhandari, N., Bahl, R., & Mazumdar, S., 2003. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised con-trolled trial. Lancet. 361(9367), p.1418-23. 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