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A Call to Action on Breastfeeding: A Fundamental Public Health Issue

Policy Date: 11/6/2007
Policy Number: 200714

BACKGROUND AND NEED FOR A COMPREHENSIVE BREASTFEEDING POLICY
The American Public Health Association (APHA) has long recognized that scientific evidence shows that human milk is the most appropriate food for almost all human infants 1–5 and has recognized that there are barriers to breastfeeding.1,3–5 Increasingly, maintaining breastfeeding as the norm is seen as an important preventative health measure. For a variety of social, economic, educational, institutional, and political reasons, breastfeeding rates do not approach the levels recommended by major health authorities, both in the United States and globally,6–9 with increasing evidence of the health risks of not breastfeeding, including the risk of chronic diseases in both mothers and their offspring and with continued threats to breastfeeding such as through aggressive advertising of human milk substitutes. This policy statement addresses the urgent calls to action9–12 on breastfeeding in the United States and for US support for breastfeeding worldwide. In addition, new findings about the impact of breastfeeding on fertility13,14 and women’s health15 and evolving concerns about transmission of HIV and environmental contaminants through breast milk require an update in APHA breastfeeding policy, which was last comprehensively addressed in 1982.4

All major health authorities now recommend that infants receive no other food or drink besides breast milk for the first 6 months of life (“exclusive breastfeeding”), with continued breastfeeding for at least 1 to 2 years of life, with rare exceptions.6–9 These authorities recommend initiation of breastfeeding immediately after birth and timely introduction of appropriate complementary foods. The United States has established federal goals for breastfeeding in its Healthy People 2010 statement, including 75% of initiation in the early postpartum period, 50% continuing to 6 months postpartum, and 25% of all women breastfeeding at 1 year,1,16 as well as new goals of 60% exclusive breastfeeding for 3 months and 25% for 6 months. However, data from the Centers for Disease Control and Prevention (CDC) show that 73.8% of US mothers initiate breastfeeding, yet only 41.5% are still breastfeeding at 6 months and 20.9% are still breastfeeding at 1 year.17 Only 11.3% are meeting the medical recommendation to breastfeed exclusively for 6 months.17 Worldwide, breastfeeding rates vary significantly by country, with most falling far short of the goals of the United Nations Standing Committee on Nutrition: 60% exclusive breastfeeding in infants younger than 6 months of age, continued breastfeeding in at least 70% of infants aged 6 to 9 months with appropriate complementary foods, and continued breastfeeding of 75% in children aged 20 to 23 months.18 Currently, no region of the world has 6-month exclusive breastfeeding rates greater than 50%,19 although some individual countries do better than this.

Barriers to Breastfeeding
The health and scientific communities themselves have contributed barriers to breastfeeding. The WHO/UNICEF Baby-friendly Hospital Initiative (BFHI) is a package of 10 evidenced-based steps shown to increase sustained breastfeeding rates,20,21 but it has been achieved only by fewer than 3% of maternity hospitals and birth centers in the United States22 and only approximately 25% of maternity centers worldwide.23

Maternity and birthing practices that are not medically indicated persist and unnecessarily interfere with the establishment of breastfeeding. Health professionals have inadequate training, education, and resources to provide appropriate breastfeeding support. Scientific journals often do not adequately distinguish between exclusive breastfeeding and other breastfeeding patterns when they discuss effects of breastfeeding.

Legislation and policies do not adequately support breastfeeding. The United States lacks consistent legislation to support the socioeconomic need for paid maternity leave, necessary for support of exclusive breastfeeding. It should be noted that not all women have a recognized entitlement to family and medical leave, and when the leave is unpaid and unprotected, a large proportion of women are not able to take sufficient leave to establish lactation or to support exclusive breastfeeding; this contrasts with Canada, European Union countries, and many other developed and developing countries worldwide where paid maternity leave is required. The United States also lacks national legislation to protect women from persecution or harassment for breastfeeding in public.

Worksites generally do not support the needs of lactating employees, nor are there national laws to require worksite lactation support. Universal requirements do not exist for third-party payers to cover lactation support and services or breast pumps, which would allow working mothers to continue to breastfeed according to medical recommendations. As a result, there are wide disparities in access to skilled breastfeeding support and care across socioeconomic, sociocultural, and racial groupings. Both CDC and the US Department of Health and Human Services have noted that disparities persist in breastfeeding across racial and ethnic groups, as well as regionally across the United States.11,24 Finally, current global levels of organizational investment in breastfeeding will not suffice to meet US goals for breastfeeding or international goals for child survival.

In addition, there is increasing aggressive advertising of human milk substitutes, including widespread hospital distribution of discharge packs that advertise substitutes for human milk, inappropriate advertisements, direct marketing to parents and health practitioners and other violations of the World Health Organization (WHO) International Code of Marketing of Breast-milk Substitutes(the International Code).25 A US Government Accountability Office report26concluded that advertising of infant formula is widespread and increasing. It also concluded that infant formula marketing, particularly hospital discharge packs, discourages breastfeeding and that breastfeeding rates are lower among mothers who are young, not college educated, or unmarried. The CDC also noted that formula marketing has a disproportionately negative impact on US mothers already at high risk for early weaning, namely, first-time mothers, those with less formal education, those who are non-White, or those who are ill postpartum.11

Finally, cultural emphasis in the United States and elsewhere on the sexuality of the human breast, at the expense of its nutritional function, has created significant barriers to cultural acceptance of breastfeeding. Family members, the public, and mothers themselves have demonstrated discomfort about possible exposure of the breast while feeding. Partners and family members who do not encourage breastfeeding can adversely impact the decision to breastfeed.27–29 At the same time there is a general lack of public appreciation of the health risks of not breastfeeding and associated public health implications, a situation exacerbated by common use of language emphasizing the “benefits” of breastfeeding, which implies that artificial feeding is the acceptable norm. Media portrayal of breastfeeding is also not consistently supportive or accurate.

Prior APHA Policies
In the past, APHA has called for government agencies to develop a national campaign to promote breastfeeding in the hospitals and health centers in their jurisdictions4 and for governments to work with health care providers, institutions, and reimbursing agencies to ensure that all women have access to breastfeeding care and services before and after giving birth.1 APHA has noted that hospital-based practices are key to the success of breastfeeding, and the education of health care workers can increase the success of breastfeeding.4 APHA has also called on the federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to encourage breastfeeding and breastfeeding counseling.4 APHA supports the Nestlé boycott3 as well as the International Code3,25 and subsequent World Health Assembly Resolutions. APHA has supported the US Health and Human Services Blueprint for Action on Breastfeeding (APHA 2001-14),1,12 which highlights the need for worksite protection and promotion of the Baby-friendly Hospital Initiative.

APHA has also called on the media to portray breastfeeding as normal, desirable, and achievable for women of all cultures and socioeconomic levels1 and supported universal health coverage,30 which should include breastfeeding care and services. Finally, APHA has urged proactive steps to prevent chemical contamination of human milk by reducing sources of contamination in the environment.31

Policies of Other Health Professional Organizations That Promote, Protect, and Support Breastfeeding
The American Academy of Pediatrics8 (p496) noted that “exclusive breastfeeding is the reference or normative model against which all alternative feeding methods must be measured, with regard to growth, health, development and all other short- and long-term outcomes.” The American College of Obstetricians and Gynecologists7also advocated for health professionals and employers to support breastfeeding. The American Academy of Family Physicians supports breastfeeding6,32 and noted that the strongest evidence indicates that 6 months of exclusive breastfeeding is optimal, that the risks to the infant increase as the period of exclusive breastfeeding decreases, that the highest risk is in babies who received no human milk, and that there are improved outcomes associated with longer breastfeeding durations.6 The American College of Nurse Midwives33 and the American Dietetic Association34 (p810) both support breastfeeding, with the latter noting that breastfeeding is “a public health strategy for improving child health survival, improving maternal morbidity, controlling health care costs, and conserving natural resources.”

Global Policies and Declarations
The WHO/United Nations Children's Fund (UNICEF) Global Strategy on Infant and Young Child Feeding9 approved by the World Health Assembly and UNICEF Executive Board, both of which include US representatives, is a call for urgent action, including widespread implementation of the Baby-friendly Hospital Initiative and legislation of the International Code, establishment of national authorities with oversight regarding breastfeeding, creative legislation for maternity protection in the workplace, attention to HIV and emergencies, and the need for community action.

The Innocenti Declaration 200510 called for support of the Innocenti Declaration of 1990 and the WHO/UNICEF Global Strategy and its 9 operational targets. The United Nations Convention on the Rights of the Child (1989),35 [article 24 section (e)] signed by the United States in 1995, stated that all nations must take appropriate measures “to ensure that all segments of society . . . are supported in the use of basic knowledge of . . . the advantages of breastfeeding . . ..” The 28-country European Blueprint36 recognized the importance of breastfeeding in promoting lifelong health.

US Breastfeeding Policies
The CDC Guide to Breastfeeding Interventions11 called for support of evidence-based interventions for improving breastfeeding rates, including maternity care practices such as the Baby-friendly Hospital Initiative, peer support, maternal education, and media and social marketing campaigns. It gives special attention to worksite lactation support, noting that approximately 70% of employed mothers with children younger than 3 years of age work full time and that working outside the home is associated with a shorter duration of breastfeeding. It encourages use of the federal government’s Health Resources and Services Administration Maternal Child Health Bureau’s resource, The Business Case for Breastfeeding. The US Health and Human Services Blueprint for Action on Breastfeeding12 has been endorsed by the APHA and is summarized previously.

CURRENT RESEARCH AND ANALYSES ON BREASTFEEDING
The US Agency for Healthcare Quality Research15 analysis of all available research concluded that not breastfeeding is associated with an increased risk of these diseases in offspring: acute otitis media, gastrointestinal infections, lower respiratory tract infections requiring hospitalization, asthma in young children, obesity in adolescence and later life, type 1 and 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), necrotizing enterocolitis. Further, an increased risk of maternal type 2 diabetes and maternal breast and ovarian cancers are associated with not breastfeeding and with shorter durations of breastfeeding.

Other analyses have demonstrated the global impact of breastfeeding. The Bellagio Study Group concluded that 1.3 million child deaths per year worldwide could be prevented with 6 months of exclusive breastfeeding and continued breastfeeding for the first year of life.37 Other research has shown that shorter duration of breastfeeding is linked with an increased risk of pediatric and adolescent overweight.38–41 Breastfeeding, globally, is a major contributor to birth spacing and fertility reduction.42,43 The American College of Obstetricians and Gynecologists and the WHO eligibility criteria stress the importance of the Lactational Amenorrhea Method as contributing to adequate child spacing.44 WHO45also concluded that nonbreastfed subjects had higher mean blood pressure and cholesterol later in life, as well as higher prevalence of obesity and type 2 diabetes.

TRANSMISSION OF CONTAMINANTS AND VIRUSES FROM MOTHER TO CHILD
A small number of children will need donor milk or breast milk substitutes for medical reasons. Substitutes are recommended for children of HIV-positive mothers for whom such substitutes are acceptable, feasible, affordable, sustainable, and safe, although the evidence of decreased transmission of HIV with exclusive breastfeeding compared to with mixed feeding46,47 underlines the need for continued support for exclusive breastfeeding even in endemic areas where substitutes are not feasible.

Health professionals, researchers, and political decisionmakers should recognize that human milk may serve as a biomarker for certain environmental contaminants.12,47 Environmental contaminants can be conveyed into human milk, either because of unusual maternal exposures or, most commonly, as a result of low-level exposures to persistent organic pollutants (POPs) and other contaminants, some of which may accumulate in body tissues throughout a woman’s life and then can be subsequently conveyed to her infant during pregnancy or lactation. However, expert groups have judged that breastfeeding demonstrates clear overall benefits for the child, despite the presence of POPs and other contaminants.48 An expert panel concluded that “Few, if any, adverse effects have been documented as being associated with consumption of human milk containing background levels of environmental chemicals, and none have been clinically or epidemiologically demonstrated,” and human milk may contain elements that prevent absorption of xenobiotics or inactivate them.47 (p1827) APHA is, however, concerned that industry and environmental regulators exercise caution in approving any potential toxin, any new persistent organic pollutants, or new uses for POPs currently on the market, to protect the environment, which includes human milk.

APHA is concerned that human milk substitutes are also susceptible to contamination by environmental contamination, bacterial contamination,49 and manufacturing errors (e.g., metal shards, chemical or plastic contamination, lack of Vitamin C, and overdose of iron, insufficient iron and calcium and phosphorus, in 2006 and 2007 alone).

APHA RECOMMENDATIONS
As the nation’s oldest and largest public health organization, the APHA calls on health professionals, researchers, and political decisionmakers in the United States and globally to take the following steps:
1. Affirm that exclusive breastfeeding for 6 months with continued breastfeeding for at least the first 1 to 2 years of life, is the biologic norm and that all alternative feeding methods carry health risks in comparison, with rare exceptions.8,9
2. Recognize that breastfeeding is appropriately viewed as a public health issue12 and insist that maternal/child and comprehensive public health policies include attention to breastfeeding protection, education, promotion, and support, with particular attention to exclusive breastfeeding, early breastfeeding initiation, and disparities in breastfeeding rates.
3. Identify the exclusive breastfeeding rate as a leading health indicator in the goals for the nation and ensure the national collection of comprehensive, unbiased, accurate, consistent breastfeeding data, including data on breastfeeding initiation, duration, and exclusivity.9 (Leading health indicators in Healthy People 2010 reflect the major health concerns of our nation, have the ability to motivate action, have available data to track progress, and have relevance to broad public health issues.)
4. Insist on consistent, recognized, or both explicit definitions for patterns of breastfeeding within scientific publications and reports, including definitions of exclusive breastfeeding, full breastfeeding, mixed feeding, and complementary feeding.36,50–52
5. Require that any medical recommendation or intervention that may disrupt initiation of breastfeeding or interrupt breastfeeding be based on reliable evidence that also takes into consideration the risks of alternative feeding,9 including both short-term and long-term sequelae to mother and child.
6. Denounce aggressive marketing of human milk substitutes, particularly marketing in health care settings, and insist on compliance with the International Code of Marketing of Breast-milk Substitutes.9,10
7. Provide adequate funding for breastfeeding in both domestic and foreign aid programs, as well as adequate funding for basic and program research. Increased dedicated funding for breastfeeding support is needed by the National Institutes of Health, CDC, and The US Department of Agriculture, as well as for US Agency for International Development and in the United States support to United Nations agencies, especially UNICEF, WHO, and the United Nations High Commissioner for Refugees.10
8. Implement activities outlined in Innocenti Declaration 2005 to operationalize the 9 target areas of the WHO Global Strategy on Infant and Young Child feeding, as affirmed by all nations at the World Health Assembly, 2003 and 2005. 10
9. Join all developed and many developing countries in ratifying and implementing International Labor Organization conventions in support of at least 14 weeks of paid maternity leave.
10. Ratify the Stockholm Convention on Persistent Organic Pollutants51 and participate vigorously in its effort to identify and eliminate exposures to environmental contaminants that impact pregnant women and contaminate foods, including human milk (and human milk substitutes), as well as exercise caution in assessment of new persistent substances and potential toxins, and recognize the importance of monitoring contaminants in human milk as biomarkers. The US government should grant funding on the relative effects of contaminants on the health and development of nursing infants, in the context of the risks of alternative feeding, while taking into account the transfer of contaminants during pregnancy.
11. Support legislation and programs that enable women to succeed with breastfeeding in the United States, including protection for breastfeeding in public, paid maternity leave and worksite lactation protection, access to skilled lactation care and services covered by third-party payers, adequate funding to meet Healthy People 2010 goals across all socioeconomic sectors of the United States, adequate funding and support to carry out the recommendations from the HHS Blueprint for Action on Breastfeeding, compliance with ethical formula marketing as set forth in the International Code,9,11,12 direct breastfeeding support in any government program that deals with infant feeding and maternal health, and all programs that further the goals set by the WHO/UNICEF Global Strategy.
12. Incorporate all components of the Baby-friendly Hospital Initiative into the requirements of accreditation of all maternity services9,10 and include its community-based components in disaster planning, community programming, and outpatient clinical practices.

APHA also calls on political decisionmakers, domestically and globally, the US government, bilateral and multilateral agencies, other multilateral organizations and global financial institutions to provide adequate funding for breastfeeding support in development, emergency and economic aid to developing and less-developed countries.10

This policy updates and revises APHA policy number 82-26 and allows for the archiving of policies 79-92 and 82-16. It updates and revises breastfeeding aspects of APHA policy numbers 95-02 and 2005-5. This policy will serve as a guide for sections to archive other breastfeeding-related policies.

REFERENCES
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2. American Public Health Association. American Public Health Association Policy Statement 74-03. Breast Feeding. Washington, DC: American Public Health Association; 1974. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=745. Accessed December 10, 2007.
3. American Public Health Association. American Public Health Association Policy Statement81-26. Nestle Boycott. Washington, DC: American Public Health Association; 1981. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=998. Accessed December 10, 2007.
4. American Public Health Association. American Public Health Association Policy Statement 82-26. Breastfeeding. Washington, DC: American Public Health Association; 1982. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1030. Accessed December 10, 2007.
5. American Public Health Association. American Public Health Association Resolution Statement 79-22. Infant Feeding Advertising. In: APHA public policy statements, 1948–present, cumulative. Washington, DC: American Public Health Association; 1979. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=944. Accessed December 14, 2007.
6. American Academy of Family Physicians. Breastfeeding (Policy Statement). 2001. Available at: www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html. Accessed December 11, 2007.
7. American College of Obstetricians and Gynecologists. Breastfeeding. Washington, DC; 2003.
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10. Innocenti Declaration 2005. Florence, Italy: Innocenti Research Center; 2005.
11. Shealy K, Li R, Benton-Davis S, Grummer-Strawn L. The CDC Guide to Breastfeeding Interventions. Atlanta, GA: US Department of Health and Human Services, Center for Disease Control and Prevention; 2005.
12. US Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, DC: US Department of Health and Human Services, Office on Women’s Health; 2000.
13. Rutstein SO. Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. Int J Gynaecol Obstet. 2005;89(suppl 1):S7–S24.
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17. Centers for Disease Control and Prevention. Breastfeeding: Data and Statistics: Breastfeeding Practices—Results from the National Immunization Survey Among Children Born in 2004. September 6, 2007. Available at: www.cdc.gov/breastfeeding/data/NIS_data/data_2004.htm. Accessed January 3, 2008.
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20. DiGirolamo A, Grummer-Strawn L, Fein S. Maternity care practices: implications for breastfeeding. Birth. 2001;28:94–100.
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22. Baby-friendly USA. US Baby-friendly hospitals and birth centers as of May 2007. Available at: www.babyfriendlyusa.org/eng/03.html. Accessed December 11, 2007.
23. Labbok M. Updated 2006 UNICEF records on the Baby-friendly Hospital Initiative 2006. with permission of UNICEF.
24. Centers for Disease Control and Prevention. National Immunization Survey. Washington, DC: Department of Health and Human Services; 2005.
25. World Health Organization. International Code of Marketing of Breast-Milk Substitutes. Geneva, Switzerland: World Health Organization; 1981.
26. US Government Accountability Office Report to Congressional Addressees. Breastfeeding: Some Strategies Used to Market Infant Formula May Discourage Breastfeeding; State Contracts Should Better Protect Against Misuse of WIC Name. Washington, DC: US Governmental Accountability Office; 2006. GAO-06-282.
27. Kessler LA, Gielen AC, Diener-West M, Paige DM. The effect of a woman’s significant other on her breastfeeding decision. J Hum Lact. 1995;11:103–109.
28. Bentley ME, Caulfield LE, Gross SM, et al. Sources of influence on intention to breastfeed among African-American women at entry to WIC. J Hum Lact. 1999;15:27–34.
29. Humphreys AS, Thompson NJ, Miner KR. Intention to Breastfeed in Low-Income Pregnant Women: The Role of Social Support and Previous Experience. Birth. 1998;25:169–174.
30. American Public Health Association. American Public Health Policy Statement 95-02. Toward a Comprehensive, Universal Health Program; 1995. Washington, DC: American Public Health Association; 1982. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=97. Accessed December 14, 2007.
31. American Public Health Association. American Public Health Association Policy Statement 2005-5: Protecting Human Milk From Persistent Toxic Chemical Contaminants. Washington, DC: American Public Health Association; 2005. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1321. Accessed December 10, 2007.
32. Moreland J, Coombs J. Promoting and supporting breast-feeding. Am Fam Physician. 2000;61:2093–2100, 2103–2104.
33. American College of Nurse Midwives. Position Statement: Breastfeeding. Silver Spring, MD: American College of Nurse Midwives; 2004.
34. American Dietetic Association. Position of the American Dietetic Association: Promoting and Supporting Breastfeeding. Journal of the American Dietetic Association. 2005;105:810–818.
35. United Nations Office of the High Commissioner for Human Rights. Convention on the Rights of the Child. New York: United Nations; 1989.
36. European Commission. Protection. Promotion and Support of Breastfeeding in Europe: a Blueprint for Action. Dublin Castle, Ireland; 2006.
37. Jones G, Steketee R, Black R, Bhutta Z, Morris S. The Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet. 2003;362:65–71.
38. Bergmann KE, Bergmann RL, Von Kries R, et al. Early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding. Int J Obes Relat Metab Disord. 2003;27:162–172.
39. Grummer-Strawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics. 2004;113(2):e81–6.
40. Shields L, O’Callaghan M, Williams GM, Najman JM, Bor W. Breastfeeding and obesity at 14 years: a cohort study. J Paediatr Child Health. 2006;42:289–296.
41. American Academy of Pediatrics. American College of Obstetricians and Gynecologists. Breastfeeding Handbook for Physicians. Elk Grove Village, IL: American Academy of Pediatrics; 2005.
42. Becker S, Rutstein O, Labbok M. Estimation of births averted due to breastfeeding and increases in levels of contraception needed to substitute for breastfeeding. J Biosoc Sci. 2003;35:559–574.
43. Academy of Breastfeeding Medicine. Clinical Protocol #13: Contraception during breastfeeding. New Rochelle, New York: Academy of Breastfeeding Medicine; 2005.
44. The World Health Organization Task Force on Methods for the Natural Regulation of Fertility. The World Health Organization multinational study of breast-feeding and lactational amenorrhea II: Factors associated with length of amenorrhea. Fertil Steril. 1998;70:461–471.
45. Horta B, Bahl R, Martinex J, Victora C. Evidence on the Long-Term Effects of Breastfeeding: Systematic Reviews and Meta-Analyses. Geneva, Switzerland: World Health Organization; 2007.
46. World Health Organization. Consensus Statement: WHO HIV and Infant Feeding Technical Consultation. Geneva, Switzerland; 2006.
47. Berlin CM Jr, LaKind JS, Fenton SE, et al. Conclusions and recommendations of the expert panel: technical workshop on human milk surveillance and biomonitoring for environmental chemicals in the United States. J Toxicol Environ Health A. 2005;68:1825–1831.
48. Dorea JG. Maternal exposure to endocrine-active substances and breastfeeding. Am J Perinatol. 2006;23:305–312.
49. Jones TF, Ingram LA, Fullerton KE, et al. A case-control study of the epidemiology of sporadic salmonella infection in infants. Pediatrics. 2006;118:2380–2387.
50. World Health Organization. Report of Informal Meeting to Review and Develop Indicators for Complementary Feeding. Washington, DC: WHO; 2002.
51. World Health Organization. Indicators for Assessing Breastfeeding Practices. Geneva, Switzerland: WHO, Division of Diarrhea and Acute Respiratory Disease Control; 1991.
52. World Health Organization. The WHO global data bank on breastfeeding and complementary feeding. Available at: www.who.int/research/iycf/bfcf/bfcf.asp. Accessed December 11, 2007.