Exclusive breastfeeding

THE PROS AND CONS OF BREASTFEEDING

1. EXCLUSIVE BREASTFEEDING: PROS AND CONS

2. BY   ADEJUMOBI ADEJUMOKE 15/0177 ALAO ADENIKE S. 15/0184 EZEKIEL ADA - EZE H. 15/0190 OMOGE ADEYEMI O. 15/0199   SPECIAL TOPIC ON HUMAN NUTRITION (PHS 491)   DEPARTMENT OF PUBLIC HEALTH FACULTY OF BASIC MEDICAL SCIENCES ADELEKE UNIVERSITY, EDE, OSUN STATE   IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF B.Sc. IN PUBLIC HEALTH   1 ST OCTOBER , 2018 2

3. 3 TABLE OF CONTENT INTRODUCTION DEFINITIONS OF BREASTFEEDING WHY EXCLUSIVE BREASTFEEDING IS A PUBLIC HEALTH CONCERN REASONS WHY SOME WOMEN DO NOT BREASTFEED THEIR BABY FACTORS INFLUENCING BREATFEEDING PROS OF BREASTFEEDING CONS OF BREASTFEEDING CONCLUSION RECOMMENDATIONS REFERENCES

4. INTRODUCTION Public health organisations, including the World Health Organisation recommend 6months of exclusive breastfeeding for optimal growth, cognitive development and health. Exclusive breastfeeding for 6 months is the optimal method of infant feeding (WHO, 2001). The WHO recommends exclusive breastfeeding for 6 months and continued breastfeeding until 2 years of age along with complementary foods (Kramer & Kakuma, 2001). Although the health benefits of exclusive breastfeeding are widely acknowledged, opinions and recommendations are strongly divided on the optimal duration of exclusive breastfeeding and the practice of exclusive breastfeeding in different cultures and regions. This has led to many lactating women not practicing exclusive breastfeeding. (UNICEF, 2012). 4

5. As expected, breastfeeding initiation is positively associated with the pros of breastfeeding and negatively with the cons (Kools et al., 2005). The attitude towards breastfeeding in this study was measured prenatally by two different scales ‘Pros’ and ‘Cons’ which contained questions about the perceived advantages and disadvantages of breastfeeding. (Kools et al., 2005). In Nigeria, child malnutrition, which occurs in more than 60% of children has been identified to be responsible for more than 50% of infant’s death in the country. Between 1996 and 2006, the rate of exclusive breastfeeding for the first 6 months of life increased from 33% to 37%. Significant increases were made in sub-Saharan Africa, where rates increased from 22% to 30%, and Europe, where rates increased from 10% to 19%. In Latin America and the Caribbean, excluding Brazil and Mexico, the percentage of infants exclusively breastfed increased from 30% in 1996 to 45% in 2006. (UNICEF, 2007) 5

6. 6 Socio-demographic influences play a major role in explaining the low rates of exclusive breastfeeding. The importance of mothers’ social groups and networks in affecting the infant feeding beliefs and practices should never be underestimated. (Alder EM et. al, 2004). Depression arising from sickness affects infant feeding choices since depressed women may doubt their ability to feed the infants leading to early termination of breastfeeding efforts. (Hellin K and G Waller 1992). Moreover, early return to work is also a significant factor in the decision whether or not to breastfeed and thus a more conducive work environment (providing breastfeeding mothers with nurseries, breast milk expressing equipment and longer maternity leave incentives) with regard to breastfeeding might encourage the practice. (Arora S, Mcjunkin C, Wehrer J and P Kuhn, 2000).

7. DEFINITIONS OF BREASTFEEDING WHO has defined breastfeeding as the normal method to provide infants with the nutrients they need for healthy growth and development (WHO, 2013). Breastfeeding: the method of feeding a baby with milk directly from the mother's breast (Bristow, 2012). Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development (WHO, 2013). Exclusive breastfeeding: breast milk only, excluding water, other liquids, and solid foods (WHO, 2013). Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or solids are given – not even water – with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines. (WHO, 2013). 7

8. 8 WHY EXCLUSIVE BREASTFEEDING IS A PUBLIC HEALTH CONCERN For infants to survive, grow and develop properly they require the right proportion of nutrients. Breast milk is rich in nutrients and anti-bodies and contains the right quantities of fat, sugar, water and protein. These nutrients are major pre-requisites to the health and survival of the baby. When a child is exclusively breast fed, their immune system is strengthened, enabling it to life-threatening illnesses like pneumonia and diarrhoea amongst other infections. Reports indicate that babies who are not breast fed for the first six months of life are 15 times more likely to die from Pneumonia compared to newborns that are breast fed exclusively for six months after birth. (Healthy Newborn Network).

9. Infants who continued to be exclusively breastfed tended to be those who remained healthy and on an accepted growth trajectory. (Sauls H, 1979). The World Health Organization estimates that around 220,000 children could be saved every year with exclusive breastfeeding. Breastfeeding is healthier than formula feeding; it contains all necessary nutrients for a baby and protects against several infections and diseases. Breastfeeding helps you to recuperate more rapidly after pregnancy and has health advantages for the mother. The availability of information about formulafeeding, for example, was found to be negatively correlated with the duration of breastfeeding (Howard et al., 2000). In this experimental study, comparing women who received promotion materials related to formulafeeding and a control group, a larger proportion of women in the experimental group stopped breastfeeding during the first two weeks. 9

10. REASONS WHY SOME WOMEN DO NOT BREASTFEED THEIR BABY Lack of Support: In the past, formula feeding was popular and very common. Many of our own mothers used formula, and they do not understand breastfeeding. They have little or no experience with nursing a child, so they cannot offer advice, guidance, or help. Sometimes, they are not even supportive. Partners and friends may not have enough information about breastfeeding to understand this choice. Husbands may fear that breastfeeding will interfere with the couple relationship. Since husbands or partners play a vital role in breastfeeding success, without their support many women will choose not to breastfeed. Early Return To Work or School: It can be overwhelming to handle a new baby, family responsibilities, a home, and the additional stress of work or school. If the stress of breastfeeding is too much for a woman, she may decide not to breastfeed. 10

11. Attitudes of Doctors and Nurses: Some healthcare professionals are not educated in breastfeeding technique or how to handle breastfeeding issues. If the mother's or the baby's health care provider does not support and understand breastfeeding, then problems will not be resolved and the mother will not be encouraged to continue to nurse. Lack of Help and Resources: Many first time mothers do not have breastfeeding support once they leave the hospital. They do not know where to turn to for help, or who to go to with questions if they run into problems. If women are not given follow-up instructions and information on the breastfeeding resources available, they can easily give up on breastfeeding. Financial Barriers: Lactation specialists and pump rentals can be expensive. If women do not know where to go for assistance, then they may not be able to afford to get the help they need to continue to breastfeed. 11

12. Personal Issues: Embarrassment, body image issues, fear, and lack of confidence can all contribute to negative feelings about breastfeeding. Some women cannot see the breasts as anything but sexual objects. Concerns about exposing the breasts to nurse can make women feel uncomfortable. When thoughts of breastfeeding are embarrassing, uncomfortable, or shameful, it is more likely a woman will decide against breastfeeding. Health Concerns: Even though women with many types of health issues can breastfeed and are often encouraged to do so, it can still be difficult. Certain health conditions can cause a low milk supply, or a mom might worry about the medications that she has to take and how it will affect her baby. It can be overwhelming and exhausting. Women who have had breast cancer may not be able to breastfeed after radiation therapy or a mastectomy. Plus, there are some health-related issues, such as HIV infection, when breastfeeding is not recommended. 12

13. A True Low Breast Milk Supply: Only a small percentage of women who want to breastfeed can’t due to lactation failure or a true low breast milk supply. A true low milk supply is usually the result of an underlying condition. With treatment, some issues can be corrected, so a mother can go on to build a milk supply. However, some problems cannot be resolved. The causes of a true low milk supply include: Insufficient glandular tissue (hypoplastic breasts) Polycystic ovary syndrome (PCOS) Hypothyroidism A previous breast surgery such as mastectomy or a breast reduction surgery Prior radiation treatment for breast cancer 13

14. 14 Dependency on Illegal Drugs: The use of illegal drugs is not compatible with pregnancy, breastfeeding, or parenting. Besides being illegal, street drugs are dangerous for a mother and her child. Drugs do get into the breast milk and pass to the baby. When babies receive illicit drugs through breast milk, it can cause irritability, sleepiness, poor feeding, growth problems, neurological damage, and even death. The use of recreational drugs puts a mother at risk of contracting infectious diseases such as Human immunodeficiency virus (HIV) and Human T-cell lymphotropic virus (HTLV) and impairs her ability to care for her child. Mothers who use illegal drugs during pregnancy and breastfeeding can find themselves in trouble with the law and lose custody of their children. Medication: Many medications are compatible with breastfeeding, but some are not. Certain prescription drugs can hurt the baby, and other medications can cause a decrease in the milk supply. Some of the medications that

15. are not compatible with breastfeeding are chemotherapy drugs, antiretroviral medications, radioactive iodine, some sedatives, seizure medication, and medicines that may cause drowsiness and suppress breathing. Medications that can decrease the supply of breast milk include cold and sinus medications that contain pseudoephedrine and certain types of hormonal birth control. Infectious Disease: However, there are a few infectious diseases that can pass to a baby through breast milk and the risk of transmission outweighs the benefits of breastfeeding. These conditions include: HIV: The human immunodeficiency virus (HIV) is the virus that causes acquired immunodeficiency syndrome (AIDS), HTLV: The human T-cell lymphotropic virus (HTLV-1 &2) is a virus that can lead to leukemia and lymphoma. Human T-cell lymphotropic virus 2 (HTLV-2) can cause brain and lung issues, Active tuberculosis infection (TB), Herpes on the breast, etc. 15

16. FACTORS INFLUENCING BREASTFEEDNING Psychosocial Factors Knowledge and attitudes (psychosocial factors) are important factors that influence breastfeeding prevalence in general (Chambers, McInnes, Hoddinott, & Alder, 2007). Mothers usually obtained their knowledge about breastfeeding from different resources such as: physicians, books or articles about breastfeeding, internet, friends and families, advertisement, traditional birth attendants (TBAs), religious leaders, place of work, worship centers and from mother to mother etc. (M. Auger, personal communication, November 6, 2013). Health care providers should be aware that their own beliefs and attitudes toward breastfeeding may affect a woman’s choice to breastfeed (Auger, 2013). Mothers’ trust their health care providers; therefore, care providers opinions regarding a particular issue such as breastfeeding could be considered. 16

17. Demographic Characteristics: Maternal Age, Maternal Level of Education, and Family Income According to CDC (2010), there is a significant association between breastfeeding rates and socio-demographic characteristics for mothers including maternal age, maternal education level, and family income. It has been found that breastfeeding rates increased with increasing maternal age for all race-ethnicity groups. Older mothers are more likely to choose breastfeeding than young mothers (McDowell, 1999; Wang, 2006; & Kennedy-Stephenson, 2010). However, low level of maternal education has been liked with low breastfeeding rates (Bertini, Perugi, Dani, Pezzati, Tronchin, Rubaltelli, 2003). Also, breastfeeding rates were higher among mothers who have high family incomes than for mothers who have low family income (McDowell, Wang, & Kennedy-Stephenson, 2010). It is well documented that, in the U.S., women who are of high-income status and are college - educated tend to have the highest breastfeeding rate, while young mothers from low socio-economic backgrounds with low educational levels have the lowest breastfeeding rate. 17

18. Hospital Practices To improve breastfeeding rates it is important to involve healthcare providers in the process of encouraging mothers to choose breastfeeding for their children. A published joint statement from WHO and UNICEF to improve breastfeeding rates recommended that all healthcare facilities encourage breastfeeding choice (W HO & UNICEF, 2003). Studies have shown that health care professionals such as physicians have inadequate training in breastfeeding management (ADA Reports, 1997). Although health care professionals have been shown to positively influence breastfeeding women, research shows that they also provide women with inaccurate and/or inadequate breastfeeding information and recommendations. Surveys evaluating health care professionals’ knowledge and attitudes about breastfeeding revealed that these professionals do strongly advocate to their clients that breastfeeding is the optimum method of infant feeding (Pascoe et al., 2002). 18

19. Biomedical Factors WHO provides a list of medical conditions for both mothers and babies that affect breastfeeding (WHO, 2009). This report suggests permanent avoidance of breastfeeding for mothers who have HIV, and temporary avoidance of breastfeeding for mothers who have ; herpes simplex virus type 1 (HSV-1); illnesses that prevent mothers from taking care of their babies such as sepsis; and maternal medications that could affect the infants health. WHO provides, also, a list of health conditions including: breast abscess, hepatitis B, hepatitis C, mastitis, and tuberculosis, that mothers with these conditions could continue breastfeeding but they should consider bottle feeding instead. Also, infants with specific medical conditions including classic galactosemia, maple syrup urine disease, and phenylketonuria, should not receive breast milk or any other milk except specialized formula according to doctors’ orders. 19

20. On the other hand, other conditions including infants born weighing less than 1500g (very low birth weight), infants born at less than 32 weeks of gestational age (very pre-term), and newborn infants who are at risk of hypoglycemia, may need other food in addition to breast milk for a limited period ( WHO, 2009). Sources of Support Lack of support from a significant other and negative attitude of the significant other toward breastfeeding have been observed as major predictors of bottle feeding. Fathers who support bottle feeding are more likely to believe that “breastfeeding is bad for the breasts and interferes with sex” (p.509, Losch et al., 1995). Research shows that fathers have less knowledge about and positive attitudes toward breastfeeding compared to mothers (Sharma and Petosa, 1997). A study that evaluated a corporate lactation program that provided breastfeeding education and services for male employees and their partners showed that fathers who participated in breastfeeding education programs were more supportive of their partners and their female colleagues who breastfed. 20

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22. PROS OF BREASTFEEDING FOR THE BABY Breast milk is the most complete form of nutrition for infants: A mother's milk has just the right amount of fat, sugar, water, and protein that is needed for a baby's growth and development. Most babies find it easier to digest breast milk than they do formula. Increased survival: Studies in developing and industrialized countries confirm the life saving benefits of breastfeeding, particularly in preventing diarrhea, pneumonia and sudden infant death syndrome (SIDS) deaths. Decreased morbidity: Infectious and chronic illness is reduced by exclusive breastfeeding, beyond the impact of breastfeeding alone. Premature babies do better when breastfed compared to premature babies who are fed formula. 22

23. Adequacy: Mean intakes of human milk provide sufficient energy and protein to meet mean requirements during the first six months of infancy. Since infant growth potential drives milk production, the distribution of intakes likely matches the distribution of energy and protein requirements. Improved growth parameters: Exclusive breastfeeding helps overcome low birth weight (LBW) and reduces stunting. Reduced cardiac risk factors: Early breastfeeding, especially exclusive, is associated with reduced obesity and other factors related to heart disease. Breastfed infants grow exactly the way they should : They tend to gain less unnecessary weight and to be leaner. This may result in being less overweight later in life. Breastfed babies score slightly higher on IQ tests, especially babies who were born pre-maturely 23

24. Breast milk tastes good to your child: Breast milk is sweet and creamy, a flavor that is much different and, arguably, better than formula. Also, the taste of the foods you eat is passed along to your baby, which can diversify their diet right from the start. Breast milk is easy for your newborn to digest: Your body makes breast milk specifically for your baby. It is easier to digest than formula and may help prevent gas and colic. A breastfed baby's bowel movements are not as smelly, and they're not as irritating to a baby's skin and can reduce diaper rash. Breastfed babies tend to experience less diarrhea and constipation as well. Breast milk is the healthiest food for the baby: Breastfeeding provides your baby with a variety of health and developmental benefits. The natural ingredients found in breast milk help protect your baby from illness and disease during infancy. They also continue to provide your child with better health as he or she grows. 24

25. FOR THE MOTHER Nursing uses up extra calories, making it easier to lose the pounds of pregnancy. It also helps the uterus to get back to its original size and lessens any bleeding a woman may have after giving birth. Breastfeeding, especially exclusive breastfeeding (no supplementing with formula), delays the return of normal ovulation and menstrual cycles. Breastfeeding lowers the risk of breast and ovarian cancers, and possibly the risk of hip fractures and osteoporosis after menopause. Breastfeeding makes your life easier: It saves time and money. You do not have to purchase, measure, and mix formula. There are no bottles to warm in the middle of the night. A mother can give her baby immediate satisfaction by providing herbreast milk when her baby is hungry. 25

26. Breastfeeding requires a mother to take some quiet relaxed time for herself and her baby. Breastfeeding can help a mother to bond with her baby: Physical contact is important to newborns and can help them feel more secure, warm and comforted. Breastfeeding mothers may have increased self-confidence and feelings of closeness and bonding with their infants. Breastfeeding is natural: Breastfeeding is the most natural way to feed your baby. Your body was created as the ideal way to supply your child with the perfect source of nutrition. Breast milk is the healthiest food for your child: Breastfeeding provides your baby with a variety of health and developmental benefits. The natural ingredients found in breast milk help protect your baby from illness and disease during infancy. They also continue to provide your child with better health as he or she grows. 26

27. Exclusive breastfeeding can prevent another pregnancy for up to 6 months: If you breastfeed exclusively without adding any supplements, your child is under six months old, and your period has not yet returned, then you can use the lactational amenorrhea method (LAM) for birth control. When you meet the criteria and follow it correctly, this natural birth control method is up to 98 percent effective. You can always pump: Pumping your breast milk can give you a bit more freedom. It can make it easier for you to spend time away from your baby, so you can return to work or do other activities that you enjoy. It can also allow your partner to participate in feedings. Nighttime feedings are faster and easier: When you breastfeed, you don't have to make and warm bottles in the middle of the night. 27

28. Breastfeeding is relaxing: While you're breastfeeding, your body releases a hormone called oxytocin, a feel-good hormone that promotes relaxation. It also provides you with time each day to take a break, sit down with your feet up, and spend quality time with your baby. Breastfeeding delays the return of your period: Breastfeeding can prevent your period from returning for six months or even longer. Typically, menstruation returns approximately one month after you stop breastfeeding exclusively. Breastfeeding is convenient: Your breasts are the perfect way to supply your baby with the optimal nutrition at the perfect temperature. There's no need to worry about preparing and heating formula, and there won't be any bottles to clean up after feedings. Breastfeeding is comforting: A scared, injured, or sick child can be more easily comforted by breastfeeding. 28

29. FOR THE SOCIETY Breastfeeding saves on health care costs. Total medical care costs for the nation are lower for fully breastfed infants than never-breastfed infants since breastfed infants typically need fewer sick care visits, prescriptions, and hospitalizations. Breastfeeding contributes to a more productive workforce. Breastfeeding mothers miss less work, as their infants are sick less often. Employer medical costs also are lower and employee productivity is higher. Breastfeeding is better for our environment because there is less trash and plastic waste compared to that produced by formula cans and bottle supplies. Breastfeeding does have some physical costs for women. 29

30. CONS OF BREASTFEEDING Breast milk has agents (called antibodies) in it to help protect infantsfrom bacteria and viruses. Recent studies show that babies who are not exclusively breastfed for 6 months are more likely to develop a wide range of infectious diseases including ear infections, diarrhea, respiratory illnesses and have more hospitalizations. Also, infants who are not breastfed have a 21% higher postneonatal infant mortality rate in the U.S. Some studies suggest that infants who are not breastfed have higher rates of sudden infant death syndrome (SIDS) in the first year of life, and higher rates of type 1 and type 2 diabetes, lymphoma, leukemia, Hodgkin's disease, overweight and obesity, high cholesterol and asthma. More research in these areas is needed (American Academy of Pediatrics, 2005). Babies who are not breastfed are sick more often and have more doctor's visits 30

31. Also, when you breastfeed, there are no bottles and nipples to sterilize. Unlike human milk straight from the breast, infant formula has a chance of being contaminated You will have less freedom: When you breastfeed, you are always on call. You and your breasts need to be available for every feeding, day and night. It can be exhausting, especially during the first few months when you will be breastfeeding your baby every two to three hours around the clock. Breastfeeding can be painful: You may have to deal with some of the uncomfortable or even painful problems common with breastfeeding. These include things like mastitis, breast engorgement, plugged milk ducts, and sore nipples. Your partner can't breastfeed: Your partner might want to feed the baby and may feel left out of the breastfeeding relationship. 31

32. It can be stressful if you are very modest: Some women may feel uncomfortable and embarrassed about breastfeeding around others or in public. If you find it difficult to go out with your baby, you might end up staying home more often. This may lead you to experience loneliness or feel isolated. Breastfeeding can be difficult in the beginning: Not every baby latches on immediately or breastfeeds well. Breastfeeding might be harder than you think, and you may end up feeling disappointed or discouraged. For some, breastfeeding is a learning process. You will have to make the lifestyle choices: You have to think about your diet and lifestyle choices when you breastfeed. Your baby may have a reaction to different foods in your diet. So you may have to stop eating dairy products or other items that you enjoy. There are also some things that you should avoid like caffeine, alcohol, and nicotine which can be harmful to your baby. Stress and other factors can also affect breastfeeding and even decrease your breast milk supply. 32

33. CONCLUSION Breast milk remains the best and most secure form of nutrition for infants. The health benefits of exclusive breastfeeding to infants especially in developing countries should not be underrated. Breastfeeding is well recognized as the best food source for infants. It has been advocated as a cost effective means of improving the child’s health, mother’s health and mother - infant bonding. Breast feeding is the safest, least allergic and best infant feeding method. It has nutritional, immunological, behavioral and economic benefits and also provide desirable mother infant bonding. Despite the demonstrated benefits of breastfeeding, breastfeeding prevalence and duration in many countries, states and local governments are still lower than the international recommendation of exclusive breastfeeding for the first six months of life. 33

34. RECOMMENDATIONS To avert the problems of child malnutrition, morbidity and mortality, high rate of child infections that may arise from the lowering of the 6 months universal exclusive breastfeeding recommendation policy duration in developing countries, the 6 months of exclusive breastfeeding should instead be promoted in all developing countries and 4-6 months in all developed countries. The breastfeeding promotion programmes should be delivered by qualified and competent health professionals. The programmes should further highlight the importance of breastfeeding in relation to iron deficiency anaemia, child malnutrition, protection against infant infections, breastfeeding and food safety and hygiene and the health benefits that breastfeeding confers to the breastfeeding mothers. 34

35. Moreover, women’s rights and status have been found to be of much importance for the prevention of childhood malnutrition. Now is the time to conduct research accordingly, on promoting the effects of breastfeeding that do not take into account the real duration of breastfeeding before setting up generalized new recommendations. This will reduce possible bias in the exclusive breastfeeding recommendation policy, confusion among breastfeeding mothers and reduce the incidences of malnutrition in developing countries. 35

36. REFERENCES World Health Organization. Global Strategy for Infant and Young Child Feeding: the Optimal Duration of Exclusive Breastfeeding. World Health Organization, Geneva. 2001. Health Canada. Exclusive Breastfeeding Duration: Health Canada Recommendation. 2004. Available at: www.healthcanada.ca/nutrition. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dezikovich I and S Shapiro Promotion of breastfeeding intervention trial (PROBIT): a randomized trial in the Republic of Belarus. J. Am. Med. Assoc. 2001; 285 (4): 413–420. Labbok MA Effects of breastfeeding on mother. Pediatr. Clinics. North America. 2001; 48: 143–158. World Health Organisation. Global Data Bank on Infant and Young Child Feeding. 2009. UNICEF. Progress for children: a world fit for children. Statistical Review Number 6. New York. 2007. Hill A A Short Textbook of Medical Statistics. Hodder and Stoughton, London. 1977; 27 36

37. Kramer MS and R Kakuma The optimal duration of exclusive breastfeeding: a systematic review. World Health Organization (WHO/NHD/01.08; WHO/FCH/01.23). Geneva. 2001. Butte N, Lopez-Alarcon MG and C Garza Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. WHO, Geneva. 2002; 153-178. Hellin K and G Waller Mothers' mood and infant feeding: prediction of problems and practices. J. Reprod. Infant. Psychol. 1992;10: 39–51. Arora S, Mcjunkin C, Wehrer J and P Kuhn Major factors influencing breastfeeding rates: mother’s perception of father’s attitude and milk supply. Pediatr. 2000; 106 (5): 67–71. Bauchner H, Leventhal J and E Shapiro Studies of breast-feeding and infections: how good is the evidence? JAMA. 1986; 256:887–892. Committee on Nutrition American Academy of Pediatrics Pediatric Nutrition Handbook. Am. Acad. Pediatr. Elk Grove Village, Illinois. 1998. 37

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39. THANK YOU ALL FOR LISTENING… ANY QUESTION? 39