PHILIPPINE PEDIATRIC SOCIETY, INC.

A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2004 Vol. 1 No. 1

B reastfeeding
Philippine Pediatric Society, Inc. Philippine Society of Pediatric Gastroenterology and Nutrition, Inc.

Exclusive breastfeeding is ideal during the first 6 months of life. After this period, the introduction of complementary foods as well as continued breastfeeding is recommended until at least 1 year, and preferably beyond. It supports optimal growth and development as well as protects the baby from several acute and chronic diseases. Contraindications to breastfeeding are rare and few. Several benefits of breastfeeding have also been demonstrated among mothers, parents, employers, insurers and the country. Global attempts to encourage, promote and support breastfeeding through the WHO/UNICEFs Baby Friendly Hospital Initiative have been successfully implemented in 171 countries worldwide with good results. The Philippines supported this effort by passing Republic Act (RA) 7600, also known as The Rooming-In and Breastfeeding Act of 1992 in Congress. This policy summarizes appropriate recommendations to further encourage, promote and support the practice of breastfeeding in the country. KEYWORDS: breastfeeding, formula-feeding, baby-friendly hospital URL: http://www.pps.org.ph/policy_statements/breastfeeding.pdf

BACKGROUND Breast milk or human milk provides the ideal nutrition to support the optimal growth and development of infants.1,2 Exclusive breastfeeding is ideal during the first 6 months of life. After this period, the introduction of complementary foods as well as continued breastfeeding is recommended until at least 1 year, and preferably beyond. Breast milk is nutritionally complete, supplying essential amino acids for growth and providing protective factors. Breastfeeding has a number of advantages, which have been extensively documented. First and foremost, breast milk has been known to boost the infants host defense. The bioactive components in breast milk, which are not found in infant formula, include lysozymes, immunoglobulins, hormone and growth factors, immune function modulators, antiinflammatory and cellular components that protect the infant from infection.1,3 The practice of breastfeeding has been shown to aid in the gastrointestinal function of infants. With the use of breast milk, feeding-related problems such as constipation1, diarrhea1,3-7 and colic1 are minimized. Breastfeeding has also been shown to be protective against several diseases. It reduces the prevalence and subsequent morbidity of respiratory illness and infection in infancy. 3,4,6,8 It is also associated with a reduction in upper respiratory symptoms among premature infants during their first year of life.9 Several studies show strong evidence that breastfeeding protects the infant from
finalized April 2004

urinary tract infections,3,5,6,10 otitis media,3,6,11,12 bacteremia, 3,6 bacterial meningitis,6 botulism,6 and necrotizing enterocolitis.3,5,6 A lowered risk for sudden infant death syndrome (SIDS)13 and insulin-dependent diabetes mellitus (IDDM)14 were also reported among infants who are breastfed. Breastfeeding also affords psychological benefits to both the mother and the infant. It facilitates maternal-infant bonding and improves long-term cognitive1 and motor abilities1, 15 in term infants especially with prolonged breastfeeding. Breastfeeding confers several other advantages and benefits to the mother. It promotes better postpartum uterine involution and provides emotional satisfaction from the maternal-infant bonding.1 Several studies show a reduction in the risk of developing breast1, 16-18 and endometrial cancers19 among women who have breastfed. Breastfeeding for at least 6 months also enhances maternal weight loss postpartum 15,20 and results in lactational amenorrhea as a form of contraception.15,21 Another benefit derived from the practice of breastfeeding is the potential savings from the significant reduction in health care costs. 2,22 This proves that the medical and economic value of breastfeeding is high as it offers cost savings for parents, insurers, employers and the society. 23 In particular, breastfeeding offers food expenditure savings for the family compared to the costly use of infant formulas.1 A study revealed that an estimated cost of using breast milk substitute in the Philippines is $16 million.24 Employers can benefit from reduced employee

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Breastfeeding

absenteeism for care attributable to child sickness, lower health care costs, and improved employee productivity.25 It also serves as a means of saving the country valuable foreign exchange that may otherwise be used for milk importation. 26 It is not enough that the benefits of breastfeeding be identified and emphasized. It is also important to note the concurrent risks associated with not breastfeeding. Yoon et al studied the effect of not breastfeeding on the risk of diarrheal and respiratory mortality in children below 2 years old in Cebu. They found that failing to initiate breastfeeding or ceasing to breastfeed in the first 6 months of life resulted in an 8- to 10-fold increase in the rate of diarrheal mortality. Furthermore, the rate of mortality associated with both diarrhea and acute lower respiratory infection was increased nearly six times by not breastfeeding.27 Bottle-feeding or formula-feeding has also been associated with increased risk of several diseases. This was presented in an epidemiological review made by Cunningham et al. Before World War II, a marked increase in respiratory deaths among bottle-fed infants was repeatedly documented in Western Europe and North America. In the 1970s, a fivefold excess of lower respiratory infections in bottle-fed infants from a middleclass population was observed. Hospitalization for respiratory infections has also been repeatedly shown to be more frequent in bottle-fed infants. Bottle feeding was also shown to increase the risk of otitis media, and H. influenzae bacteremia and meningitis.28 The risk of death from diarrhea in bottle-fed infants may be 20 times that of breastfed infants and bottle feeding also increases the risk that the infant will not receive adequate stimulation and attention during feeds.29 Another important concern that must be addressed is the fact that there are special instances wherein the practice of breastfeeding is not recommended. Contraindications to breastfeeding are few compared to the benefits that can be gained from its practice. Among the contraindications to breastfeeding are: galactosemia in the infant,30 and maternal use of illegal drugs, anti-neoplastic agents and radiopharmaceuticals.1 Active tuberculosis infection is a relative contraindication, with breastfeeding being allowed after observed treatment with antiKochs therapy for 2 weeks. During the two weeks of treatment, breast milk can still be given to the infant by cup or dropper. The breast milk should be expressed in a strictly aseptic manner and given to the infant by a caregiver other than the mother. Maternal HIV infection is another relative contraindication to breastfeeding. While giving appropriate breast milk substitutes is usually recommended, HIV-positive mothers may still opt to give their infants expressed and heat-treated breast milk. Heat treatment of expressed breast milk from an HIV-positive mother has been proven to be effective in killing the virus.29 There are some instances, however, when breastfeeding is preferred even if the mother is HIV-positive. A policy statement developed by UNAIDS, WHO and UNICEF states, When children born to women living with HIV can be ensured uninterrupted access to

nutritionally adequate breast-milk substitutes that are safely prepared and fed to them, they are at less risk of illness and death if they are not breastfed. However, when these conditions are not fulfilled, in particular in an environment where infectious diseases and malnutrition are the primary causes of death during infancy, artificial breast milk substitutes substantially increase childrens risk of illness and death.31 A study by Coutsoudis showed that exclusive breastfeeding of infants for 3 months or more had no excess risk of HIV infection over 6 months than those never breastfed. Mixed breastfeeders, on the other hand, had higher cumulative probabilities of HIV detection by 6 months.32 As a means to promote and reiterate the importance of breastfeeding, the WHO/UNICEF launched a ten-step program called The Baby-Friendly Hospital Initiative in 1992. The program focuses primarily on the health of both mother and infant. It advocates that every facility that provides maternity services and care for newborns should; (1) have a written breastfeeding policy that is routinely communicated to all health care staff, (2) train all health care staff in skills necessary to implement this policy, (3) inform all pregnant women about the benefits and management of breastfeeding, (4) help mothers initiate breastfeeding within half an hour of birth, (5) show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants, (6) give newborn infants no food or drink other than breast milk, unless medically indicated, (7) practice rooming-in - that is, allow mothers and infants to remain together -24 hours a day, (8) encourage breastfeeding on demand, (9) give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants, and (10) foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. 1,3,15,33 The program has been successfully launched in 171 countries all around the world, transforming over 14,500 hospitals in 125 countries in less than one decade. 15 In a single baby-friendly facility in Panama, the Ministry of Health reported a 58% reduction in respiratory infections and 15% reduction in cases of neonatal diarrhea among infants in just one year. A hospital in Northeastern Brazil reported dramatic cost savings from decreased hospitalization of infants upon implementing the Baby-Friendly Hospital Initiative. Similar results are seen even in developing countries in Asia and Latin America.34 The importance of breastfeeding was also addressed at the 1989 UN Convention on the Rights of the Child. Article 24 states, States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health.States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures:(e)to ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation..35

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PPS Policy Statement

The Philippines adopted the practice of rooming-in as a national policy to encourage, protect and support the practice of breastfeeding. In 1992, Republic Act (RA) No. 7600 known as The Rooming-In and Breastfeeding Act of 1992 was approved by the Philippine Congress.26,36 It stresses the distinct advantages of breastfeeding which will benefit not only the baby and the mother but also the hospital and the country. 26 The State of the Worlds Children 2003 shows that in the Philippines, only 37% of children less than 6 months are exclusively breastfed.37 This underscores the need for increased promotion of breastfeeding.

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RECOMMENDATIONS 6. Role of Parents 7. 1. Breast milk is the ideal food for infants. Exclusive breastfeeding of infants from birth to six months is highly encouraged and should continue, with the addition of solid foods, for at least 24 months. No food or drink other than breast milk, unless medically indicated, should be given to infants. Should the mother and the infant be separated from each other, every effort should be pursued in order to continuously provide the infant with breast milk, either thru direct breastfeeding or thru the mothers expressed milk. Mothers should assert their right to breastfeed and actively seek information on the benefits of breastfeeding and the proper way to breastfeed. They are encouraged to talk to relatives and friends who have previous experiences with breastfeeding and to ask their doctor for advice. Referral to a breastfeeding support group may be requested from their doctors. The decision to breastfeed or not to breastfeed must be an informed one. Fathers should also seek proper information on breastfeeding and encourage their wives to breastfeed. Fathers should offer support through proper nutrition, freedom from illness, worry, and stress. Fathers should even offer taking on some chores done by the breastfeeding mother to facilitate breastfeeding.

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appropriate counseling from pediatricians and should be provided with relevant and current information on the benefits and methods of breastfeeding their babies. Physicians should encourage family and societal support of breastfeeding. They should educate the parents on how to optimize benefits derived from breastfeeding and explain the roles that each parent should fulfill in order to maintain breastfeeding of the infant. Physicians should also carefully assess whether there is a medical contraindication to breastfeeding. The benefits of breastfeeding should be weighed against the risks of not giving the infant breast milk. Physicians should encourage mothers to breastfeed on demand. Before hospital or clinic discharge, physicians should observe actual breastfeeding to assess proper technique, offer advice to improve breastfeeding and solve problems encountered. Physicians should refer mothers to breastfeeding support groups to ensure the health of the lactating mother. Physicians should follow up early by phone or ask for early home or office visitation and return visit after discharge to note for other problems and to reinforce breastfeeding.

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Role of Hospital Administrators 1. Hospitals and medical institutions providing maternal medical care should strictly enforce policies and procedures to facilitate the practice of breastfeeding. There should be strict compliance with the rules and regulations in Republic Act 7600. They should ensure that this policy is routinely communicated to all health care staff. They should also initiate and support the training of all health care staff in the skills necessary to implement this policy. It is encouraged that hospitals create Maternal and Child Health Committees whose primary function is to monitor the violations of the provisions of RA 7600. Hospitals are encouraged to create and maintain dedicated lactation support groups to teach the art and science of breastfeeding. Mothers who are unable to comply with the breastfeeding act should be referred to these support groups for education/reeducation. Hospitals should work towards the elimination of activities that put barriers against the practice of breastfeeding (e.g. distribution of free infant formulas to mothers during hospital confinement, seminars or mothers classes conducted by milk companies). By the same token, incentives for mothers who decide to breastfeed may be provided.

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Role of Physicians 1. Promotion of breastfeeding should start during the mothers pregnancy. Prenatal, perinatal, and even postnatal visits to obstetricians should be a venue for informing mothers the importance of breastfeeding. Obstetricians should also give the mothers clear instructions on how to breastfeed and how to maintain lactation even if they are separated from their infants. During the hospital stay, parents should also receive

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PPS Policy Statement

Breastfeeding PPS Committee on Nutrition Randy Urtula, MD PPS Section on Neonatology Gloria Ramirez, MD Amelia Fernandez, MD Sheila Ann Masangkay, MD Ma. Asuncion Silvestre, MD Ma. Luisa Manlapaz, MD PPS Committee on the Promotion of Breastfeeding Mary Jean Guno, MD

5. Hospitals should develop a well-articulated community-based program in their catchment area that utilizes a combination of counseling strategies, educational materials (posters and print materials), mass media, and community-based activities to promote breastfeeding at the grassroots level. Role of the Government 1. The Department of Health together with other government agencies, professional and nongovernment organizations, and the media should enforce the dissemination of information, the education and training of physicians, nurses, midwives, nutritionists, dietitians, community health workers and traditional birth attendants (TBAs) and other health personnel on current and updated lactation management. 2. Legislators and policymakers should strictly enforce laws that promote, protect, and support breastfeeding. 3. The media should be directed to take an active role in promoting and supporting breastfeeding practices. In advertisements for infant formula, there should always be a reminder regarding the benefits of breastfeeding. Advertisements should also include the risks of formula feeding so as to provide mothers with the necessary information in order to make an informed choice regarding breastfeeding. 4. The Department of Health and the Department of Interior and Local Government should organize and maintain lactation support groups in the communities to ensure the sustenance of exclusive breastfeeding of infants. 5. Advertisements for milk formulas should first pass an Advertising Board created by the Department of Health under the Maternal and Child Health Committee in order to screen and approve contents of the milk before these advertisements are aired.
Document prepared by Committee on Policy Statements Chairperson: Carmencita David-Padilla, MD Co-chairpersons: Aurora Bauzon, MD; Irma Makalinao, MD Members: Cynthia Cuayo-Juico, MD; Nerissa Dando, MD Health Policy Consultant: Marilyn Lorenzo, RN, DRPH Adviser: Joel Elises, MD Council on Community Service and Child Advocacy Directors: Genesis Rivera, MD; Noreen Chua, MD; Alejandro Menardo, MD; May Montellano, MD Research Associates: Vicente Jose Velez, Jr., MD; Maria Giselle Velez, MD; Debbierey Bongar, MD; Aizel de la Paz, MD; Lady Christine Ong Sio, MD PANEL OF EXPERT REVIEWERS Philippine Society of Pediatric Gastroenterology and Nutrition,Inc.

ACKNOWLEDGEMENTS The Committee on Policy Statements recognizes the contribution of the following: PPS Advisory Board PPS Council on Administrative Affairs PPS Council on Community Service and Child Advocacy PPS Council on Research and Publications PPS Council on Subspecialties and Sections PPS Council on Training and Continuing Pediatric Education PPS Bicol Chapter PPS Cebu Central / Eastern Visayas Chapter PPS Central Luzon Chapter PPS North Central Mindanao Chapter PPS Northeastern Luzon Chapter PPS Northern Luzon Chapter PPS Southern Tagalog Chapter PPS Committee on Nutrition PPS Committee on the Promotion of Breastfeeding PPS Section on Neonatology Child Neurology Society of the Philippines, Inc. Pediatric Infectious Disease Society of the Philippines, Inc. Philippine Academy of Pediatric Pulmonologists, Inc. Philippine Society for Developmental and Behavioral Pediatrics,Inc. Philippine Society of Allergy, Asthma, and Immunology, Inc. Philippine Society of Pediatric Gastroenterology and Nutrition,Inc. Philippine Society of Pediatric Metabolism and Endocrinology, Inc. Philippine Society of Pediatric Oncology, Inc. Philippine Society of Pediatric Surgeons, Inc. Department of Health-Child Health Program Department of Health-Health Policy Development and Planning Bureau

REFERENCES 1. Cabrera R. Nutrition. In: Michael Manalaysay, Rosa Cabrera, Honorio dela Cruz, Pelagio Iriarte (Eds). Pediatrics in General Practice. DCT Workshop, Inc., 1st Ed, 2003; pp 63-7. 2. The Importance of Breastfeeding and Breastfeeding Support. Oregon Department of Human Services (Child and Family Health). Available at http:// www.ohd.hr.state.or.us/bf/index.cfm. Accessed on

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PPS Policy Statement

September 4, 2003. 3. Hanson LA. Breastfeeding provides passive and likely long-lasting active immunity. Ann Allergy Asthma Immunol. 1998 Dec; 81(6):523-33. 4. Arifeen S, Black RE, Antelman G, Baqui A, Caulfield L, Becker S. Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among children in Dhaka slums. Pediatrics. 2001 Oct; 108(4):E67. 5. Wold AE, Adlerberth I. Breast feeding and the intestinal microflora of the infant - implications for protection against infectious diseases. Adv Exp Med Biol. 2000;478:77-93. 6. Hanson LA. Human milk and host defense: immediate and long-term effects. Acta Paediatr. Suppl. 1999 Aug; 88(430):42-6. 7. Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK, Infant Feeding Study group. Effect of community-based promotion of exclusive breastfeeding on diarrheal illness and growth: a cluster randomizedcontrolled trial. Lancet. 2003 Apr 26; 361(9367):1418-23. 8. Oddy WH, Sly PD, de Klerk NH, Landau LI, Kendall GE, Holt PG, Stanley FJ. Breastfeeding and respiratory morbidity in infancy: a birth cohort study. Arch Dis Child. 2003 Mar; 88(3):224-8. 9. Blaymore Bier JA, Oliver T, Ferguson A, Vohr BR. Human milk reduces outpatient upper respiratory symptoms in premature infants during their first year of life. J Perinatol. 2002 Jul-Aug; 22(5):354-9. 10. Pisacane A, Graziano L, Mazzarella G, Scarpellino B, Zona G. Breast-feeding and urinary tract infection. J Pediatr. 1992 Jan; 120(1):87-9. 11. Duffy LC, Faden H, Wasielewski R, Wolf J, Krystofik D. Exclusive breastfeeding protects against colonization and day care exposure to otitis media. Pediatrics. 1997 Oct; 100(4):E7. 12. Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM. Exclusive breast-feeding for at least 4 months protects against otitis media. Pediatrics. 1993 May; 91(5):867-72. 13. Ford RP, Taylor BJ, Mitchell EA, Enright SA, Stewart AW, Becroft DM, Scragg R, Hassall IB, Barry DM, Allen EM, et al. Breastfeeding and the risk of sudden infant death syndrome. Int J Epidemiol. 1993 Oct; 22(5):885-90. 14. Mayer EJ, Hamman RF, Gay EC, Lezotte DC, Savitz DA, Klingensmith GJ. Reduced risk of IDDM among breastfed children. The Colorado IDDM Registry. Diabetes 1998 Dec; 37(12);1625-32. 15. Dewey KG, Cohen RJ, Brown KH, Rivera LL. Effects of exclusive breastfeeding for four versus six months on maternal nutritional status and infant motor development: results of two randomized trials in Honduras. J Nutr. 2001 Feb; 131(2): 262-7. 16. Newcomb PA. Lactation and breast cancer risk. J Mammary Gland Biol Neoplasia. 1997 Jul; 2(3):311-8.

17. Newcomb PA, Egan KM, Titus-Ernstoff L, TrenthamDietz A, Greenberg ER, Baron JA, Willett WC, Stampfer MJ. Lactation in relation to postmenopausal breast cancer. Am J Epidemiol. 1999 Jul 15; 150(2):174-82. 18. Newcomb PA, Storer BE, Longnecker MP, Mittendorf R, Greenberg ER, Clapp RW, Burke KP, Willett WC, MacMahon B. Lactation and a reduced risk of premenopausal breast cancer. N Engl J Med. 1994 Jan 13; 330(2):81-7. 19. Newcomb PA, Trentham-Dietz A. Breastfeeding practices in relation to endometrial cancer risk, USA. Cancer Causes Control. 2000 Aug; 11(7):663-7. 20. Dewey KG, Heinig MJ, Nommsen LA. Maternal weightloss patterns during prolonged lactation. Am J Clin Nutr. 1993 Aug; 58(2):162-6. 21. Ramos R, Kennedy KI, Visness CM. Effectiveness of lactational amenorrhea in prevention of pregnancy in Manila, Philippines: non-comparative prospective trail. BMJ. 1996 Oct 12; 313(7062):909-12. 22. Ball TM, Wright AL. Health care costs of formula-feeding in the first-year of life. Pediatrics. 1999 Apr; 103(4 Pt 2):970-6. 23. Ball TM, Bennett DM. The economic impact of breastfeeding. Pediatr Clin North Am. 2001 Feb; 48(1):253-62. 24. Levine RE, Huffman SL. The economic value of breastfeeding, the national, public sector, hospital and household levels: a review of the literature. Center to Prevent Childhood Malnutrition. Washington, DC. 1990. 25. Workplace Breastfeeding Support. United States Breastfeeding Committee. Available at http:// www.usbreastfeeding.org/Issue-Papers/Workplace.pdf. Accessed on September 4, 2003. 26. Republic Act No. 7600. An Act providing incentives to all government and private health institutions with rooming-in and breastfeeding practices and for other purposes. Available at http://www.chanrobles.com/ republicactno7600.htm. Accessed on September 4, 2003. 27. Yoon PW, Black RE, Moulton LH, Becker S. Effect of not breastfeeding on the risk of diarrheal and respiratory mortality in children under 2 years of age in Metro Cebu, the Philippines. Am J Epidemiol. 1996 Jun 1; 143(11): 1142-8. 28. Cunningham AS, Jelliffe DB, Jelliffe EFP. Breast-feeding and health in the 1980s: a global epidemiologic review. J Pediatr. 1991; 118(5):659-66. 29. WHO; Joint United Nations Program on HIV/AIDS (UNAIDS); United Nations International Childrens Emergency Fund (UNICEF). HIV and infant feeding: a guide for health care managers and supervisors.. Geneva: WHO; UNAIDS; UNICEF; 1998v. Available at http:// w h q l i b d o c . w h o . i n t / h q / 1 9 9 8 / WHO_FRH_NUT_CHD_98.2.pdf Accessed on February 18, 2004. 30. dela Cruz K, Santos-Velez G, Yaplito-Lee J. Galactosemia. In: CD Padilla, EM Cutiongco, CF Domingo (Eds).

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Inherited disorders of metabolism in the newborn: a guide for primary physicians. UP Manila Office of Research, 2001; 39-52. 31. WHO; Joint United Nations Program on HIV/AIDS (UNAIDS); United Nations International Childrens Emergency Fund (UNICEF). HIV and infant feeding: guidelines for decision makers. Geneva: WHO; UNAIDS; UNICEF; 1998. Available at: http://whqlibdoc.who.int/ hq/1998/WHO_FRH_NUT_CHD_98.1.pdf Accessed on February 18, 2004. 32. Coutsoudis A, Pillay K, Kuhn L et al. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS. 2001;15:379-87. 33.WHO/UNICEF Baby-Friendly Hospital Initiative. Available at http://www.cdc.gov/breastfeeding/ compend-babyfriendlywho.htm. Accessed on September

11, 2003. 34. Protecting, promoting and supporting breastfeeding. The State of the Worlds Children 1998 (Focus on Nutrition). Available at http://www.unicef.org/sowc98/ approach3.htm. Accessed on September 11. 2003. 35. Office of the United Nations High Commissioner for Human Rights. Convention on the Rights of the Child. Geneva, Switzerland: November 1989. Available at: http:/ /www.unhchr.ch/html/menu3/b/k2crc.htm Accessed on February 20, 2004. 36. Food and nutrition: Philippines is pro-breastfeeding. The Food and Nutrition Research Institute, Department of Science and Technology. Available at: http:// www.dost.gov.ph/media/article.php?sid=251. Accessed on September 4, 2003. 37. UNICEF. Statistical Tables. The State of the Worlds Children 2003. Available at: http://www.unicef.org/ sowc03/contents/pdf/tables.pdf Accessed on February 20, 2004.

The publication of the Policy Statements of the Philippine Pediatric Society, Inc. is part of an advocacy for the provision of quality health care to children. The recommendations contained in this publication do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the creation of additional policies. Furthermore, information contained in the policies is not intended to be used as a substitute for the medical care and advice of physicians. Nuances and pecularities in individual cases or particular communities may entail differences in the specific approach. All information is based on the current state of knowledge. Changes may be made in this publication at any time.
The activities of the Committee on Policy Statements were partly supported by educational grants from Dumex, Mead Johnson, and Nestle.