• Every infant and child has the right to good nutrition according to the “Convention on the Rights of the Child”.
• Undernutrition is associated with 45% of child deaths.
• Globally in 2020, 149 million children under 5 were estimated to be stunted (too short for age), 45 million were estimated to be wasted (too thin for height), and 38.9 million were overweight or obese.
• About 44% of infants 0–6 months old are exclusively breastfed.
• Few children receive nutritionally adequate and safe complementary foods; in many countries less than a fourth of infants 6–23 months of age meet the criteria of dietary diversity and feeding frequency that are appropriate for their age.
• Over 820 000 children’s lives could be saved every year among children under 5 years, if all children 0–23 months were optimally breastfed. Breastfeeding improves IQ, school attendance, and is associated with higher income in adult life. (1)
• Improving child development and reducing health costs through breastfeeding results in economic gains for individual families as well as at the national level.

Undernutrition is estimated to be associated with 2.7 million child deaths annually or 45% of all child deaths. Infant and young child feeding is a key area to improve child survival and promote healthy growth and development. The first 2 years of a child’s life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better development overall.

Optimal breastfeeding is so critical that it could save the lives of over 820 000 children under the age of 5 years each year.

WHO and UNICEF recommend:

• early initiation of breastfeeding within 1 hour of birth;
• exclusive breastfeeding for the first 6 months of life; and
• introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to 2 years of age or beyond.

However, many infants and children do not receive optimal feeding. For example, only about 44% of infants aged 0–6 months worldwide were exclusively breastfed over the period of 2015-2020.

Recommendations have been refined to also address the needs for infants born to HIV-infected mothers. Antiretroviral drugs now allow these children to exclusively breastfeed until they are 6 months old and continue breastfeeding until at least 12 months of age with a significantly reduced risk of HIV transmission.

Breastfeeding

Exclusive breastfeeding for 6 months has many benefits for the infant and mother. Chief among these is protection against gastrointestinal infections which is observed not only in developing but also industrialized countries. Early initiation of breastfeeding, within 1 hour of birth, protects the newborn from acquiring infections and reduces newborn mortality. The risk of mortality due to diarrhoea and other infections can increase in infants who are either partially breastfed or not breastfed at all.

Breast-milk is also an important source of energy and nutrients in children aged 6–23 months. It can provide half or more of a child’s energy needs between the ages of 6 and 12 months, and one third of energy needs between 12 and 24 months. Breast milk is also a critical source of energy and nutrients during illness, and reduces mortality among children who are malnourished.

Children and adolescents who were breastfed as babies are less likely to be overweight or obese. Additionally, they perform better on intelligence tests and have higher school attendance. Breastfeeding is associated with higher income in adult life. Improving child development and reducing health costs results in economic gains for individual families as well as at the national level.(1)

Longer durations of breastfeeding also contribute to the health and well-being of mothers: it reduces the risk of ovarian and breast cancer and helps space pregnancies–exclusive breastfeeding of babies under 6 months has a hormonal effect which often induces a lack of menstruation. This is a natural (though not fail-safe) method of birth control known as the Lactation Amenorrhoea Method.

Mothers and families need to be supported for their children to be optimally breastfed. Actions that help protect, promote and support breastfeeding include:

• adoption of policies such as the International Labour Organization’s “Maternity Protection Convention 183” and “Recommendation No. 191”, which complements “Convention No. 183” by suggesting a longer duration of leave and higher benefits;
• adoption of the “International Code of Marketing of Breast-milk Substitutes” and subsequent relevant World Health Assembly resolutions;
• implementation of the “Ten Steps to Successful Breastfeeding” specified in the Baby-Friendly Hospital Initiative, including:
  • skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeeding within the first hour of life;
  • breastfeeding on demand (that is, as often as the child wants, day and night);
  • rooming-in (allowing mothers and infants to remain together 24 hours a day);
  • not giving babies additional food or drink, even water, unless medically necessary;
• provision of supportive health services with infant and young child feeding counselling during all contacts with caregivers and young children, such as during antenatal and postnatal care, well-child and sick child visits, and immunization; and
• community support, including mother support groups and community-based health promotion and education activities.

Breastfeeding practices are highly responsive to supportive interventions, and the prevalence of exclusive and continued breastfeeding can be improved over the course of a few years.

Complementary feeding

Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth may falter. Guiding principles for appropriate complementary feeding are:

• continue frequent, on-demand breastfeeding until 2 years of age or beyond;
• practise responsive feeding (for example, feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact);
• practise good hygiene and proper food handling;
• start at 6 months with small amounts of food and increase gradually as the child gets older;
• gradually increase food consistency and variety;
• increase the number of times that the child is fed: 2–3 meals per day for infants 6–8 months of age and 3–4 meals per day for infants 9–23 months of age, with 1–2 additional snacks as required;
• use fortified complementary foods or vitamin-mineral supplements as needed; and
• during illness, increase fluid intake including more breastfeeding, and offer soft, favourite foods.

Feeding in exceptionally difficult circumstances

Families and children in difficult circumstances require special attention and practical support. Wherever possible, mothers and babies should remain together and get the support they need to exercise the most appropriate feeding option available. Breastfeeding remains the preferred mode of infant feeding in almost all difficult situations, for instance:

• low-birth-weight or premature infants;
• mothers living with HIV in settings where mortality due to diarrhoea, pneumonia and malnutrition remain prevalent;
• adolescent mothers;
• infants and young children who are malnourished; and
• families suffering the consequences of complex emergencies.

HIV and infant feeding

Breastfeeding, and especially early and exclusive breastfeeding, is one of the most significant ways to improve infant survival rates. While HIV can pass from a mother to her child during pregnancy, labour or delivery, and also through breast-milk, the evidence on HIV and infant feeding shows that giving antiretroviral treatment (ART) to mothers living with HIV significantly reduces the risk of transmission through breastfeeding and also improves her health.

WHO now recommends that all people living with HIV, including pregnant women and lactating mothers living with HIV, take ART for life from when they first learn their infection status.

Mothers living in settings where morbidity and mortality due to diarrhoea, pneumonia and malnutrition are prevalent and national health authorities endorse breastfeeding should exclusively breastfeed their babies for 6 months, then introduce appropriate complementary foods and continue breastfeeding up to at least the child’s first birthday.

• Questions and answers on HIV and infant feeding

WHO response

WHO is committed to supporting countries with implementation and monitoring of the “Comprehensive implementation plan on maternal, infant and young child nutrition”, endorsed by Member States in May 2012. The plan includes 6 targets, one of which is to increase, by 2025, the rate of exclusive breastfeeding for the first 6 months up to at least 50%. Activities that will help to achieve this include those outlined in the “Global strategy for infant and young child feeding”, which aims to protect, promote and support appropriate infant and young child feeding.

UNICEF and WHO created the Global Breastfeeding Collective to rally political, legal, financial, and public support for breastfeeding. The Collective brings together implementers and donors from governments, philanthropies, international organizations, and civil society. The Collective’s vision is a world in which all mothers have the technical, financial, emotional, and public support they need to breastfeed.

WHO has formed the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and Subsequent Relevant World Health Assembly Resolutions, also known as NetCode. The goal of NetCode is to protect and promote breastfeeding by ensuring that breastmilk substitutes are not marketed inappropriately. Specifically, NetCode is building the capacity of Member States and civil society to strengthen national Code legislation, continuously monitor adherence to the Code, and take action to stop all violations.

In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

WHO provides simple, coherent and feasible guidance to countries for promoting and supporting improved infant feeding by HIV-infected mothers to prevent mother-to-child transmission, good nutrition of the baby, and protect the health of the mother.