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LINKAGES n Academy for Educational Development n 1825 Connecticut Avenue, NW, Washington, DC 20009 Phone (202) 884-8700 n Fax (202) 884-8977 n E-mail linkages@aed.org n Website www.linkagesproject.org Q QFAQ SHEET 5 Frequently Asked Questions (FAQ) October 2002 Exclusive Breastfeeding:The Only Water Source Young Infants Need Healthy newborns enter the world well hydrated and remain so if breastfed exclusively, day and night,even in the hottest, driest climates. Nevertheless, the practice of giving infants water during the first sixmonths—the recommended period for exclusive breastfeeding—persists in many parts of the world,with dire nutritional and health consequences. This FAQ discusses these consequences and the role ofbreastfeeding in meeting an infant’s water requirements. Why is exclusive breastfeeding recom-mended for the first six months?International guidelines recommend exclusivebreastfeeding for the first six months based on scientificevidence of the benefits for infant survival, growth, and de-velopment. Breastmilk provides all the energy and nutrientsthat an infant needs during the first six months. Exclusivebreastfeeding reduces infant deaths caused by commonchildhood illnesses such as diarrhea and pneumonia, has-tens recovery during illness, and helps space births.Is early supplementation with water acommon practice? And if so, why?The practice of giving water and other liquids such as teas,sugar water, and juices to breastfed infants in the firstmonths is widespread throughout the world, as illustratedin Figure 1. This practice often begins in the first month oflife. Research conducted in the outskirts of Lima, Perushowed that 83 percent of infants received water and teas inthe first month. Studies in several communities of theGambia, the Philippines, Egypt, and Guatemala reportedthat over 60 percent of newborns were given sugar waterand/or teas.The reasons given for water supplementation of infants vary Source: Demographic and Health Surveys,1990-1995.Based on 24 hour recall for respondents’ children under 4 months of age at timeof survey 10025 i g e r i a a m b i a a n z a n i a a l i u r k e y n d i a h i l i p p i n e s a z a k h s t a n a r a g u a y m i n i c a n R e p . Not breastfedBreastmilk andother liquids/solidsBreastmilk andplain water onlyBreastmilk only Figure 1. Feeding Practices Among Young Infants QQ Q Q Exclusive Breastfeeding: The Only Water Source Young Infants Need ~ Frequently Asked QuestionsHow do breastfed babiesget enough water?Depending on temperature, humidity,and the infant’s weight and level ofactivity, the average daily fluid require-ment for healthy infants ranges from80–100 ml/kg in the first week of lifeto 140–160 ml/kg between 3–6months. These amounts are availablefrom breastmilk alone if breastfeedingis exclusive and unrestricted (on-de-mand day and night) for two reasons:Breastmilk is 88 percent water. Thewater content of breastmilk consumedby an exclusively breastfed baby meetsthe water requirements for infants andprovides a considerable margin ofsafety. Even though a newborn getslittle water in the thick yellowish firstmilk (colostrum), no additional wateris necessary because a baby is born withextra water. Milk with higher water con-tent usually “comes in” by the third orfourth day. Figure 2 shows the princi-pal components

of breastmilk.Breastmilk is low in solutes. One of themajor functions of water is to flush out,through the urine, excess solutes. Dis-solved substances (for example, so-dium, potassium, nitrogen, andchloride) are referred to as solutes.The kidneys—though immature up tothe age of approximately threemonths—are able to concentrate ex-cess solutes in the urine to maintain ahealthy, balanced body chemistry. Be-cause breastmilk is low in solutes, theinfant does not need as much water asan older child or adult.What about infants inhot, dry climates?Water in breastmilk exceeds theinfant’s water requirements in normalconditions and is adequate forbreastfed infants in hot, dry climates.Studies indicate that healthy, exclu-sively breastfed infants in the first sixmonths of life do not require addi-tional fluids even in countries with ex-tremely high temperatures and lowhumidity. Solute levels in the urineand blood of exclusively breastfed ba-bies living in these conditions werewithin normal ranges, indicating ad-equate water intakes.Can giving water to aninfant before six monthsbe harmful?Offering water before the age of sixmonths can pose significant healthhazards.Water supplementation increases therisk of malnutrition. Displacingbreastmilk with a fluid of little or nonutritional value can have a negativeimpact on an infant’s nutritional sta-tus, survival, growth, and development.Consumption of even small amounts ofwater or other liquids can fill aninfant’s stomach and reduce the baby’sappetite for nutrient-rich breastmilk.Studies show that water supplementa-tion before the age of six months canreduce breastmilk intake by up to 11percent. Glucose water supple-mentation in the first weekof life has been associ-ated with greaterweight loss andlonger hospitalstays.Water supplementation increases therisk of illness. Water and feedingimplements are vehicles for the intro-duction of pathogens. Infants are atgreater risk of exposure to diarrhea-causing organisms, especially in envi-ronments with poor hygiene andsanitation. In the least developedcountries, two in five people lack ac-cess to safe drinking water. Breastmilkensures an infant’s access to an ad-equate and readily available supply ofclean water.Research in the Philippines confirmsthe benefits of exclusive breastfeedingand the harmful effect of early supple-mentation with non-nutritive liquidson diarrheal disease. Depending onage, an infant was two to three timesmore likely to experience diarrhea ifwater, teas, and herbal preparationswere fed in addition to breastmilk thanif the infant was exclusively breastfed.Should water be given tobreastfed infants whohave diarrhea?In the case of mild diarrhea, increasedfrequency of breastfeeding is recom-mended. When an infant has moder-ate to severe diarrhea, caregiversshould immediately seek the advice ofhealth workers and continue tobreastfeed, as recommended in theIntegrated Management of ChildhoodIllness (IMCI) guidelines. Infants thatappear dehydrated may require OralRehydration Therapy (ORT), whichshould only be given upon advice of ahealth worker. Oral Rehydration Solution (ORS), used inORT, helps replace water and electrolyteslost during episodes of diarrhea. Super ORS,with a carbohydrate base of rice or cereal forbetter absorption, has been developed toimprove treatment. Source: Lawrence R. Breastfeeding: A guide for the medical profession. 4

th ed.St. Louis: Mosby-Year Book, Inc. 1994 Figure 2. Composition of Breastmilk Fat 3.8%Protein 0.9%Lactose 7.0%Other 0.2%Water 88.1% Q Exclusive Breastfeeding: The Only Water Source Young Infants Need ~ Frequently Asked QuestionsHow can programsaddress the commonpractice of watersupplementation?To address the widespread practiceof water supplementation in earlyinfancy, program managers shouldunderstand the cultural reasons forthis practice, analyze existing data,conduct household trials of im-proved practices, and develop effec-tive communication strategies fortargeted audiences.Health care providers and commu-nity volunteers need to be informedthat breastmilk meets the water re-quirements of an exclusivelybreastfed baby for the first sixmonths. They may also require train-ing on how to communicate mes-sages and negotiate behavior change.Examples of messages developed inbreastfeeding promotion programsthat address local beliefs and atti-tudes about the water needs of in-fants are shown in the box.Providing accurateinformation, tailoringmessages to address thebeliefs and concerns ofdifferent audiences, andnegotiating with mothersto try out a new behaviorcan help establish exclusivebreastfeeding as a newcommunity norm. Communicating the Message “Don’t Give Water” The following messages have been used in programs to convincemothers, their families, and health workers that exclusivelybreastfed infants do not need to be given water in the first sixmonths. The most effective ways of communicating the messagesdepend on the audience and the practices, beliefs, concerns, andconstraints to good practices in a particular setting.Make clear the meaning of exclusive breastfeeding s Exclusive breastfeeding means giving only breastmilk. Thismeans no water, liquids, teas, herbal preparations, or foodsthrough the first six months of life. (It is important to name thedrinks and foods commonly given in the first six months. Oneprogram found that women did not think the advice “do notgive water” applied to herbal teas or other fluids.)Take ideas often associated with water and apply them tocolostrum Colostrum is the welcoming food for newborns. It is also thefirst immunization, protecting a baby from illness. s Colostrum cleans the newborn’s stomach. Sugar water is notneeded.Explain why exclusively breastfed babies do not need water s Breastmilk is 88 percent water. s Every time a mother breastfeeds, she gives her baby waterthrough her breastmilk. s Breastmilk has everything a baby needs to quench thirst andsatisfy hunger. It is the best possible food and drink that can beoffered a baby so the baby will grow to be strong and healthy.Point out the risks of giving water s Giving water to babies can be harmful and cause diarrhea andillness. Breastmilk is clean and pure and protects againstdisease. An infant’s stomach is small. When the baby drinks water, thereis less room left for the nourishing breastmilk that is necessaryfor the infant to grow strong and healthy.Link good breastfeeding practices to adequate fluid intake s When a mother thinks her baby is thirsty, she should breastfeedimmediately. This will give the baby all the water that isneeded. LINKAGES n Academy for Educational Development n 1825 Connecticut Avenue, NW, Washington, DC 20009 Phone (202) 884-8000 n Fax (202) 884-8977 n E-mail linkages@aed.org n Website www.linkagesproject.o

rg Q Exclusive Breastfeeding: The Only Water Source Young Infants Need- Frequently Asked Questions is a publication ofLINKAGES: Breastfeeding, LAM, Related Complementary Feeding, and Maternal Nutrition Program,and was made possible through support provided to the Academy for Educational Development (AED)by the GH/HIDN of the United States Agency for International Development (USAID), under the termsof Cooperative Agreement No. HRN-A-00-97-00007-00. The opinions expressed herein are those of theauthor(s) and do not necessarily reflect the views of USAID or AED. What are the water needs of childrenafter six months of age?Guidelines for water intake after six months are less clearthan for the first half of infancy. At six months complemen-tary foods—foods given in addition to breastmilk to meet aninfant’s increased nutrient requirements—should be intro-duced. The types of foods a child consumes will affect thechild’s water needs. For the most part, the water require-ments of infants 6–11 months can be met throughbreastmilk. Additional water can be provided through fruitsor fruit juices, vegetables, or small amounts of boiled wateroffered after a meal.Caution should be taken to ensure that water and other liq-uids do not replace breastmilk. Water can also replace ordilute the nutrient content of energy-dense complementaryfoods. Gruels, soups, broths, and other watery foods given toinfants usually fall below the recommended energy densityfor complementary foods (0.6 kcal/g). Reducing theamount of water added to these foods could improve thenutritional status of children in this age group. ReferencesRelated LINKAGES Publications s Facts for Feeding: Birth, Initiation ofBreastfeeding, and the First Seven Days afterBirth, 2002 s Facts for Feeding: Breastmilk - A Critical Sourceof Vitamin A for Infants and Young Children, 2000 s Facts for Feeding: Recommended Practices toImprove Infant Nutrition during the First SixMonths, 2001 s Quantifying the Benefits of Breastfeeding: ASummary of the Evidence, 2002 s Recommended Feeding and Dietary Practicesto Improve Infant and Maternal Nutrition, 1999 Almroth SG, Bidinger P. No need for water supplementa-tion for exclusively breastfed infants under hot and aridconditions. T Roy Soc Trop Med H 1990; 84,602-4.Armelini PA, Gonzalez CF. Breastfeeding and fluid intakein a hot climate. Clin Pediatr 1979; 18:424-5.Brown K et al. Infant-feeding practices and theirrelationship with diarrheal and other diseases in Huascar(Lima), Peru. Pediatrics 1989 Jan;83(1):31-40.Glover J, Sandilands M. Supplementation of breastfeedinginfants and weight loss in hospital. J Hum Lact 1990Dec;6(4):163-6.Goldberg NM, Adams E. Supplementary water for breast-fedbabies in a hot and dry climate – not really a necessity. ArchDis Child 1983; 58:73-74.Hosssain M et al. Prelacteal infant feeding practices in ruralEgypt. J Trop Pediatr 1992 Dec; 38(6):317-22.Popkin BM et al. Breast-feeding and diarrheal morbidity.Pediatrics 1990 Dec; 86(6):874-82.Sachdev HPS et al. Water supplementation in exclusivelybreastfed infants during summer in the tropics. Lancet 1991April; 337:929-33.Victora C et al. Infant feeding and deaths due to diarrhea:A case-control study. Am J Epidemiol 1989 May;129(5):1032-41.World Health Organization. Breastfeeding and the use ofwater and teas. Division of Child Health and DevelopmentUpdate, No. 9 (reissued, Nov. 1997