with adequate hygiene, as in Belarus (23) and Scotland (24). Other acute infections, including otitis media (25), Haemophilus influenzae meningitis (26), 1 When describing age ranges, a child 6–23 months has completed 6 months but has an age less than 2 years. Source: UNICEF. Progress for children: a world fit for children. Statistical Review, Number 6. New York, UNICEF, 2007. Figure 2 Trends in exclusive breastfeeding rates (1996–2006) 0 10 20 30 40 50 0 10 20 30 40 50 Percentage of infants exclusively breastfed for the first six months of life CEE/CIS Middle East/ North Africa Sub-Saharan Africa East Asia/Pacific (excluding China) South Asia Developing countries (excluding China) around 1996 around 2006 The importance of infant and young child feeding and recommended practices 5 and urinary tract infection (27), are less common and less severe in breastfed infants. Artificially-fed children have an increased risk of longterm diseases with an immunological basis, including asthma and other atopic conditions (28,29), type 1 diabetes (30), celiac disease (31), ulcerative colitis and Crohn disease (32). Artificial feeding is also associated with a greater risk of childhood leukaemia (33). Several studies suggest that obesity in later childhood and adolescence is less common among breastfed children, and that there is a dose response effect, with a longer duration of breastfeeding associated with a lower risk (34,35). The effect may be less clear in populations where some children are undernourished (36). A growing body of evidence links artificial feeding with risks to cardiovascular health, including increased blood pressure (37), altered blood cholesterol levels (38) and atherosclerosis in later adulthood (39). Regarding intelligence, a meta-analysis of 20 studies (40) showed scores of cognitive function on average 3.2 points higher among children who were breastfed compared with those who were formula fed. The difference was greater (by 5.18 points) among those children who were born with low birth weight. Increased duration of breastfeeding has been associated with greater intelligence in late childhood (41) and adulthood (42), which may affect the individual’s ability to contribute to society. For the mother, breastfeeding also has both short- and long-term benefits. The risk of postpartum haemorrhage may be reduced by breastfeeding immediately after delivery (43), and there is increasing evidence that the risk of breast (44) and ovarian (45) cancer is less among women who breastfed. Exclusive breastfeeding for 6 months The advantages of exclusive breastfeeding compared to partial breastfeeding were recognised in 1984, when a review of available studies found that the risk of death from diarrhoea of partially breastfed infants 0–6 months of age was 8.6 times the risk for exclusively breastfed children. For those who received no breast milk the risk was 25 times that of those who were exclusively breastfed (46). A study in Brazil in 1987 found that compared with exclusive breastfeeding, partial breastfeeding was associated with 4.2 times the risk of death, while no breastfeeding had 14.2 times the risk (47). More recently, a study in Dhaka, Bangladesh found that deaths from diarrhoea and pneumonia could be reduced by one third if infants were exclusively instead of partially breastfed for the first 4 months of life (48). Exclusive breastfeeding for 6 months has been found to reduce the risk of diarrhoea (49) and respiratory illness (50) compared with exclusive breastfeeding for 3 and 4 months respectively. If the breastfeeding technique is satisfactory, exclusive breastfeeding for the first 6 months of life meets the energy and nutrient needs of the vast majority of infants (51). No other foods or fluids are necessary. Several studies have shown that healthy infants do not need additional water during the first 6 months if they are exclusively breastfed, even in a hot climate. Breast milk itself is 88% water, and is enough to satisfy a baby’s thirst (52). Extra fluids displace breast milk, and do not increase overall intake (53). However, water and teas are commonly given to infants, often starting in the first week of life. This practice has been associated with a two-fold increased risk of diarrhoea (54). For the mother, exclusive breastfeeding can delay the return of fertility (55), and accelerate recovery of pre-pregnancy weight (56). Mothers who breastfeed exclusively and frequently have less than a 2% risk of becoming pregnant in the first 6 months postpartum, provided that they still have amenorrhoea (see Session 8.4.1). Complementary feeding from 6 months From the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary feeding becomes necessary to fill the energy and nutrient gap (57). If complementary foods are not introduced at this age or if they are given inappropriately, an infant’s growth may falter. In many countries, the period of complementary feeding from 6–23 months is the time of peak incidence of growth faltering, micronutrient deficiencies and infectious illnesses (58). Even after complementary foods have been introduced, breastfeeding remains a critical source of nutrients for the young infant and child. It provides about one half of an infant’s energy needs up to the age of one year, and up to one third during the second year of life. Breast milk continues to supply higher quality nutrients than complementary foods, and also protective factors. It is therefore recommended that breastfeeding on demand continues with adequate complementary feeding up to 2 years or beyond (13). Complementary foods need to be nutritionallyadequate, safe, and appropriately fed in order to meet 6 Infant and Young Child Feeding – Model Chapter for textbooks the young child’s energy and nutrient needs. However, complementary feeding is often fraught with problems, with foods being too dilute, not fed often enough or in too small amounts, or replacing breast milk while being of an inferior quality. Both food and feeding practices influence the quality of complementary feeding, and mothers and families need support to