Is exclusive breastfeeding an option or a necessity in Africa? A pooled study using the deuterium oxide dose-to-mother technique

Submitted: 12 July 2018
Accepted: 1 August 2019
Published: 29 April 2020
Abstract Views: 1294
PDF: 708
HTML: 20
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.


Given the valuable health, development, and economic benefits of human milk Exclusive Breastfeeding (EBF) is recommended by the World Health Organisation for the first six months of an infant’s life. Many resource-limited regions in Africa do not line-up with these recommendations, therefore EBF promotion efforts on the continent need to be scaled up and monitored. This study explores the human milk intake volumes of 5 countries (Benin, Central African Republic, Morocco, South Africa and Tanzania) both at country level and in a pooled sample of children at 3 months (n= 355) and at 6 months (n=193). Mean human milk intake volumes in the pooled samples were 697.6 g/day at 3 months and 714.9 g/day at 6 months. EBF was determined both by maternal recall as well as using the deuterium oxide dose-to-mother technique, using two different cut-offs of non-milk oral intake. Comparison of these results showed substantial over-reporting of EBF by maternal recall, which suggests that actual rates of EBF are even lower than reported, thus highlighting the importance of scaling-up EBF promotion strategies.

WHO. Infant and young child nutrition: global strategy on infant and young child feeding. Geneva, Switzerland; 2002.

Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016;387,475-90. DOI:

UNICEF. “From the first hour of life” Making the case for improved infant and young child feeding everywhere, UNICEF data and analytics, Division of data, research and policy and nutrition section, New York; 2016.

Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226-34. DOI:

Jones G, Steketee RW, Black RE, et al. How many child deaths can we prevent this year? Lancet 2003;362:65-71. DOI:

Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010;125:e1048-56. DOI:

Rollins NC, Bhandari N, Hajeebhoy N, et al. on behalf of The Lancet Breastfeeding Group. Why invest, and what will it take to improve breastfeeding practices? Lancet 2016;387:491-504.

UN Sustainable development goals 2016. (Accessed 09 July 2018).

Hatloy A, Oshaug A. Human milk: an invisible food resource. J Hum Lact 1997;13:299-305. DOI:

Aguayo VM, Ross J. The monetary value of human milk in Francophone west Africa: a PROFILES analysis for nutrition policy communication. Food Nutr Bull 2002;23:153-61. DOI:

Bernard JY, De Agostini, M, Forhan, A, et al. Breastfeeding duration and cognitive development at 2 and 3 years of age in the EDEN mother-child cohort. J Pediatr 2013;163:36-42 e1. DOI:

WHO Regional Office for Africa. Atlas of African Health Statistics 2018: universal health coverage and the Sustainable Development Goals in the WHO African Region, 2018.

Mulol H, Coutsoudis A. Breastmilk output in a disadvantaged community with high HIV prevalence as determined by the deuterium oxide dose-to-mother technique. Breastfeed Med 2016;11:64-9. DOI:

WHO, UNICEF. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV, Geneva 2016.

WHO. Acceptable medical reasons for use of breast-milk substitutes 2009,1-11. (Accessed 09 July 2018).

International Business Times, Sep 8, 2016. (Accessed 09 July 2018).

WHO. Progress on sanitation and drinking water. Update and MDG assessment, WHO Press; 2015.

Sachdev HP, Krishna J, Puri RK, et al. Water supplementation in exclusively breastfed infants during summer in the tropics. Lancet 1991;337:929-33. DOI:

WHO. Indicators for assessing infant and young child feeding practices. Part 1 Definitions. Geneva, Switzerland; 2008.

Li R, Scanlon KS, Serdula MK. The validity and reliability of maternal recall of breastfeeding practice. Nutr Rev 2005;63:103-10. DOI:

Coward WA, Cole TJ, Sawyer MB, Prentice AM. Breast-milk intake measurement in mixed-fed infants by administration of deuterium oxide to their mothers. Hum Nutr-Clin Nutr 1982;36:141-8.

IAEA. Stable isotope technique to assess intake of human milk in breastfed infants, Human health series no. 7, Vienna; 2010. Available from (Accessed 09 July 2018).

Da Costa TH, Haisma H, Wells JC, et al. How much human milk do infants consume? Data from 12 countries using a standardized stable isotope methodology. J Nutr 2010;140:2227- 32. DOI:

Moore SE, Prentice AM, Coward WA, et al. Use of stable-isotope techniques to validate infant feeding practices reported by Bangladeshi women receiving breastfeeding counseling. Am J Clin Nutr 2007;85:1075-82. DOI:

Medoua GN, Sajo Nana EC, Ndzana AC, et al. Breastfeeding practices of Cameroonian mothers determined by dietary recall since birth and the dose-to- the-mother deuterium-oxide turnover technique. Matern Child Nutr 2012;8:330-9. DOI:

Samuel TM, Thomas T, Bhat S, Kurpad AV. Are infants born in baby-friendly hospitals being exclusively breastfed until 6 months of age? Eur J Clin Nutr 2012;66:459-65. DOI:

Motswagole BS, Matenge STP, Mongwaketse T, et al. Application of the deuterium-oxide dose-to-mother technique to determine the exclusivity of breasfeeding in women in Kanye, Botswana. South Afr J Clin Nutr 2015;28:128-33. DOI:

Mulol H, Coutsoudis A. Limitations of maternal recall for measuring exclusive breastfeeding rates in South African mothers. Int Breastfeed J 2018;13:19. DOI:

Diana A, Liu Z, Luftimas D, et al. Development of a non-milk water intake cutoff to identify exclusive breastfed infants using the deuterium oxide dose-to-mother technique. Ann Nutr Metab 2017;71(Suppl 2):1119.

Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa

statistic. Fam Med 2005;37:360–3. DOI:

Fleiss JL, Cohen J. The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability. Educ Psychol Meas 1973;33:613-9. DOI:

Ghasemi A, Zahediasl S. Normality tests for statistical analysis: a guide for non-statisticians. Int J Endocrinol Metab. 2012;10:486-9. DOI:

Supporting Agencies

International Atomic Energy Agency

Mulol, H., Coutsoudis, A., Amoussa Hounkpatin, W., Urio, E., Kenguela Wabolou, P., Sissinto, Y., & El-Kari, K. (2020). Is exclusive breastfeeding an option or a necessity in Africa? A pooled study using the deuterium oxide dose-to-mother technique. Journal of Public Health in Africa, 11(1).


Download data is not yet available.