DRAFT - Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months
A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada
This statement by the Infant Feeding Joint Working Group provides health professionals with evidence-informed principles and recommendations. Provinces, territories, and health organizations can use it as a basis for developing practical feeding guidelines for parents and caregivers in Canada.
This statement promotes the communication of accurate and consistent messages on infant nutrition in the first six months of life. Guidance on nutrition from six months to two years of age will be covered in a separate statement, available in 2013/14.
For information and ideas about how to answer the questions of parents and caregivers, see: In Practice: Talking to families about infant nutrition.
Principles and recommendations for infant nutrition from birth to six months
Breastfeeding - exclusively from birth for about the first six months, and sustained for up to two years or longer, with appropriate complementary feeding starting at six months -- is important for the nutrition, immunologic protection, growth, and development of infants and toddlers.
Breastfeeding is the normal and unequalled method of feeding infants.
- Recommend exclusive breastfeeding for about the first six months of life with the introduction of complementary foods at six months being led by the infant's signs of readiness.
Breastfeeding initiation and duration rates increase with active protection, support, and promotion.
- Implement the policies and practices of the Baby-Friendly Initiative (BFI) for hospitals and community health services.
Supplemental vitamin D is recommended for breastfed infants.
- Recommend a daily vitamin D supplement of 10 µg (400 IU) to breastfed infants.
First complementary foods should be iron-rich.
- Recommend meat, and meat alternatives, and iron-fortified cereal as an infant's first complementary foods.
Routine growth monitoring is important to assess infant health and nutrition.
- Use the World Health Organization (WHO) Growth Charts for Canada for optimal monitoring of infant growth.
Feeding changes are unnecessary for most common health conditions in infancy.
Continued breastfeeding is recommended for most health conditions in infancy.
- Explain that feeding changes do little to manage infantile colic.
- Educate about the wide variation in normal bowel function, noting that true constipation is rare.
- Reassure that reflux or 'regurgitation' is common and rarely needs treatment.
- Manage mild to moderate dehydration from acute gastroenteritis with oral rehydration therapy and continued breastfeeding.
Breastfeeding is rarely contraindicated.
Breastfeeding and special circumstances.
Comment
A section on the importance of breastfeeding in emergencies should be added – this should include poverty, lack of access to potable water, lack of dependable electricity sources…
- Recommend an acceptable alternative to breastfeeding for mothers who are HIV-infected.
- Advise that most medications are compatible with breastfeeding. Take a case-by-case approach when a mother is using medications or drugs.
Recommendations on the use of breastmilk substitutes
Some infants may not be exclusively breastfed for personal, medical, or social reasons. Their families need support to optimize the infant's nutritional well-being. The International Code of Marketing of Breast-milk Substitutes (WHO, 1981) advises health professionals to inform parents about the importance of breastfeeding, the personal, social, and economic costs of formula feeding, and the difficulty of reversing the decision not to breastfeed. Individually counsel those families who have made a fully informed choice not to breastfeed on the use of breastmilk substitutes.
Acknowledgements
The Infant Feeding Joint Working Group collaborated with Health Canada on this statement. Members of the working group came from the following organizations:
- Canadian Paediatric Society's Nutrition and Gastroenterology Committee (CPS)
- Dietitians of Canada (DC)
- Breastfeeding Committee for Canada (BCC)
- Public Health Agency of Canada (PHAC)
- Health Canada (HC)
The working group received guidance from the Infant Feeding Expert Advisory Group as well as broad stakeholder consultation.
Members of the Infant Feeding Expert Advisory Group: Alison Barrett, James Friel, Laura Haiek, Sheila Innis, Gerry Kasten, Jack Newman, Daniel Roth, Nancy Watters
Participants on the Infant Feeding Joint Working Group:Genevieve Courant (BCC), Jeff Critch (CPS), Jessica DiGiovanni (PHAC), Erin Enros (HC), Tanis Fenton (DC), Deborah Hayward (HC), Hélène Lowell (HC), Jennifer McCrea (HC), Brenda McIntyre (HC), Julie Voorneveld (PHAC), Christina Zehaluk (HC).
Breastfeeding is the normal and unequalled method of feeding infants.
- Recommend exclusive breastfeeding for about the first six months of life with the introduction of complementary foods at six months being led by the infant's signs of readiness.
Rationale
Exclusive breastfeeding from birth forduring the first six months of life is accepted as the nutrition standard for infants, according to the Dietary Reference Intakes (IOM, 2006). With exclusive breastfeeding, an infant is fed only breastmilk. The infant is given no other food or liquid, not even water (WHO, 2008). Infants who are exclusively breastfed may still receive vitamin and mineral supplements or medicines, in the form of drops or syrups. They may be given oral rehydration solution, if needed (WHO 2008).
The mother-baby dyad needs special recognition and support. “Mothers and babies form an inseparable biological and social unit; the health and nutrition of one group cannot be divorced from the health and nutrition of the other.” (WHO/UNICEF Global Strategy 2003).
Breastmilk supplies the correct quantity, quality, and absorption of nutrients (Butte, Lopez-Alarcon, & Garza, 2002). Infants digest it easily and efficiently (WHO, 2009). To support optimal growth, the balance of nutrients in breastmilk fluctuateschanges during feedings and over time to meet the infant’s unique growth and development requirementsas the infant matures (Kent et al., 2006; Riordan & Wambach, 2010). Beyond nutrients, breastmilk's unique and complex composition includes bioactive factors, such as growth factors, anti-infective immunoglobulins and white blood cells (Riordan & Wambach, 2010). It also contains factors that aid in the digestion and the absorption of nutrients (Hamosh, 1996; Sheard, 1988).
The importance of breastfeeding is well recognized for infants' short and long-term health (Horta, Bahl, Martines, & Victoria, 2007; Ip et al., 2007; León-Cava, Lutter, Ross, & Martin, 2002). For example, breastfeeding is associated with enhanced cognitive development, and appears to protect against gastrointestinal infections, acute otitis media, respiratory tract infection, and sudden infant death syndrome (Kramer et al., 2008; Quigley et al., 2011; Ip et al., 2007; Hauck, Thompson, Tanabe, Moon, & Vennemann, 2011). Observational research also points to the protective effect of breastfeeding against obesity later in life (Arenz, Rückerl, Koletzko & von Kries, 2004, Ip et al., 2007).
Breastfed infants self-regulate intake volume compared to infants who are fed by bottle, formula, or expressed breast milk. These infants will have increased bottle emptying, poorer self- regulation, and excessive weight gain in late infancy (older than 6 months) compared with infants who only nurse from the breast. (Li R, Fein SB, Grummer-Strawn LM. Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics. 2010;125(6). Available at: content/full/125/6/e1386)
Exclusive breastfeeding from birth to six months of age is associated with continued protection against gastrointestinal infections and illness (Kramer et al., 2003; Kramer & Kakuma, 2002) as well as from respiratory tract infections (Chantry, Howard, & Auinger, 2006). The breastfeeding mother also benefits from exclusively breastfeeding her infant to six months. Her return to pre-pregnancy weightweight loss is more rapid after birth and there may be a delayed return of menses (Kramer & Kakuma, 2002).
By about six months of age, infants are developmentally ready for other foods (Naylor & Morrow, 2001). The signs of physiological and developmental readiness include:
- Better head control
- Ability to sit up and lean forward
- Ability to let the caregiver know when they are full (i.e., turns head away)
- Showing an interest in food when others are eating (Grenier & Leduc, 2008)
At this stage, infants should be offered nutritious and safe complementary foods, along with continued breastfeeding (PAHO, 2003). The first foods introduced should be nutrient-rich family foods iron-rich.
Comment
- Adding the word “about” creates confusion in a population based policy statement.
- The definition of exclusive breastfeeding should include the words – “from birth”.
- The addition of the word “about” does not concur with the decisions of the World Health Assembly and the recommendations made in the WHO Global Strategy for Infant and Young Child Feeding (2003).
The WHA Resolution 54.2 para 2(4) urges Member states to:
“4) to strengthen activities and develop new approaches to protect, promote and support exclusive breastfeeding for six months as a global public health recommendation, taking into account the findings of the WHO expert consultation on optimal duration of exclusive breastfeeding”
The government of Canada agreed with Resolution 54.2 at the 54th World Health Assembly, May 2001.
The conclusion of the Naylor & Morrow(2001) expert review on which the WHO recommendations are based in part state:
“The consensus opinion of the expert review group was that given the available information and the lack of evidence of significant harm to either normal mothers or normal infants, there is no reason to conclude that exclusive breastfeeding should not continue to six months.”
The current WHO Executive Board recommendations state: Counselling and support for optimal breastfeeding (early initiation, exclusive breastfeeding for the first six months and continued breastfeeding up to two years of age or beyond). (WHO. 130th Session of the Executive Board. Report by the Secretariat. Maternal, infant and young child nutrition: draft comprehensive implementation plan. EB130/10, December 2011.)
References
[References removed for brevity. References can be viewed in Health Canada's online draft statement.]
Breastfeeding initiation and duration rates increase with active protection, support, and promotion.
- Implement the policies and practices of the Baby-Friendly Initiative (BFI) for hospitals and community health services.
Rationale
Breastfeeding initiation rates in Canada have increased considerably in recent decades, from less than 25% in 1965 (Millar & Maclean, 2005) to 87.5% in 2009 (Statistics Canada, 2010). Yet, of the mothers who initiate breastfeeding, some stop after less than one week, and more than 20% stop before their infant is one month old (Statistics Canada, 2010).
The percentage of Canadian mothers exclusively breastfeeding their infants to six months remains low, at 25% (Statistics Canada, 2010). That is why mothers require greater supportto breastfeed exclusively for the first six months, and to continue breastfeeding for up to two years or longer.
The WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) was created to improve breastfeeding outcomes for infants and their mothers (WHO/UNICEF, 2009). The BFHI practices have been shown to increase the duration and exclusivity of breastfeeding (Kramer et al., 2001, Merten, Dratva, & Ackermann-Liebrich, 2005; DiGirolamo, Grummer-Strawn, & Fein, 2008; Declercq, Labbok, Sakala, & O'Hara, 2009; Moore, Anderson, & Berman, 2009; Cattaneo & Buzzetti, 2001).
The BFHI is based on the evidence-informed policies and practices described in Ten Steps to Successful Breastfeeding, the Global Strategy for infant and Young Child Feeding (WHO/UNICEF, 2003), the International Code of Marketing of Breast-milk Substitutes, and subsequent World Health Assembly resolutionson nutrition for infants and young children.
Comment
One of the primary reasons why exclusive breastfeeding rates remain low is the lack of monitoring and enforcement of the provisions of the International Code and Subsequent WHA resolutions. The International Code is a fundamental tool to support mothers in their infant feeding decisions. Much more action is required to protect breastfeeding from commercial interference. This obligation should not be placed exclusively on BFHI implementation. Health Canada has a key leadership role and obligation to take action to ensure that the Code and Resolutions are given meaningful effect for all Canadian mothers and their children.
Include the following text:
The Global Strategy for Infant and Young Child feeding (WHO/UNICEF, 2003) Article 44 states that:
“44. Manufacturers and distributors of industrially processed foods in- tended for infants and young children also have a constructive role to play in achieving the aim of this strategy. They should ensure that processed food products for infants and children, when sold, meet applicable Codex Alimentarius standards and the Codex Code of Hygienic Practice for Foods for Infants and Children. In addition, all manufacturers and distributors of products within the scope of the International Code of Marketing of Breast-milk Substitutes, including feeding bottles and teats, are responsible for monitoring their marketing practices according to the principles and aim of the Code. They should ensure that their conduct at every level conforms to the Code, subsequent relevant Health Assembly resolutions, and national measures that have been adopted to give effect to both.”
In Canada, the Baby-Friendly Initiative (BFI) has been adapted from the BFHI to reflect the continuum of care between hospital and community services. It is described in the Integrated Ten Steps for Hospitals and Community Health Services. The 'Baby-Friendly' designation is given to a maternity hospital or a community health facility that puts the Ten Steps into practice and adheres to the Code. Implementation of the BFI is led by provincial and territorial governments in collaboration with the Breastfeeding Committee for Canada.
WHO/UNICEF's Ten Steps to Successful Breastfeeding (global criteria)
(Reproduced from WHO/UNICEF, 2009)
Step 1
Have a written policy on breastfeeding that is routinely communicated to all health care staff.
Step 2
Train all health care staff in the skills necessary to implement the policy.
Step 3
Inform all pregnant women about the benefits and management of breastfeeding.
Step 4
Help mothers initiate breastfeeding within a half-hour of birth. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.
Step 5
Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
Step 6
Give newborn infants no food or drink other than breastmilk, unless medically indicated.
Step 7
Practice rooming-in -- allow mothers and infants to remain together -- 24 hours a day.
Step 8
Encourage breastfeeding on demand.
Step 9
Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
Step 10
Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Breastfeeding Committee for Canada's Integrated Ten Steps for Hospitals and Community Health Services (the interpretation for Canadian practice)
(Reproduced from Breastfeeding Committee for Canada, 2011)
Step 1
Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.
Step 2
Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.
Step 3
Inform pregnant women and their families about the importance and process of breastfeeding.
Step 4
Place babies in uninterrupted skin-to-skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: encourage mothers to recognize when their babies are ready to feed, offering help as needed.
Step 5
Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.
Step 6
Support mothers to exclusively breastfeed for the first 6 months, unless supplements are medically indicated.
Step 7
Facilitate 24 hour rooming-in for all mother-infant dyads: mothers and infants remain together.
Step 8
Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
Step 9
Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).
Step 10
Provide a seamless transition between the services provided by the hospital, community health services, and peer-support programs. Apply principles of primary health care and population health to support the continuum of care. Implement strategies that affect the broad determinants that will improve breastfeeding outcomes.
Summary of the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions
This Code seeks to protect and promote breastfeeding by ensuring the ethical marketing of breastmilk substitutes by industry.
- No advertising of these products (i.e., formula, bottles, nipples, pacifiers) to the public.
- No free samples of these products to mothers
- No promotion of artificial feeding products in health care facilities, including the distribution of free or low-cost supplies
- No company representatives to advise mothers
- No gifts or personal samples to health workers
- No words or pictures idealizing artificial feeding, including pictures of infants on the labels of products
- Information to health workers should be scientific and factual.
- All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and the cost and hazards associated with artificial feeding.
- Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
WHA Resolution 39.28 (1986) - Any food or drink given before complementary feeding is nutritionally required mayinterfere with the duration or maintenance of breastfeeding and therefore shouldneither be promoted nor encouraged for use by infants during this period.The practice being introduced in some countries of providing infants with specially formulated milks (so-called follow-up milks) is not necessary.