The Lactational Amenorrhea Method (LAM)

Breastfeeding and Fertility throughout History

Lactation Amenorrhea means the absence of menstruation while breastfeeding. The role of breastfeeding in delaying the return of menstruation and decreasing of fertility has been known for centuries. Aristotle, in his Historia Animalium Book VII, written in 350 B.C, says “Women continue to have milk until their next conception; and then the milk stops coming and goes dry, alike in the human species and in the quadripedal vivipara. So long as there is a flow of milk the menstrual discharge does not take place as a general rule, though the discharge has been known to occur during the period of suckling”. He continues the same subject in book V, noting that women may become pregnant while lactating: “While women are suckling children, menstruation does not occur according to nature, nor do they conceive; if they do conceive, the milk dries up”.

Dr. Roger Short reminds us of these famous quotations in his elegant series of articles on Breastfeeding, Fertility and Population Growth, also reflecting the wide spread perception that breastfeeding is not a reliable contraceptive method for every woman.

The understanding of the link between the mode of infant feeding and child survival, as well as the evidence on how normal breastfeeding patterns are interfered with can be traced back throughout human history from historical and even mythological sources. Both Moses and Mohammed survived because of wet-nurses after being rescued. Romulus and Remus, mythological founders of Rome, were suckled by a wolf and Zeus was suckled by a goat. Among the Pharaonic Egyptians, Babylonians and Hebrews, breastfeeding lasted about 36 months and 24 months in Byzantine and Islamic countries. The wealthier Romans and Greeks hired wet-nurses (the Romans had 16-month wet nursing contracts and the Greeks had 6-month contracts) to ensure the child’s survival (Short, 1992). It has been noted that if women stop breastfeeding due to the child’s death or any other reason, the women would soon become pregnant.

Breastfeeding and Fertility and the !Kung

A very good illustration of breastfeeding related infertility is derived from studies of the hunter- gathering societies in Africa, Australia and South America. Nancy Howell of the University of Toronto in her study of the !Kung of the Kalahari Desert of Southern Africa has shown that the !Kungs, “who use no modern forms of contraception and have no fertility-regulating practices such as late marriage, taboo on intercourse during lactation or infanticide, average 4.7 children and a mean birth interval of 4.1 years”. Further studies on the breastfeeding pattern revealed that the frequency of breastfeeding was about 4 times per hour, with frequent night suckling, even while the mother was sleeping, with a total duration of breastfeeding for 3-4 years. The same breastfeeding pattern was found in Papua New Guinea and is considered as “normal” for human species, as human milk is low in fat and protein and frequent suckling is necessary to ensure adequate nutritional supply to cover the needs of the fast growing infant. The same pattern of breastfeeding and a birth interval for four or five years have been found in chimpanzees and gorillas, which share about 98% of genetic information with humans (Short,1984).

Breastfeeding, Fertility and Child Spacing in the Modern World

Returning to the modern world, we have to admit that there are rare societies from the developed and even the developing world who keep up the same breastfeeding frequency and between birth intervals. This is so, even though it is estimated by WHO that breastfeeding contributes to natural birth spacing, providing 30% more protection against pregnancy than all the organized family planning programs in the developing world (Kleinman1987; WHO, 1993 and 1996). Hospital practices that separate the mother and child after birth, early supplementation; poor or no knowledge of breastfeeding management; absence of family or community support, often combined with the mother’s early return to the workforce; all interfere with an optimal breastfeeding pattern and subsequently are causing early unwanted pregnancies, if no other contraceptive is available.

Short duration of breastfeeding, in turn, increases maternal and infant mortality and morbidity. There is gross evidence to show that a birth interval of two or more years significantly enhances infant survival and reduces maternal morbidity. Dr Short, in analyzing data from 150,000 women from 29 countries in the World Fertility Survey, estimated that if mothers could space their pregnancies by an average of at least two years “the current annual total of 2.6 million deaths of children under one year of age might be expected to fall by at least 20% resulting in saving about half a million lives a year.”

Further decline of breastfeeding will increase monetary expenses related to fertility regulation. In 1988, Roger Short stated that, in his estimation, if the breastfeeding rate were to decline 25%, it would require almost a tripling of contraceptive prevalence in Senegal, a 38% increase in current contraceptive use in Indonesia and 7% in Mexico.

The Bellagio Consensus

Despite the variety of modern family planning methods available, many women do not use them. Breastfeeding appears to be an acceptable and culturally appropriate, non-invasive and cost-effective natural method of regulation against unwanted pregnancy. However, there was not enough scientific evidence to prove this, and therefore breastfeeding was not accepted until recently as a reliable contraceptive, despite a thousand years of its empirical effectiveness. In fact, for many years doctors told women that the adage “breastfeeding can delay a new pregnancy” was nothing less than a “grandmother” myth and that a modern woman should not rely on this “barbaric” method. Not surprisingly, a definition of the Lactation Amenorrhea method of contraception could not be found in any medical dictionary. In the 1980s, enough knowledge of lactation infertility had finally accumulated, a conference was held to discuss “under what circumstances a breastfeeding woman could postpone her pregnancy.” The conference attendees came to a consensus about the conditions under which breastfeeding can be used as a safe and effective method of family planning. This consensus is known as the “Bellagio Consensus,” named for the venue of the conference in Italy:

“the maximum birth spacing effect of breastfeeding is achieved when a mother ‘fully’ or nearly fully breastfeeds and remains amenorrhoeic. When those two conditions are fulfilled, breastfeeding provides more than 98% protection from pregnancy in the first six months”.

This set the definition of the Lactational Amenorrhea Method (LAM) as a family planning method and the algorythm for its use.

The three core questions for determining the appropriateness of the LAM for any mother are:

  • Have your menses returned?
  • Are you supplementing regularly or allowing long periods without breastfeeding either day or night?
  • Is your baby more than six months old?

If a mother answers “YES” to one or more of the questions, she is advised to choose another contraceptive method, but is encouraged to continue to breastfeed. (Labbok, 1994; WHO, 1992)If a mother answers “NO” to all three, she can use the LAM, and she does not need a complementary contraceptive method, as there is only a one to two percent chance of pregnancy.

Another important conclusion derived from many studies done within the last 10 years on the LAM is that while breastfeeding alone is not a reliable contraceptive, the Lactational Amenorrhea Method is. Results of the WHO multicenter study confirmed that the 6 months lifetable pregnancy rates during the correct use of the LAM were less than 2%. An Australian study showed that the risk of pregnancy in those who remained amenorreheic was 1.7% at six months and 7% at 12 months, despite a mean age of introduction of complementary feeding in 5.3 months postpartum (Short 1991, Lewis 1991). These effects are comparable to the effect of other temporary methods of contraception: to the 6% of unwanted pregnancies in the first year of use of spermicides and diaphragms, in 3% in male condom users; 0.10% new pregnancies with perfect use of combined oral contraceptive pills at the end of the first year and 3% of new pregnancies among typical users (Kennedy 1998).

Those studies also confirmed that the LAM is a well-accepted contraceptive method, both in developed and developing countries, and has few or no disadvantages. Among the disadvantages named were short duration of use, complicated breastfeeding practice, especially night feeding, and absence of protection against Sexually Transmitted Diseases (STDs), particularly in areas with high incidence of HIV and Hepatitis C infections. On the positive side, among other advantages, the LAM can be a transitional or introductory family planning method especially among first users. It can also simultaneously promote exclusive breastfeeding and therefore increase its benefits for maternal/infant health, in addition to giving sound economical savings within a family and the community.

A second meeting in 1995 confirmed the Bellagio Consensus statement and all three LAM criteria. Experts carefully concluded that, under certain circumstances, “it may be possible to relax the requirement of full and nearly full breastfeeding” and “it may be possible to extend LAM beyond six months postpartum. ” The firm conclusion regarding the amenorrhea criterion confirmed that this criterion is not possible to eliminate and that “the end of amennorhoea is the clearest marker indicating increasing risk of pregnancy.”

Understanding the LAM

An understanding of the underlying mechanisms of the LAM, both by a health professional and a mother, is crucial for the LAM’s effectiveness and for successful protection against early pregnancy. Breastfeeding regulation of both menstruation and milk production begins with suckling and its effect on the hypothalamus. Nipple stimulation alters the pituitary hormonal production responsible for ovulation, by suppressing the release of the gonadotropin releasing hormone, which subsequently disorganizes the secretion of luteinising hormone and follicle stimulating hormone, which in turn suppresses ovulation. Concurrently suckling stimulates milk production by pituitary releasing of oxytocin and prolactin.

LAM at the Individual Level

While at the population level the LAM has been shown to be an effective and reliable contraceptive method, at the individual level, return of menses and fertility is highly variable. The WHO multinational Study of Breastfeeding and Lactation Amenhorrea results stated that “the duration of amenorrhea were substantial, ranging from a median of 4 months in New Deli (India) to 9 months in Cheggdu (China)” (WHO 1998). The Australian study (a well nourished population) revealed that mean duration of the anovulation was 322 days and 289 days of amenorrhea (Lewis,1991).

Both studies confirmed that women from developed countries are more likely to delay supplementation (around 5 months), whereas women from developing countries start supplementation much earlier, sometimes right after birth.

Frequency of breastfeeding and breastfeeding pattern (duration of each feed, interval between feeds as well as the strength of suckling), introduction of food other than breast milk, even the time when the supplement is given (before or after breastfeeding), can interfere with the resumption of menses. “The risk of a first menses increased substantially once 50% of the total number of feeds the infant received consisted of supplements” (WHO, 1998). Night feeding is likely to be a very important determinant of the prolonged amenorrhea, together with full or nearly full breastfeeding.

The use of pacifiers, the use of bottles, the introduction of solids or fluids, long intervals between feedings, the absence of night feedings, or anything else that interferes with suckling can both decrease milk production and stimulate ovulation. Sick infants, premature infants, infants with cleft lip/palate can experience difficulties with suckling, and mothers of these children should pay extra attention to ensure enough nipple stimulation. In the absence of lactation, ovulation resumes on an average of six to seven weeks postpartum, when the woman becomes fertile again.

As mentioned above, there are three conditions under which the LAM provides 98% protection:

1) No menstruation

2) Before 6 months postpartum

3) Frequent unrestricted breastfeeding, including night feedings

If any of those conditions are not met, the mother should immediately start to use an additional method of contraception if she does not wish to become pregnant. A mother should be advised to use breastfeeding compatible methods. If hormonal methods are chosen, the mother should be informed that pills containing estrogen may decrease her milk supply, and therefore should be avoided.

References

Family Health International, 1988. Breastfeeding as a family planning method: consensus statement. Lancet ii:1204-1205.

Hight-Laukaran V, Labbok MH, et al., 1997. Multicentral Study of the Lactational Amenorrhea Method (LAM):II. Acceptability, Utility, and Policy Implications,Contraception 55 (6): 337-346.

Institute for Reproductive Health, 1995. Consensus staetement on the Lactational Amenorrhea Method for family planning (Conference held Bellagio, Italy 11-14 Dec,1995), Institute for Reproductive Health, Georgetown University Medical Centre.

Kennedy KI, Kotelchuck M 1998, Policy considerations for the introduction and promotion of the Lactation Amenorrhea Method: advantages and disadvantages of LAM. J Hum Lact 14(3):191-203.

Kleinman RL and Senanayake(eds),1987, Breastfeeding: Fertility and Contraception. London: International Planned Parenthood Federation.

Labbok M et al.,1994. The Lactational Amenorrhea Method(LAM): a postpartum introductory family planning method with policy and program implications(review).Adv Contraception 10(2): 93-109.

Labbok M et al,1997. Multicentral Study of the Lactational Amenorrhea Method(LAM): I. Efficacy, Duration, and Implications for Clinical Application. Contraception55(6): 327-336.

Lewis P, Brown J, Renfree M, Short R, 1991. The resumption of ovulation and menstruation in a well-nourished population of women breastfeeding for an extended period of time. Fertility and Sterility,55(3):.529-536.

Rogers I, 1997. Lactation and fertility, Early Human Development 49 Suppl.(1997) S185-S190.

Short R, 1984. Breast Feeding. Scientific American, April 1984,259(4): 23-29.

Short R et al., 1991. Contraceptive effects of extended lactational amenorrhea: beyond the Bellagio Consensus. Lancet 1991, 337: 715-17.

Short R, 1992. Breastfeeding, Fertility and Population Growth, in Nutrition and Population Links, ACC/SCN Symposium Report from ACC/SCN 18th Session Symposium, 1992: 33-46.

Short R, 1994. Human Reproduction in an Evolutionary Context, in eHuman Reproductive Ecology, interactions of environment, fertility, and behaviour, edited by Cambell&Wood, The New York Academy of Sciences, New York, 1994: 416-425.

Thapa S, Short R, 1988. Breast feeding, birth spacing and their effects on child survival. Nature, 335 (6192): 679-682.

UNICEF, WHO, UNIESCO, and UNFPA,1993. Facts for Life: a Communication Challenge, revised edition Wallingford, UK: P&LA.

WHO, Breastfeeding and Child spacing, 1992, Facts about Infant Feeding, Issue 2, November 1992: 1-4.

WHO Task Force on Methods for the Natural Regulation of Fertility, 1998. The World Health Organisation Multinational Study of Breastfeeding and Lactational Amenorrhea. I. Description of infant feeding patterns and the return of menses. Fertil Steril 70(3): 448-460.

WHO Task Force on Methods for the Natural Regulation of Fertility, 1998. The World Health Organisation Multinational Study of Breastfeeding and Lactational Amenorrhea. II.Factors associated with the length of amennorhea, Fertil Steril 70(3): 461-471.

 

Exclusive Breastfeeding

Human milk is all the food a full-term, healthy newborn baby needs for the first few months of his/her life. It is an amazing thing to contemplate! A woman nourishes and grows a baby while he or she lives inside the woman’s body and she can do the same after the baby is born. Some women find it hard to believe that the milk they produce is sufficient for a growing baby for several months. They have doubts and sometimes, their family and friends don’t believe it is possible for a baby to receive only breast milk for the first months of an infant’s life. While we know and understand that there are some women who do indeed have difficulty supplying all the milk their baby needs in the first few months, this kind of a situation is not very common.

Throughout the world, insufficient milk production, mostly perceived, is the main reason for early supplementation and weaning. Whether it is perceived or a fact, for the mother it is a real situation. This perception of a low milk supply leads women to supplement with other liquids or foods and to not practice exclusive breastfeeding. Although this issue will be discussed in future months when other topics are discussed, such as common breastfeeding problems, it is important to discuss it here as well, since supplementation with other foods and liquids obviously interferes with the implementation of exclusive breastfeeding. For this discussion, we would like to talk about the importance of exclusive breastfeeding and the practice of exclusive breastfeeding, while acknowledging that it does not happen for all women.

Several well-known organizations have public statements encouraging exclusive breastfeeding for the first 4-6 months of a baby’s life.

The American Academy of Pediatrics (http://www.aap.org/) says:

“Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.”http://www.aap.org/policy/re9729.html  

World Alliance for Breastfeeding Action (http://www.waba.org.br/) says:

“Exclusive breastfeeding without other foods or fluids for the first 6 months of life is the best start for all babies.” http://www.waba.org.br/acsh7.htm  

The World Health Organization (http://www.who.int/) and UNICEF (http://www.unicef.org) say in the Innocenti Declaration:

“As a global goal for optimal maternal and child health and nutrition, all women should be enabled to practise exclusive breastfeeding and all infants should be fed exclusively on breastmilk from birth to 4-6 months of age. Thereafter, children should continue to be breastfed, while receiving appropriate and adequate complementary foods, for up to two years of age or beyond. This child-feeding ideal is to be achieved by creating an appropriate environment of awareness and support so that women can breastfeed in this manner.” http://www.infactcanada.ca/whocode/innocent.htm

newYou will find additional information on WHO and UNICEF definitions in our collection of supporting documents.

La Leche League International (http://www.lalecheleague.org/) believes:

“For the healthy, full-term baby, breast milk is the only food necessary until baby shows signs of needing solids, about the middle of the first year after birth.”

The Nursing Mothers’ Association of Australia (http://www.nmaa.asn.au/) says:

“Breast milk is sufficient for the growth and development of healthy, full-term babies for at least six months. Other fluids, solids or vitamins are unnecessary before this unless medically indicated.”

To begin, there are many reasons why simply breastfeeding your baby is so important.

Research shows that breastfeeding your baby confers a host of immunological benefits to the baby. Breastfed babies have a lower risk of developing ear infections, urinary tract infections, asthma, childhood cancers, diabetes and allergies.

We also know that breastfeeding has benefits to the mother as well. By breastfeeding her baby a woman reduces her risk of breast cancer, ovarian cancer and osteoporosis. In addition, many women find breastfeeding as an effective method of preventing pregnancy for the first 4-6 months after delivery.

Breastfeeding a baby is very important, but exclusively breastfeeding (nothing but human milk) a baby is an important piece of the complete breastfeeding experience. There are many reasons why exclusively breastfeeding an infant is so important.

Unnecessary supplementation with infant formula or cow’s milk can interfere with the physiological benefits of exclusive breastfeeding. For example, the additional iron in infant formula can bind with lactoferrin (an important protein in human milk that confers protection against infection) and make it less available to fight infection.

Additionally, delaying the addition of cow’s milk protein and other allergenic foods (such as eggs, wheat and nuts) can reduce the incidence of food-related allergies, asthma and eczema.

Babies who are exclusively breastfed and have unrestricted access to the breast don’t need water. Giving additional water to infants is related to an increased risk of diarrhea, decreased consumption of breast milk (and therefore fewer calories) and a more likely probability to be weaned from the breast before 3 months of age.

Babies who drink enough breast milk to satisfy their caloric and nutritional needs will receive all the water they need, even in very hot and dry parts of the world.

In many countries, where water is scarce and hard to get, being able to just breastfeed without adding water is a convenience for the mother and the family. In addition, there are no bottles or utensils or tools to wash and, therefore, no need for water in that regard.

Finally, by not restricting a baby’s time at the breast and by not offering supplemental liquids or foods, a mother helps maintain her milk supply, reduces the risk of nipple confusion or preference by the baby and thereby helps to ensure she will have a plentiful supply of milk for her baby.

References

Lawrence R.A. 1999. Breastfeeding: A Guide for the Medical Profession (5th ed.) St. Louis, MO: C.V. Mosby Company.

Riordan J., Auerbach K.G., 1993. Breastfeeding and Human Lactation, Sudbury, MA, Jones and Bartlett Publishers.

World Health Organization, 1991. “Breast-feeding and the use of water and teas,” Division of Child Health and Development UPDATE, No .9 (reissued Nov. 1997). Also available at: http://www.who.int/chd/publications/newslet/update/updt-09.htm

Complementary Feeding

Complementary Feeding

What is meant by “complementary feeding?” What are the factors to be considered in complementary feeding? What are the benefits of breast milk as the baby begins to learn to eat new foods and liquids? Do mothers encounter difficulties when they begin to introduce new foods into the exclusively breastfed baby’s diet?

The second topic to be addressed by the Breastfeeding Topic of the Month website is Complementary Feeding, which is any foods that provide nutrients and that are given in addition to breast milk, prepared at home or commercially.

Concerns

While there is increasing evidence that women are breastfeeding less and less, there is also international concern when the introduction of complementary foods is delayed. A mother or other caregiver might find it difficult to determine when or how to begin feeding a breastfed baby with complementary foods and might put off the decision. Cultural beliefs can also interfere, as the variety of foods is huge. Family interference, particularly when the mother starts to leave the baby with another caretaker, must also be considered.

In any case, postponing the introduction of complementary foods past a certain time can jeopardise the growth and development of a child.

Breast Milk Provides for Infant Needs

It is known that breast milk provides all the infant needs for about the first 6 months, and that it can contribute in some populations, with half (50%) of the energy requirements in the second semester of a child’s life, and one third (around 30%) in the second year. Therefore, although it is generally agreed that children should continue to be breastfed at least until the second year of life, international agencies (WHO/UNICEF) also recommend that after 6 months, all children should get complementary foods, in addition to breast milk.

What Different Agencies/Organisations Say about Complementary Feeding

La Leche League International (http://www.lalecheleague.org/) Young babies do best without the early addition of solids to their diet. Human milk is the perfect food for at least the first 6 months for the healthy, full-term infant, and there is usually no reason for adding any foods to the breastfed baby’s diet before that time. (Womanly Art of Breastfeeding, 1997, page 231)

World Health Organisation (http://www.who.int/) during the 1990s, recommendations of the World Health Assembly have been issued regarding appropriate age to begin complementary feeding: Resolution 43.3 (1990) mentions the age range of 4 to 6 months as a transitional period to allow breast-fed infants to adjust to consuming solid foods; In 1992, Resolution WHA 45.34 affirms: “from the age of about 6 months infants should begin to receive a variety of locally available and safely prepared foods rich in energy, in addition to breast milk, to meet their changing nutritional requirements” . The sentence “from about 6 months” was repeated in Resolution WHA 47.5. It is also important to mention that WHO had previously issued a resolution in 1986 affirming that no follow-on milks are necessary as part of complementary foods, but preferably family food. (Please refer to the exclusive breastfeeding topic for further information on this.)

American Academy of Paediatrics (http://www.aap.org/) Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth. Infants weaned before 12 months of age should not receive cow’s milk feedings but should receive iron-fortified formula. Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast milk diet. (Breastfeeding and the Use of Human Milk, 12/97 RE9729)

LINKAGES (USAID funded breastfeeding project)( www.linkagesproject.org/) has a publication “Facts for Feeding. Guidelines for Appropriate Complementary Feeding of Breastfed Children 6-24 months of Age” that is very informative.

Nursing Mothers Association of Australia (http://www.nmaa.asn.au/) Breastmilk provides all the baby ‘s nutritional needs for the first six months of life; – It is still the most important food for the first 12 months;- It is important to watch for signs that the baby is ready for solids; – For the first 12 months solids should be seen as a complement to breastmilk rather than meeting all the nutritional needs of the baby. (Breastfeeding Management in Australia, NMAA, 1997, Edited by Wendy Brodribb , “Chapter 5, Introduction of Solids”)

Studies are not always consistent, but a recent and important one, carried out in Honduras, showed no advantage of complementation before 6 months, in terms of growth. Actually, other food or fluid in diet was shown to decrease the amount of energy provided by breast milk.

Starting Solids

When the infant starts receiving complementary foods, the main concern should be the nutrient/energy density and bioavailability of the nutrients of the foods provided, the frequency of meals, and the amount of food eaten per meal. There are also other factors in the complementary food intake: appetite, monotony, taste and viscosity and the caretaker’s behaviour. It is a good idea to test different samples before to choose a brand (http://www.formybaby.org).

The Readiness Factor

The readiness to accept solid foods should be assessed. Not all babies will be ready for solids at the same age. Some will be ready to start earlier than 6 months, while others will not be ready for solid foods until later in the second half of the first year. Some babies who are susceptible to food allergies may even refuse solids until 8 or 9 months of age. The mother should be aware of her baby’s overall health and weight gain and offer solid foods periodically (every few days) until the baby is interested.

Signs of Readiness

Before a mother begins to introduce solid foods to her baby, it is recommended that she look for “signs of readiness.” These signs would include the baby’s ability to sit up or support his own back and head, a reduction in the tongue-thrust reflex (the baby does not automatically push the spoon out of his mouth), some hand to mouth skills and an increased demand to nurse that is not related to illness or teething (Breastfeeding Answer Book, LLLI, 1997).

Nutrient Requirements, Calories and Density

Consideration should be given to the possible lack of micronutrients (iron, vitamin A, zinc, calcium, vitamin B6, B12, iodine, selenium etc) in the common foods eaten in a given community. For the breastfed infant, human milk will be enough in terms of vitamins in the mother’s nutrition, although a mother may change her habits during the time she is breastfeeding (a vegetarian versus a non-vegetarian, for instance).

If the child is taking less breast milk from the sixth month on, the energy content required of the complementary food received will increase from 270 Kcal/day during 6-8 months to 450 and 750 Kcal/day at ages 9-11 and 12-23 months respectively. The variety and quantity, therefore, will be essential to meet the child’s nutritional requirements for growth and development.

The energy density that is provided by the complementary foods will depend on the different patterns of breast milk intake and the child’s age. At a minimum, complementary foods should provide 0.70Kcal/g. For this reason, usually fruit juices, vegetables or soups are not recommended, because they have a very low energy density.

Factors Involving the Child

The reduced gastric capacity of the infant (30-40 ml/Kg) is another factor in fulfilling the energy requirements of the child. The frequency of complementary foods to be offered to a child should vary according to the energy density of the food chosen.

Proteins

Regarding the proteins in complementary food content, it is important to consider quality and digestibility, being more appropriate to choose proteins of animal origin, due to the growth needs in early childhood. A vegetarian diet can provide high quality protein if sufficient and appropriate combinations of plant-based foods are ingested.

Iron, Calcium and Vitamin A

IRON: how much of iron is absorbed and available to the metabolism is the main concern in the complementary foods chosen. Iron from vegetable origin is not well-absorbed (1-6%) compared to iron from animal origin (up to 22%). Also, the presence of other nutrients such as ascorbic acid (oranges, other citric, etc) enhance iron absorption from meat, fish, etc. Iron is less absorbed from egg yolk, animal milk, tea or coffee. High density of iron is found in liver and beef; low density of iron (and low bioavailability) is typical in animal milk and its by-products. If iron requirements are not overestimated, it is recommended the mother provide the child complementary foods enriched with iron, or iron supplementation.

CALCIUM: As with iron or zinc, animal products also provide higher density and bioavailability of calcium. On the other hand, different foods interfere in calcium absorption such as oranges and other citrics, and some fibers found in cereals or fruits. Bioavailability of calcium is reduced in a vegetarian diet. A good recommendation to fulfil calcium requirements is milk products and fish. It is Important to point out that animal milk in natura is not recommended due to the risk of intestinal microhemorragy and contamination.

VITAMIN A – Human milk has sufficient Vitamin A if the mother’s diet is rich in this micronutrient. If not, it is recommended to supplement the mother with Vitamin A.

Giving Foods – Before or after the Baby Breastfeeds?

Internationally, there is no consensus yet on whether complementary foods should be fed to the child before or after he/she has breastfed.

new2.gif (1134 bytes)Additional Perspectives

We have prepared a document with some additional information on complementary feeding and encourage you to read it, as well.