Matern Child Health J DOI 10.1007/s10995-015-1793-z
COMMENTARY
Breastfeeding Support and Messaging: A Call to Integrate Public Health and Psychological Perspectives Rachel Vanderkruik1 • Elizabeth Lemon1 • Sona Dimidjian1
Ó Springer Science+Business Media New York 2015
Abstract Introduction Appropriate attention to maternal mental health is missing in many public health breastfeeding promotion efforts. Although there are many benefits to breastfeeding for both mom and infant, the relationship between maternal mental health and breastfeeding is complex. Breastfeeding may not be the most effective or feasible option for all mothers. Methods We highlight a key international breastfeeding promotion program and argue that consideration for maternal mental health could be further incorporated into the initiative. We provide examples of how this could be done and also state that further guidance on the best alternative feeding practices to ensure the healthy development of infants is needed. Results and Conclusion There is an opportunity to enhance public health breastfeeding initiatives by integrating a perinatal mental health perspective into their guidelines and accompanying resources. Keywords Breastfeeding Depression Postpartum depression Public health initiatives
& Rachel Vanderkruik [email protected]; https://www.cucrest.com Elizabeth Lemon [email protected]; https://www.cucrest.com Sona Dimidjian [email protected] 1
Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO 80309, USA
Significance This commentary makes the case for integrating public health and psychological perspectives around breastfeeding promotion and messaging efforts and provides specific examples of how this can be accomplished. The recent publication by Borra et al. [4] entitled, ‘‘New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions’’ points to a critical gap in public health breastfeeding promotion efforts—appropriate attention to maternal mental health. The authors found that risk of postpartum depression (PPD) was lowest among women who had planned to and did indeed breastfeed their babies; however, women who planned to but did not go on to breastfeed their babies were at greatest risk of PPD [4]. These findings emphasize that the commonly held belief that breastfeeding is protective against PPD is not as simple as often is communicated. There is substantial evidence showing the many physical health benefits of breastfeeding for both the baby (e.g. lower risk of type 2 diabetes [15], severe lower respiratory tract infection [10] and the mother (e.g. lower risk of breast [8] and ovarian cancer [10]). Given such well documented health benefits, the World Health Organization (WHO) recommends that infants should be exclusively breastfed for the first 6 months of life followed by complementary foods while continuing breastfeeding for up to 2 years [25]. A key initiative resulting from this WHO recommendation is the Baby-Friendly Hospital Initiative (BFHI), an international program that recognizes hospitals that provide an ideal level of care for mother and baby bonding and for infant feeding practices. BFHI acknowledges hospitals that successfully implement the Ten Steps to Successful Breastfeeding [17] and the International Code of Marketing
123
Matern Child Health J
of Breast-milk Substitutes [24]. The BFHI provides guidance on how hospitals can offer all new mothers the information, confidence, and skills necessary to successfully initiate and continue breastfeeding their babies [23]. This program has motivated hospitals in the US and around the world to reform their perinatal care practices in order to educate and best support a woman with breastfeeding while in the hospital and after discharge. BFHI thus addresses the issue of intent raised in Borra et al. [4] by inspiring hospitals to promote and support a woman’s choice to breastfeed as effectively as possible. However, it falls short in another regard; it does not address the complex relationship between breastfeeding and maternal mental health. Mental health problems, including but not limited to depression, are among the most common complications of pregnancy and the postpartum [6] with up to 16 % of women experiencing depression during the postpartum [3]. Perinatal depression has been associated with increased risk for negative fetal and neonatal outcomes [2] as well as developmental or behavioral problems in children [5, 9]. Depressed women often are less likely to begin breastfeeding or are more likely to quit [11], and some women believe they cannot breastfeed if taking a psychotropic medication, even though many are safe to use while nursing [18]. Recommendations regarding the safety of breastfeeding while taking various psychotropic medications can be complicated [21] and may be confusing or overwhelming to mothers as well as many healthcare professionals. Research has suggested that breastfeeding is protective of PPD [13], that breastfeeding is associated with an increased risk of depression [1], that there is no relationship between breastfeeding and PPD risk [7], or that the relationship is mediated by other factors like mother’s intention [4], breastfeeding duration [16], or parity [20]. These inconsistent findings indicate a need for research to further explore the relationship between breastfeeding and depression (as well as other perinatal mental health issues), and to identify additional potential mediating factors that can inform recommendations around infant feeding practices for the context of every mother-baby dyad. Given the prevalence and risk of adverse consequences from PPD, there is an important need to integrate appropriate guidance and consideration for maternal mental health and suitable treatments into public health initiatives related to breastfeeding. Furthermore, breastfeeding might not be the most effective or feasible option for all mothers. There has been recent attention in mainstream media and in the scientific community on the high levels of guilt that women can feel if they choose not to, or cannot, breastfeed [14, 22]. Some women who seek professional support for breastfeeding difficulties have reported their experience with healthcare
123
professionals to be negative, judgmental, or characterized by conflicting advice [19]. Research also has demonstrated a need for improved support and guidance for moms who bottle feed [12]. Further guidance on the best alternative feeding practices (e.g. bottle feeding) to ensure the healthy development of infants should be communicated along with promotion of breastfeeding. This information could aide with preventing feelings of guilt if a woman does not breastfeed. Public health messaging and initiatives around breastfeeding should be sensitive to the psychological aspects of new motherhood, mental health treatments, and infant feeding demands. Currently, the BFHI guidelines and Ten Steps do not address perinatal mental health. They provide no guidance on how to manage or provide counseling on breastfeeding practices in the context of PPD or other mental health concerns. Given the strongly established and respected nature of the BFHI, this international initiative would be an ideal platform to disseminate such critical information. While addressing mental health issues may exceed the currently defined scope of the BFHI, this initiative is uniquely positioned to positively influence the public and professional dialogue around breastfeeding and increase sensitivity to, and comfort around, relevant maternal psychological issues. For example, BFHI Step 1 could suggest that preliminary assessment of perinatal mental health and psychological concerns be incorporated into the required breastfeeding policy. BFHI Step 2, focused on training for healthcare staff, could include information about how mental health considerations might influence infant feeding options and specify how to discuss mental health issues with respect to breastfeeding practices as well as alternative infant feeding options in a nonjudgmental manner that minimizes maternal feelings of guilt. BFHI Step 3, which aims to educate women about the benefits and management of breastfeeding, could include guidance on breastfeeding in the context of treatment for PPD, including informing women that nursing on certain psychotropic medications is safe, or on alternative infant-feeding methods when appropriate. BFHI Step 10 could require inclusion of resources for services and support groups for women who bottle-feed or experience depressive symptoms while breastfeeding following discharge from the hospital. Efforts to promote and support breastfeeding practices should continue and be expanded to reach more women across all demographics and geographic areas. However, there is an opportunity to enhance these public health initiatives by integrating perinatal mental health concerns and a psychological perspective into their guidelines and accompanying resources. BFHI is one program that could implement this action with a significant and far-reaching impact. Moving forward, breastfeeding-related initiatives
Matern Child Health J
should educate women early in pregnancy not only about the benefits of breastfeeding but also about alternative infant feeding practices, help women make an informed decision about which practice is contextually best for her and her baby, provide systems-level and psychological support needed for women to carry-through on their intentions, and foster a sense of compassion and respect for every woman’s decision.
11. 12.
13.
14.
References 15. 1. Alder, E., & Bancroft, J. (1988). The relationship between breastfeeding persistence, sexuality and mood in postpartum women. Psychological Medicine, 18, 389–396. 2. Alder, J., Fink, N., Bitzer, J., Hosli, I., & Holzgreve, W. (2007). Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. The Journal of Maternal-Fetal and Neonatal Medicine, 20(3), 189–209. 3. American Psychological Association. (2007). Postpartum depression [Fact sheet]. http://www.apa.org/pi/women/programs/ depression/postpartum.aspx. Accessed 11 Jan 2014. 4. Borra, C., Iacovou, M., & Sevilla, A. (2014). New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health Journal,. doi:10.1007/s10995-014-1591-z. 5. Center on the Developing Child at Harvard University. (2009). Maternal depression can undermine the development of young children: Working paper no. 8. http://www.developingchild.har vard.edu. 6. Centers for Disease Control (CDC)—Pregnancy Complications; Reproductive Health. Retrieved January 22, 2014 from: http:// www.cdc.gov/reproductivehealth/maternalinfanthealth/pregcom plications.htm. 7. Chaundron, L. H., Klein, M. H., Remington, P., Palta, M., Allen, C., & Essex, M. J. (2001). Predictors, prodromes and incidence of postpartum depression. Journal of Psychosomatic Obstetrics and Gynaecology, 22, 103–112. 8. Collaborative Group on Hormonal Factors in Breast Cancer. (2002). Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50,302 women with breast cancer and 96,973 women without the disease. Lancet, 360, 187–195. 9. Field, T., Diego, M., & Hernandez-Reif, M. (2006). Prenatal depression effects on the fetus and newborn: A review. Infant Behav Dev., 29, 445–455. 10. Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., & DeVine D, et al. (2007). Breastfeeding and maternal and infant health outcomes in developed countries: Evidence report/technology
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Assessment No. 153. Agency for Healthcare Research and Quality. AHRQ Publication No. 07-E007. Kendall-Tackett, K. A. (2005). Depression in new mothers. Binghamton, NY: Haworth. Lakshman, R., Ogilvie, D., & Ong, K. K. (2009). Mothers’ experiences of bottle-feeding: A systematic review of qualitative and quantitative studies. Archives of Disease in Childhood, 94, 596–601. Mezzacappa, E. S., & Katkin, E. S. (2002). Breast-feeding is associated with reductions in perceived stress and negative mood in mothers. Health Psychology, 21, 187–193. Mozingo, J. N., Davis, M., Droppleman, P. G., & Merideth, A. (2000). It wasn’t working: women’s experiences with short-term breast feeding. MCN. The American Journal of Maternal Child Nursing, 25, 120–126. Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D., & Cook, D. G. (2006). Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. American Journal of Clinical Nutrition, 84, 1043–1054. Pippins, J. R., Brawarsky, P., Jackson, R. A., Fuentes-Afflick, E., & Haas, J. S. (2006). Association of breastfeeding with maternal depressive symptoms. Journal of Women’s Health, 15(6), 754–762. doi:10.1089/jwh.2006.15.754. Saadeh, R., & Akre´, J. (1996). Ten steps to successful breastfeeding: A summary of the rationale and scientific evidence. Birth, 23, 154–160. Sachs, H. C., & Committee On Drugs. (2013). The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics, 132(3), e796. Shakespeare, J., Blake, F., & Garcia, J. (2004). Breast-feeding difficulties experienced by women taking part in a qualitative interview study of postnatal depression. Midwifery, 20, 251–260. Sibolboro Mezzacappa, E., & Endicott, J. (2007). Parity mediates the association between infant feeding method and maternal depressive symptoms in the postpartum. Archives of Womens Mental Health, 10, 259–266. Suri, R. A., Altshuler, L. L., Burt, V. K., & Hendrick, V. C. (1998). Managing psychiatric medications in the breast-feeding woman. Medscape Womens Health, 3(1), 1. The Huffington Post—What Breastfeeding Moms All Over the World Have in Common. (2014). Retrieved from: http://www. huffingtonpost.com/2014/09/24/breastfeeding-all-over-the-world_ n_5863946.html. Accessed on December 1, 2014. World Health Organization. (2009). Baby-friendly hospital initiative. Revised, updated, and expanded for integrated care. Retrieved from: http://www.who.int/nutrition/publications/infant feeding/bfhi_trainingcourse/en/. World Health Organization. (1981). International Code of Marketing of Breast-Milk Substitutes. Retrieved from: http://www. who.int/nutrition/publications/infantfeeding/9241541601/en/. World Health Organization and UNICEF. (2003). Global strategy for infant and young child feeding. Geneva: World Health Organization.
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COMMENTARY
Breastfeeding Support and Messaging: A Call to Integrate Public Health and Psychological Perspectives Rachel Vanderkruik1 • Elizabeth Lemon1 • Sona Dimidjian1
Ó Springer Science+Business Media New York 2015
Abstract Introduction Appropriate attention to maternal mental health is missing in many public health breastfeeding promotion efforts. Although there are many benefits to breastfeeding for both mom and infant, the relationship between maternal mental health and breastfeeding is complex. Breastfeeding may not be the most effective or feasible option for all mothers. Methods We highlight a key international breastfeeding promotion program and argue that consideration for maternal mental health could be further incorporated into the initiative. We provide examples of how this could be done and also state that further guidance on the best alternative feeding practices to ensure the healthy development of infants is needed. Results and Conclusion There is an opportunity to enhance public health breastfeeding initiatives by integrating a perinatal mental health perspective into their guidelines and accompanying resources. Keywords Breastfeeding Depression Postpartum depression Public health initiatives
& Rachel Vanderkruik [email protected]; https://www.cucrest.com Elizabeth Lemon [email protected]; https://www.cucrest.com Sona Dimidjian [email protected] 1
Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO 80309, USA
Significance This commentary makes the case for integrating public health and psychological perspectives around breastfeeding promotion and messaging efforts and provides specific examples of how this can be accomplished. The recent publication by Borra et al. [4] entitled, ‘‘New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions’’ points to a critical gap in public health breastfeeding promotion efforts—appropriate attention to maternal mental health. The authors found that risk of postpartum depression (PPD) was lowest among women who had planned to and did indeed breastfeed their babies; however, women who planned to but did not go on to breastfeed their babies were at greatest risk of PPD [4]. These findings emphasize that the commonly held belief that breastfeeding is protective against PPD is not as simple as often is communicated. There is substantial evidence showing the many physical health benefits of breastfeeding for both the baby (e.g. lower risk of type 2 diabetes [15], severe lower respiratory tract infection [10] and the mother (e.g. lower risk of breast [8] and ovarian cancer [10]). Given such well documented health benefits, the World Health Organization (WHO) recommends that infants should be exclusively breastfed for the first 6 months of life followed by complementary foods while continuing breastfeeding for up to 2 years [25]. A key initiative resulting from this WHO recommendation is the Baby-Friendly Hospital Initiative (BFHI), an international program that recognizes hospitals that provide an ideal level of care for mother and baby bonding and for infant feeding practices. BFHI acknowledges hospitals that successfully implement the Ten Steps to Successful Breastfeeding [17] and the International Code of Marketing
123
Matern Child Health J
of Breast-milk Substitutes [24]. The BFHI provides guidance on how hospitals can offer all new mothers the information, confidence, and skills necessary to successfully initiate and continue breastfeeding their babies [23]. This program has motivated hospitals in the US and around the world to reform their perinatal care practices in order to educate and best support a woman with breastfeeding while in the hospital and after discharge. BFHI thus addresses the issue of intent raised in Borra et al. [4] by inspiring hospitals to promote and support a woman’s choice to breastfeed as effectively as possible. However, it falls short in another regard; it does not address the complex relationship between breastfeeding and maternal mental health. Mental health problems, including but not limited to depression, are among the most common complications of pregnancy and the postpartum [6] with up to 16 % of women experiencing depression during the postpartum [3]. Perinatal depression has been associated with increased risk for negative fetal and neonatal outcomes [2] as well as developmental or behavioral problems in children [5, 9]. Depressed women often are less likely to begin breastfeeding or are more likely to quit [11], and some women believe they cannot breastfeed if taking a psychotropic medication, even though many are safe to use while nursing [18]. Recommendations regarding the safety of breastfeeding while taking various psychotropic medications can be complicated [21] and may be confusing or overwhelming to mothers as well as many healthcare professionals. Research has suggested that breastfeeding is protective of PPD [13], that breastfeeding is associated with an increased risk of depression [1], that there is no relationship between breastfeeding and PPD risk [7], or that the relationship is mediated by other factors like mother’s intention [4], breastfeeding duration [16], or parity [20]. These inconsistent findings indicate a need for research to further explore the relationship between breastfeeding and depression (as well as other perinatal mental health issues), and to identify additional potential mediating factors that can inform recommendations around infant feeding practices for the context of every mother-baby dyad. Given the prevalence and risk of adverse consequences from PPD, there is an important need to integrate appropriate guidance and consideration for maternal mental health and suitable treatments into public health initiatives related to breastfeeding. Furthermore, breastfeeding might not be the most effective or feasible option for all mothers. There has been recent attention in mainstream media and in the scientific community on the high levels of guilt that women can feel if they choose not to, or cannot, breastfeed [14, 22]. Some women who seek professional support for breastfeeding difficulties have reported their experience with healthcare
123
professionals to be negative, judgmental, or characterized by conflicting advice [19]. Research also has demonstrated a need for improved support and guidance for moms who bottle feed [12]. Further guidance on the best alternative feeding practices (e.g. bottle feeding) to ensure the healthy development of infants should be communicated along with promotion of breastfeeding. This information could aide with preventing feelings of guilt if a woman does not breastfeed. Public health messaging and initiatives around breastfeeding should be sensitive to the psychological aspects of new motherhood, mental health treatments, and infant feeding demands. Currently, the BFHI guidelines and Ten Steps do not address perinatal mental health. They provide no guidance on how to manage or provide counseling on breastfeeding practices in the context of PPD or other mental health concerns. Given the strongly established and respected nature of the BFHI, this international initiative would be an ideal platform to disseminate such critical information. While addressing mental health issues may exceed the currently defined scope of the BFHI, this initiative is uniquely positioned to positively influence the public and professional dialogue around breastfeeding and increase sensitivity to, and comfort around, relevant maternal psychological issues. For example, BFHI Step 1 could suggest that preliminary assessment of perinatal mental health and psychological concerns be incorporated into the required breastfeeding policy. BFHI Step 2, focused on training for healthcare staff, could include information about how mental health considerations might influence infant feeding options and specify how to discuss mental health issues with respect to breastfeeding practices as well as alternative infant feeding options in a nonjudgmental manner that minimizes maternal feelings of guilt. BFHI Step 3, which aims to educate women about the benefits and management of breastfeeding, could include guidance on breastfeeding in the context of treatment for PPD, including informing women that nursing on certain psychotropic medications is safe, or on alternative infant-feeding methods when appropriate. BFHI Step 10 could require inclusion of resources for services and support groups for women who bottle-feed or experience depressive symptoms while breastfeeding following discharge from the hospital. Efforts to promote and support breastfeeding practices should continue and be expanded to reach more women across all demographics and geographic areas. However, there is an opportunity to enhance these public health initiatives by integrating perinatal mental health concerns and a psychological perspective into their guidelines and accompanying resources. BFHI is one program that could implement this action with a significant and far-reaching impact. Moving forward, breastfeeding-related initiatives
Matern Child Health J
should educate women early in pregnancy not only about the benefits of breastfeeding but also about alternative infant feeding practices, help women make an informed decision about which practice is contextually best for her and her baby, provide systems-level and psychological support needed for women to carry-through on their intentions, and foster a sense of compassion and respect for every woman’s decision.
11. 12.
13.
14.
References 15. 1. Alder, E., & Bancroft, J. (1988). The relationship between breastfeeding persistence, sexuality and mood in postpartum women. Psychological Medicine, 18, 389–396. 2. Alder, J., Fink, N., Bitzer, J., Hosli, I., & Holzgreve, W. (2007). Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. The Journal of Maternal-Fetal and Neonatal Medicine, 20(3), 189–209. 3. American Psychological Association. (2007). Postpartum depression [Fact sheet]. http://www.apa.org/pi/women/programs/ depression/postpartum.aspx. Accessed 11 Jan 2014. 4. Borra, C., Iacovou, M., & Sevilla, A. (2014). New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health Journal,. doi:10.1007/s10995-014-1591-z. 5. Center on the Developing Child at Harvard University. (2009). Maternal depression can undermine the development of young children: Working paper no. 8. http://www.developingchild.har vard.edu. 6. Centers for Disease Control (CDC)—Pregnancy Complications; Reproductive Health. Retrieved January 22, 2014 from: http:// www.cdc.gov/reproductivehealth/maternalinfanthealth/pregcom plications.htm. 7. Chaundron, L. H., Klein, M. H., Remington, P., Palta, M., Allen, C., & Essex, M. J. (2001). Predictors, prodromes and incidence of postpartum depression. Journal of Psychosomatic Obstetrics and Gynaecology, 22, 103–112. 8. Collaborative Group on Hormonal Factors in Breast Cancer. (2002). Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50,302 women with breast cancer and 96,973 women without the disease. Lancet, 360, 187–195. 9. Field, T., Diego, M., & Hernandez-Reif, M. (2006). Prenatal depression effects on the fetus and newborn: A review. Infant Behav Dev., 29, 445–455. 10. Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., & DeVine D, et al. (2007). Breastfeeding and maternal and infant health outcomes in developed countries: Evidence report/technology
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Assessment No. 153. Agency for Healthcare Research and Quality. AHRQ Publication No. 07-E007. Kendall-Tackett, K. A. (2005). Depression in new mothers. Binghamton, NY: Haworth. Lakshman, R., Ogilvie, D., & Ong, K. K. (2009). Mothers’ experiences of bottle-feeding: A systematic review of qualitative and quantitative studies. Archives of Disease in Childhood, 94, 596–601. Mezzacappa, E. S., & Katkin, E. S. (2002). Breast-feeding is associated with reductions in perceived stress and negative mood in mothers. Health Psychology, 21, 187–193. Mozingo, J. N., Davis, M., Droppleman, P. G., & Merideth, A. (2000). It wasn’t working: women’s experiences with short-term breast feeding. MCN. The American Journal of Maternal Child Nursing, 25, 120–126. Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D., & Cook, D. G. (2006). Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. American Journal of Clinical Nutrition, 84, 1043–1054. Pippins, J. R., Brawarsky, P., Jackson, R. A., Fuentes-Afflick, E., & Haas, J. S. (2006). Association of breastfeeding with maternal depressive symptoms. Journal of Women’s Health, 15(6), 754–762. doi:10.1089/jwh.2006.15.754. Saadeh, R., & Akre´, J. (1996). Ten steps to successful breastfeeding: A summary of the rationale and scientific evidence. Birth, 23, 154–160. Sachs, H. C., & Committee On Drugs. (2013). The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics, 132(3), e796. Shakespeare, J., Blake, F., & Garcia, J. (2004). Breast-feeding difficulties experienced by women taking part in a qualitative interview study of postnatal depression. Midwifery, 20, 251–260. Sibolboro Mezzacappa, E., & Endicott, J. (2007). Parity mediates the association between infant feeding method and maternal depressive symptoms in the postpartum. Archives of Womens Mental Health, 10, 259–266. Suri, R. A., Altshuler, L. L., Burt, V. K., & Hendrick, V. C. (1998). Managing psychiatric medications in the breast-feeding woman. Medscape Womens Health, 3(1), 1. The Huffington Post—What Breastfeeding Moms All Over the World Have in Common. (2014). Retrieved from: http://www. huffingtonpost.com/2014/09/24/breastfeeding-all-over-the-world_ n_5863946.html. Accessed on December 1, 2014. World Health Organization. (2009). Baby-friendly hospital initiative. Revised, updated, and expanded for integrated care. Retrieved from: http://www.who.int/nutrition/publications/infant feeding/bfhi_trainingcourse/en/. World Health Organization. (1981). International Code of Marketing of Breast-Milk Substitutes. Retrieved from: http://www. who.int/nutrition/publications/infantfeeding/9241541601/en/. World Health Organization and UNICEF. (2003). Global strategy for infant and young child feeding. Geneva: World Health Organization.
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