You may find the "Does LNS replace breast milk?" section on the ilins website is helpful. There are some references there that you be able to read. [url]http://ilins.org/resources#section-5[/url]

[url]http://www.ncbi.nlm.nih.gov/pubmed/21450933[/url] [url]http://www.ncbi.nlm.nih.gov/pubmed/17585038[/url]

I am not aware of any literature other than that already posted however, I think that the issue is how it is used rather than whether it is used. I have observed that sometimes organisations feel like there isn't anything that they can do to improve breastfeeding practices. There may be infants under 6 months who are malnourished but they do not have any interventions to support them and really just wait until they are 6 months so that they can provide supplementary foods (something they feel they can do). In my opinion this is problematic because the critical issue that led to the infants being malnourished (inadequate breastfeeding) has not been dealt with and will not be dealt with by the addition of supplementary foods. So to answer your question, how best to ensure that RUTF/RUSF/CSB are not a threat to breastfeeding? The answer would be to look for indications that there is a problem with breastfeeding to start with (the malnourished 6 month old for eg) and ensure that there are interventions to improve breastfeeding practices alongside the provision of RUTF/RUSF/CSB

I agree with Karleen. A good protocol for < 6 months (with supplementary suckling) and a good policy that promotes breastfeeding (and gives support) alongside RUTF/RUSF/CSB should help. Following draft guideline on marketing of ready to use supplementary foods for children might help you a bit: [url]http://www.ennonline.net/resources/898[/url]

From Fiona Kuziga: Dear Karleen, i recommend that infants under six months should be exclusively breastfed. Focus should be put on maternal health and nutrition as well as addressing clinical conditions of the infant in case of malnutrition. If you give RUTF with breastmilk then you are encouraging mixed feeding which is risky for an infant under 6 months.

From Felicity Savage: This is absolutely right. Thank you Karleen – once more we need to go back to the basics of supporting breastfeeding for all children from the beginning before there is any malnutrition. Felicity

Fiona and Felicity are absolutely right, however I think the question was more about breastfeeding in children > 6 months old, since we are speaking of RUTF/RUSF/CSB, none of which is suitable for < 6 months old. I do believe the question here is very valid, as it is easier for nutrition workers, especially when time is limited and pressure high, to give mothers the RUTF/RUSF/CSB and not spend time on ensuring that breastfeeding continues, let alone assessing breastfeeding problems and dealing with them. Mothers can indeed feel that it is OK to breastfeed less, or give the children RUTF/RUSF/CSB in priority over breastmilk. Even if there is no evidence that this happens, I think field experience show that it does or that there is a real risk. Breastfeeding support is often focussing on the < 6 months, and not dealing sufficiently with the > 6 months...

Hi Fiona, I too support exclusive breastfeeding for children under 6 months. What I was describing is a situation where organisations may have a policy supporting exclusive breastfeeding for 6 months but actually not have any interventions to support it. This means that they can't do anything for children under 6 months and where there are malnourished children under 6 months the strategy is to do nothing, let time go pass until the children are 6 months of age and then start supplementary feeding. Not a good strategy. And sorry for my repeat postings earlier, I do not know what the problem was.

I agree with felicity and the rest on promoting EXBF absolutely priority for all infants under 6 months, however I must agree with Kathleen concerning the lack of information/thinking concerning those infants in this age bracket already being mixed fed and at risk of under-nutrition? Currently, the strategy has been to do nothing and wait for them as they turn 6 months. The lack of research and information in this area is very daunting especially because in trying to emphasize the importance of breastfeeding for these infants, health workers have no key messages for anyone who is not.

From Felicity Savage: Yes it is true that there is a need to focus on supporting breastfeeding after 6 months as well as before – but we must remember that if a child is malnourished at 6 months almost certainly something has gone wrong with breastfeeding already – so we need both prevention with early support of BF and continued support or relactation from 6 months -

From Fiona Kuziga: That means that we need to address the information gap that health workers have. As long as infants >6months are mixed fed, it contributes to their morbidity thus underlying cause for malnutrition. Consider that access to safe water is also a great challenge in many countries.

From Felicity Savage: Yes, but let us not slip into the mind set of 30 years ago that if you have safe water breastfeeding doesn’t matter so much.

Bonjour, Je me permet d'intervenir. Je pense que la question était pour les plus de 6 mois. Et pour une raison précise, oui effectivement si un enfant est malnutris après 6 mois c'est qu'il y a eu des problèmes d'allaitement, et on doit prendre les mesures nécessaires pour remédier a cela, technique d'accompagnement et tout le reste. Par contre je pense que la question est en lien avec la promotion de l'allaitement maternel + de 6 mois avec un enfant malnutris et par ex le test d’appétit. Certain reproche que le test d’appétit soit réalisé avant de proposer le sein. Mais si on donne le sein et qu'on réalise le test d’appétit ensuite qu'elle sera la manière d'analyser l’appétit de l'enfant??? Je ne sais pas si l'idée de départ était celle la, mais je sais que c'est une question qu'on se pose. Merci C.

Sorry I wrote in french as usual... english version now! Hello, Let allows me to intervene. I think that the question was for more than 6 months. And for a precise reason, yes effectively if a child is malnourish after 6 months it is because there were problems of breastfeeding, and we have to take the necessary measures to remedy has it, technique of support, accompaniment and etc. On the other hand I think that the question is in connection with the promotion of the breastfeeding + 6 months malnourish child and by example the test of appetite. Few person criticism that the test of appetite is realized before proposing the breastfeed. But if we breastfeed before the appetite test then what it will be the way to analyze the appetite test of the child??? I do not know if the idea of departure was the one, but I know that it is the question that we looking around for having an answer. Thank you C.

It appears that the research on this topic has studied the impact of LNS consumption as a complementary food/supplement on breastfeeding practises. The few studies that are published suggest that as a supplement, LNS does not appear to impact breastfeeding frequency or intake. However, I have not been able to find any research that has looked at LNS/RUTF consumption in a therapeutic feeding program and its impact on breastfeeding. The quantity of LNS/RUTF provided for therapeutic feeding is of course much great than what is consumed as a complementary food; thus, I suspect that the risk of breastmilk displacement may be greater in such settings. If anyone has any research on thoughts on this - please share.

Hi Colleen, My question is not related to the impact of therapeutic food on the breast-feeding, but more the impact on the measure of the appetite test if the mother breast-fed before that this. To promote the breast-feeding in general we should propose to the mother to breast-feed before before the child take any other product. But in that case; how to measure the appetit test and not to having a "bias" for the admission of the child? What is that I am more clear? Thank you