Consultation - Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months - DRAFT

• This is a joint statement of the Canadian Paediatric Society, Dietitians of Canada, and Health Canada. It supplies health professionals with the information they need to give consistent messages about infant nutrition to parents and caregivers across Canada.
  +/-
  The statement's nine principles and related recommendations support the best possible nutrition for healthy term infants during the first six months of life. Provinces, territories, and health organizations can use this statement as a basis for developing practical feeding guidelines.

Principles and recommendations for infant feeding from birth to six months

Breastfeeding provides nutritional, immunological, and emotional benefits to infants and toddlers. Breastmilk is the best food for healthy growth and development. Healthy term infants should be exclusively breastfed to six months of age and then continue to be breastfed with appropriate complementary feeding to two years of age and beyond.

1. Breastfeeding is the normal and unequalled method of feeding infants. +/-
   1.1 Recommend exclusive breastfeeding for the first six months of life.
2. Breastfeeding increases with active protection, support, and promotion by hospitals, workplaces, and the community. +/-
   2.1 Have a written breastfeeding policy and educate all personnel on how to implement the policy.
   2.2 Explain the benefits and management of breastfeeding to pregnant women and their families.
   2.3 Teach mothers how to breastfeed and how to maintain breastmilk supply if separated from their infant.
   2.4 Encourage skin-to-skin contact and keep mothers and infants together.
   2.5 Discourage advertising and distribution of free samples of formula, bottles, nipples and pacifiers.
   2.6 Facilitate the transition between hospital and community services by providing professional and peer support for breastfeeding women.
   2.7 Support flexible work schedules and environments that permit expressing and storing of breastmilk for continued breastfeeding.
   
   Recommendations 2.1 - 2.7 are based on the evidence-informed policies and practices of the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI), including the Ten Steps to Successful Breastfeeding and the International Code of Marketing Breast Milk Substitutes.
3. Breastfeeding is rarely contraindicated. +/-
   3.1 Recommend an acceptable alternative to breastfeeding for mothers who are HIV infected. Very few other maternal infections contraindicate breastfeeding.
   3.2 Take a case-by-case approach when a mother is using drugs. Most medications are compatible with breastfeeding.
   3.3 Advise mothers to limit their alcohol intake. Mothers, who drink once in a while, in moderation, should continue to breastfeed.
   3.4 Encourage mothers who smoke to stop or reduce smoking. However, even if they keep smoking, breastfeeding is still the best choice.
4. In Canada, all infants need supplemental vitamin D. +/-
   4.1 Give a daily vitamin D supplement of 10 µg (400 IU) to breastfed infants, starting at birth.
   
   Infants fed commercial infant formula get sufficient supplemental vitamin D from the formula.
5. Commercial infant formulas are the only acceptable alternative to breastmilk. +/-
   5.1 If an infant is not breastfed or is only partially breastfed, recommend cow's milk-based formulas.
   5.2 Limit the use of soy-based formulas to infants who have galactosemia or cannot consume dairy-based products for cultural or religious reasons.
   5.3 Recommend formulas for special medical purposes only when you detect or suspect pathology in the infant.
   5.4 Cow's milk, evaporated milk formula, goat's milk, soy beverage, rice beverage, and all other beverages are inappropriate alternatives to breastmilk.
6. Milk provided to infants must be free of pathogens and fed safely. +/-
   6.1 Advise parents and caregivers to use proper preparation and storage practices to reduce the risk of bacteria-related illness.
   6.2 Warn of the risk of choking if infants are left alone while feeding. Explain the dangers of "propping" a bottle.
7. Routine growth monitoring is important for assessing infant health and nutrition. +/-
   7.1 Use the World Health Organization (WHO) Growth Charts for Canada for optimal monitoring of infant growth.
8. Avoid unnecessary interventions for common infant health conditions and illnesses. +/-
   8.1 Explain that feeding changes do little to manage infantile colic.
   8.2 Educate about the wide variation in normal bowel function in infants to avoid unnecessary interventions.
   8.3 Provide reassurance that gastroesophageal reflux (regurgitation or 'spitting up') is common in healthy infants and rarely needs treatment.
   8.4 Manage mild to moderate dehydration from acute gastroenteritis with continued feeding and an oral electrolyte solution.
9. At six months, infants need complementary foods along with continued breastfeeding to meet their nutrient needs. +/-
   9.1 Recommend complementary feeding beginning at six months with continued breastfeeding.
   9.2 Recommend nutrient-rich foods with iron as the infant's first complementary foods.

Acknowledgements

The Infant Feeding Joint Working Group collaborated on the preparation of this statement. Its members came from:

• Canadian Paediatric Society's Nutrition Committee
• Dietitians of Canada
• Public Health Agency of Canada
• Health Canada.

The working group received advice and guidance on the content of this statement from:

• Infant Feeding Expert Advisory Group
• Broad stakeholder consultation.

1. Breastfeeding is the normal and unequalled method of feeding infants.

1.1 Recommend exclusive breastfeeding for the first six months of life.

Exclusive breastfeeding means that an infant is fed only breastmilk. The infant receives no solids and no other liquids (not even water), with the following exceptions:

• vitamin or mineral supplements
• medicines
• oral rehydration therapy (WHO/UNICEF USAID, 2008).

• Benefits for infants
• Benefits for breastfeeding mothers
• Benefits of breastfeeding for the community
• In practice: Talking to families about infant nutrition
• References

Benefits for infants

Nutrition and digestion
Exclusive breastfeeding for the first six months of life is accepted as the nutrition standard for infants according to the Dietary Reference Intakes (IOM 2006). Infants digest breastmilk easily and efficiently. It supplies the best quantity, quality, and absorption of protein, fatty acids, iron, and zinc (Butte et al. 2002).

As long as infants are getting enough breastmilk and supplemental vitamin D exclusive breastfeeding will meet the energy and nutrient needs of infants to six months of age (Butte et al. 2002). However, infants who are small for their gestational age, or born to iron-deficient mothers or mothers with diabetes, are at increased risk of iron deficiency. They may benefit from iron supplements with continued exclusive breastfeeding (AAP 2005, Dewey et al 1998, Savoie et al 2002, Innis et al 1997, Georgieff et al. 1990, Friel 2003).

{NOTE to Stakeholders: The authors of this draft statement are aware of the newly published recommendation by the American Academy of Pediatrics (AAP) to supplement breastfed infants with iron (Baker et al. 2010). The evidence base for the recommendation is being considered. Stakeholder input on this issue received through this consultation will also be considered in finalizing the recommendations for Nutrition for Healthy Term Infants.}

There is much to learn about the unique and complex composition of breastmilk and colostrum. Bioactive components have been identified that aid digestion and the development of the lining of the infant's digestive tract. Other bioactive components may play a role in the development of the nerves and retina (WHO 2009).

The immune system
The anti-infective properties of breastmilk and colostrum reduce infant illness (WHO 2009). For example, acute infections such as otitis media are less common and less severe in breastfed infants than in formula-fed infants. This is particularly true for those exclusively breastfed for more than three or six months (Ip et al. 2007).

Infants who are breastfed longer have less risk of respiratory and gastrointestinal infections than those breastfed for shorter periods (Chantry et al. 2006, Kramer et al. 2003) or never breastfed (Duijts et al. 2010). Exclusive breastfeeding for four months or more is associated with a reduced risk of hospitalization from lower respiratory tract infection (Ip et al. 2007).

The evidence is controversial and unclear for the effect of breastfeeding on the development of allergies. Exclusive breastfeeding to six months does not appear to strongly affect the risk of developing allergies (Kramer & Kakuma 2002). However, several health bodies recommend exclusive breastfeeding for at least four months to decrease the risk of allergy in infants with a positive family history (Greer et al 2008. ESPGHAN 2008, Muraro et al. 2004, Høst et al. 2008).

Children with a strong family history of allergies have a reduced risk of developing atopic dermatitis if exclusively breastfed for three months or more (Gdalevich et al. 2001, Benn et al 2004). Studies have also reported a protective effect of breastfeeding against asthma, but the more recent studies have not shown consistent results (Ip et al. 2007, Scholtens et al. 2009).

To date restricting a breastfeeding mother's diet has not been shown to be effective in preventing an allergy in the infant (Greer et al. 2008, Venter et al 2009).

Intelligence and behaviour
A large number of observational studies have found an association between breastfeeding and cognitive development in children (Ip et al. 2007, Der et al 2006). The Promotion of Breastfeeding Intervention Trial (PROBIT), a large randomized trial to promote breastfeeding in Belarus, found that increased rates and longer average duration of breastfeeding was associated with higher IQ scores, particularly verbal scores, when children were tested at 6 ½ years (Kramer et al. 2008a). However, child behaviour including emotional conduct, hyperactivity and prosocial behaviour were not influenced by breastfeeding or breastfeeding duration (Kramer et al. 2008b).

Longer-term health and other benefits for infants
Observational research points to a protective effect of breastfeeding against obesity and type 2 diabetes later in life (Ip et al. 2007, Horta et al. 2007). However, in PROBIT neither breastfeeding nor breastfeeding duration were associated with child BMI, adiposity or blood pressure, or with dental caries when measured at 6 1/2 years of age (Kramer et al. 2009, 2007a, b). Long-term follow-ups from the PROBIT study will be helpful in clarifying benefits for breastfed infants as they grow-up.

An association between breastfeeding for more than six months and a reduced risk of two of the three main types of leukemia has been reported, but further high quality studies are needed in this area (Guise et al 2005, Ip et al. 2007).

Sudden infant death syndrome (SIDS)
Observational studies suggest a link between breastfeeding and a reduced risk of sudden infant death syndrome (Ip et al. 2007,). However, other risk factors, such as household smoke exposure and infant sleep position (other than supine) have stronger links with SIDS (Mitchell 2007, Ip et al. 2007).

Benefits for breastfeeding mothers

Postpartum weight loss
Women who exclusively breastfeed for longer may have a slightly greater postpartum weight loss (Kramer & Kakuma 2002).

Delayed menses
Mothers who exclusively breastfeed their infant to six months benefit from a longer delay in the return of menstruation, compared to those who partially breastfeed (Kramer & Kakuma 2002). Delaying the return to menses may mean increased birth spacing and reduced maternal iron losses (Dewey et al. 2001).

Diabetes
Breastfeeding mothers who did not develop gestational diabetes had a reduced risk of developing type 2 diabetes in later life (Stuebe et al. 2005). Breastfeeding for as little as one month may give this protection (Schwarz et al 2010). Diabetes among women is increasingly prevalent, and promotion, support and protection of breastfeeding should not be overlooked in strategies to target this chronic disease.

Breast cancer
Consistent evidence links breastfeeding to a reduced risk of breast cancer (Ip et al.2007). Studies show that breastfeeding may also be associated with a reduced risk of maternal ovarian cancer (Ip et al. 2007).

Depression
There is some evidence that postpartum depression is linked with breastfeeding for only a short time or not at all. However, it is not known if breastfeeding alters the risk of depression or if the depression itself leads the mother to stop breastfeeding (Ip et al. 2007).

Benefits of breastfeeding for the community

Breastfeeding is the least expensive method of feeding infants. The cost of not breastfeeding affects household budgets as well as the greater economy. There are more health care costs and mothers need more sick leave because of more frequent infant illness (Leon-Cava et al. 2002, Bartick & Reinhold 2010). Breastfeeding is also an ecologically sound method of infant feeding. It reduces packaging and waste, and promotes efficient use of land, water and energy.

In practice: Talking to families about infant nutrition

What can be done to help ensure good breastmilk supply?
Breastfeeding is a system of demand and supply. To establish good breastmilk production and flow for exclusive breastfeeding, infants need to feed as often and for as long as they want.

Skin-to-skin contact between mother and infant should be encouraged. After finishing the first breast, the infant is allowed to come off the breast for a short break before being offered the other side. This is infant-led feeding.

The goal in infant-led feeding is for the mother to recognize and respond to the infant's appetite and hunger cues. These cues include restlessness, rooting with the mouth to find the breast, or sucking a hand. Infants who are fed when they are hungry will obtain what they need for satisfactory growth, provided that they are suckling effectively. Providing other liquids or foods interferes with the system of demand and supply.

Infant-led feeding encourages self-regulation. It may protect against a tendency to over-feed from a cup or bottle in late infancy (Li et al. 2010).

What is a healthy diet for a breastfeeding mother?
The quality of a breastfeeding mother's diet is important for her health and energy. Diet quality has less of an effect on milk production and composition for most nutrients. Milk composition relies on the mother's nutrient stores (Riordan & Wambach 2010). While breastfeeding her infant, a woman needs to consume more nutrients to conserve her nutrient stores, and enough fluids to satisfy her thirst.

Most often, her nutritional needs can be met with a balanced diet and by following the advice for breastfeeding women in Eating Well with Canada's Food Guide. Mothers with very restricted diets, such as vegans, will likely need additional vitamin and mineral supplements.

Severe dieting (weight loss of over .7 kg/wk) can reduce the breastfeeding mother's milk supply (Riordan & Wambach 2010). After pregnancy, emphasize gradual weight loss through breastfeeding and keeping up a healthy and active lifestyle.

References

American Academy of Pediatrics. 2005. Breastfeeding and the use of human milk. Pediatrics Vol. 115 No. 2.496-506.

Baker RD, Greer FR and the American Academy of Pediatrics' Committee on Nutrition. 2010. Clinical report diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 126 [In Press].

Bartick M., Reinhold A. 2010. The Burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics. 125: e1048-e1056.

Benn et al. 2004. Breastfeeding and risk of atopic dermatitis by parental history of allergy, during the first 18 months of life. Am J Epidemiol. 160:217-223.

Butte N, Lopez-Alarcon M, Garza C. 2002. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva. World Health Organization.

Chantry C, Howeard C, Auinger P. 2006. Full breastfeeding duration and associated decrease in respiratory tract infection in US children. Pediatrics. 117: 425-432.

Der G, Batty Dm Deary IJ. 2006. Effect of breast feeding on intelligence in children: prospective study, sibling pairs analysis, and meta-analysis. BMJ.

Dewey et al. 2001. Effects of exclusive breastfeeding for four versus six months on maternal nutritional status and infant motor development: Results of two randomized trials in Honduras. J of Nutr. 131:262-7.

Dewey KG et al. 1998. Effects of the age of introduction of complementary foods on iron status of breastfed infants in Honduras. AJCN.67:878-884.

Duijts L., Jaddoe V., Hofman A., Moll H. 2010. Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy. Pediatrics.126: e18-e25.

ESPGHAN Committee on Nutrition. 2008. Complementary feeding: A commentary by the ESPGHAN. J Pediatr Gastroenterol Nutr 2008 46:99-110.

Friel JK, Aziz K, Andrews WL, Harding SV, Courage ML, Adams RJ. 2003. A double-masked, randomized control trial of iron supplementation in early infancy in healthy term breast-fed infants. J Pediatr. 143: 582-6.

Gdalevich M et al. 2001. Breastfeeding and the onset of atopic dermatitis in childhood: A systemic review and meta-analysis of prospective studies. J Am Acd Dermatol. 45(4):520-527.

Georgieff MK, Landon MB, Mills MM, Hedlund BE, Faassen AE, Schmidt RL, Ophoven JJ, Widness JA. 1990. Abnormal iron distribution in infants of diabetic mothers: spectrum and maternal antecedents. J Pediatr. 117(3): 455-61.

Greer et al. 2008. Effects of early nutritional interventions on the development of atopic disease in infants and children. Pediatrics.121; 183-191.

Guise JM, Austin D, Morris CD. 2005. Review of case-control studies related to breastfeeding and reduced risk of childhood leukemia. Pediatrics. 116(5):e724-e731.

Horta et al. 2007. Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analyses. Geneva. WHO.

Høst A, Halken S, Muraro A et al. 2008. Review up-date: dietary prevention of allergic diseases in infants and small children. Pediatr Allergy Immunol. 19:1-4

Innis SM, Nelson CM, Wadsworth LD, MacLaren IA, Lwanga D. 1997. Incidence of iron-deficiency anaemia and depleted iron stores among nine-month-old infants in Vancouver Canada. CJPH. 88(2): 80-4.

Institute of Medicine. 2006. Dietary Reference Intakes - The Essential Guide to Nutrient Requirements. Washington DC. National Academies Press.

Ip et al. 2007 Breastfeeding and maternal and infant health outcomes in developed Countries. AHRQ publication No. 07-E007. Rockville, MD. Agency for Healthcare Research and Quality.

Kramer et al. 2008a. Breastfeeding and child cognitive development: New evidence from a large randomized trial. Arch Gen Psychiatry. 65(5): 578-584.

Kramer M., Fombonne E., Igumnov S., Vanilovich I., Matush L., Mironova E., Bogdanovich N., Tremblay R., Chalmers B., Zhang X., Platt R., for the Promotion of Breastfeeding Intervention Trial Study Group. 2008b. Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: Evidence from a large, randomized trial. Pediatrics. 121: e435-e440.

Kramer M.S. et al. 2003. Infant growth and health outcomes associated with 3 compared with 6 months exclusive breastfeeding. Am J Clin Nutr. 78:291-295.

Kramer M.S., Kakuma. 2002.  The optimal duration of exclusive breastfeeding: A systematic review.

Kramer, MS., Matush, L, Vanilovich, I. Platt, R.,Bogdanovich, N., Sevkovskaya, Z., Dzikovich, I., Shishko, G., Collet, J-P., Martin, R., Gillman, MW., Davey Smith, G., Chalmers, B., Hodnett, E., Shapiro, S., for the Promotion of Breastfeeding Intervention Trial Study Group. 2007a. Effects of prolonged and exclusive breastfeeding on child height, weight, adiposity and blood Pressure at 6.5 years: Evidence from a large randomized trial. American Journal of Clinical Nutrition. 86; 1717-21.

Kramer, MS., Vanilovich, I. Matush, L, Bogdanovich, N., Zhang, X., Shishko, G., Muller-Bolla, M. Platt, RW. for the Promotion of Breastfeeding Intervention Trial (PROBIT) Study Group. 2007b. The effect of prolonged and exclusive breast-feeding on dental caries in early school-age children. Caries Res. 41: 484-488.

Kramer MS, Matush L, Vanilovich I, Platt RW, Bogdanovich N, Sevkovskaya Z , Dzikovich I, Shishko G, Collet JP, Martin RM, Smith GD, Gillman MW, Chalmers B, Hodnett E, Shapiro S. 2009. A Randomized Breast-feeding Promotion Intervention Did Not Reduce Child Obesity in Belarus. Journal of Nutrition. 139:417s-421s.

León-Cava N, Lutter C, Ross J et al. 2002. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington: Pan American Health Organization.

Li R, Fein S, Grummer-Strawn L. 2010. Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics;125: e1386 - e1393.

Mitchell EA. 2007. Recommendations for sudden infant death syndrome prevention: a discussion document. Arch Dis Child. 92(2): 155-159.

Muraro et al. 2004. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations (by an expert group of European Academy of Allergology and Clinical Immunology). Pediatr Allergy Immunol. 15:291-307.

Riordan J, Wambach K. 2010. Breastfeeding and human lactation. Jones and Bartlett Publishers, Inc. Sudbury MA. pp 497-518.

Savoie N & Rioux FM. 2002. Impact of maternal anemia on the infant's iron status at 9 months of age. CJPH. 203-7.

Scholtens S, Wijga AH, Brunekreef B, Kerkhof M, Hoeskstra MO, Gerritsen J, Aalberse R de Jongste JC, Smit HA. 2009. Breast feeding, parental allergy and asthma in children followed for 8 years. The PIAMA birth cohort study; 64. 604-609.

Schwarz EB, Brown JS, Creasman JM, Stuebe A, McClure CK, Van Den Eeden SK, Thom D. 2010. Lactation and maternal risk of type 2 diabetes: A population-based study. The American Journal of Medicine 123. 863. e1- 863.e6.

Stuebe AM, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. 2005. Duration of lactation and incidence of type 2 diabetes. JAMA.294(20):2601-10

Venter C, Pereira B, Voigt K, Grundy J, Clayton CB, Higgins B, Arshad SH, Dean T. 2009. Factors associated with maternal dietary intake, feeding and weaning practices, and the development of food hypersensitivity in the infant. Pediatr Allergy Immunol. 20: 320-327.

WHO. 2009. Infant and young child feeding (model chapter for textbooks for medical students and allied health professionals) pp 9-17. Geneva. World Health Organization.

WHO/UNICEF/USAID. 2008. Indicators for assessing infant and young child feeding practices. Geneva. World Health Organization.

2. Breastfeeding increases with active protection, support and promotion by hospitals, workplaces, and the community. - DRAFT

2.1 Have a written breastfeeding policy and educate all personnel on how to implement the policy.

2.2 Explain the benefits and management of breastfeeding to pregnant women and their families.

2.3 Teach mothers how to breastfeed and how to maintain breastmilk supply if separated from their infant.

2.4 Encourage skin-to-skin contact and keep mothers and infants together.

2.5 Discourage advertising and distribution of free samples of formula, bottles, nipples and pacifiers.

2.6 Facilitate the transition between hospital and community services by providing professional and peer support for breastfeeding women.

2.7 Support flexible work schedules and environments that permit expressing and storing breastmilk for continued breastfeeding.

Health professionals can create supportive environments for breastfeeding by promoting this practice as the normal way of feeding infants, anytime and anywhere. Recommendations 2.1 - 2.7 are based on the evidence-informed policies and practices of the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI), including the Ten Steps to Successful Breastfeeding and the International Code of Marketing Breast Milk Substitutes.

In Canada, the Baby-Friendly Initiative (BFI) had been adapted from the BFHI to reflect the continuum of care between hospital and community services. BFI is led by provincial and territorial governments in collaboration with the Breastfeeding Committee for Canada.

The PROBIT assessed the impact of the breastfeeding promotion, support and protection provided in BFHI designated hospitals. Among the reported results was a significant increase in the duration and exclusivity of breastfeeding among the women who received breastfeeding support and education. These women were much more likely to breastfeed a subsequent child exclusively and for a long duration (Kramer et al. 2008).

Currently, only twenty-five percent of Canadian mothers breastfeed exclusively to six months (Statistics Canada 2010). However, breastfeeding initiation rates in Canada have increased considerably in the last four decades, from less than 25% in 1965 (Millar & Maclean 2005) to 87.5% in 2009 (Statistics Canada 2010). Of the 87.5% of mothers who begin to breastfeed, more than half continue to six months or longer, and nearly 16% continue beyond one year (Statistics Canada 2010).

Yet, of the mothers who initiate breastfeeding, some will stop after less than one week, and more than 20% will stop before their infant is one month of age. There remains much to be done to support mothers to breastfeed exclusively for the first six months, and to continue breastfeeding for two years or more.

• Factors that influence a mother's decision to breastfeed
• Breastfeeding policy and implementation
• Pre- and postnatal counselling and assistance
• Community supports for breastfeeding
• Support in the workplace
• In practice: Talking to families about infant nutrition
• References

Factors that influence a mother's decision to breastfeed

The reason Canadian mothers most often give for not breastfeeding or trying to breastfeed is: "Bottle feeding is easier." (Health Canada 2010)

Demographic factors
Studies have found that breastfeeding mothers are typically married, educated, and of higher socio-economic status than women who choose not to breastfeed or who do so for a shorter time (Health Canada 2010). Young mothers (particularly adolescents), Aboriginal mothers, and Black mothers are less likely to breastfeed than older women from other ethnic backgrounds (Health Canada 2010, Thulier & Mercer 2009).

Biological factors
Researchers (Winjndaele et al. 2009; Weiser et al 2005; Rebhan et al. 2009; Thulier & Mercer 2009; Donath & Amir 2008) identified several factors that hinder breastfeeding including:

• perceived or actual insufficiency of milk supply
• infant health problems
• maternal obesity
• difficulty breastfeeding, such as pain or infection
• maternal smoking.

The relationship between breastfeeding and parity is unclear. The impact of caesarean birth on breastfeeding appears to have changed over time. In most cases today, caesarean birth does not impede breastfeeding (Thulier & Mercer 2009).

Social and behavioural factors
A mother's return to paid, full-time work is strongly negatively associated with breastfeeding duration (Hawkins et al. 2007b). Support from her own mother, partner, or friends has a strong influence on the duration of breastfeeding (Thulier & Mercer 2009).

Support from health professionals also impacts breastfeeding. Inconsistent, unfavourable, and even neutral attitudes towards breastfeeding on the part of health professionals are negatively associated with breastfeeding duration (Thulier & Mercer 2009). On the other hand, positive support is related to improved duration and exclusivity of breastfeeding. Results from the PROBIT demonstrate the importance of adherence to UNICEF's BFHI practices by health professionals in helping women to breastfeed (Kramer 2001).

Perhaps the most important influence on breastfeeding initiation and duration is the intention to breastfeed. Intention to breastfeed is influenced by a mother's level of confidence, interest, and attitudes towards breastfeeding. Di Girolamo et al (2008) found that intention to breastfeed more strongly influenced breastfeeding initiation and duration than early breastfeeding experiences. Scott et al. (2006, 2004) found that the mother's attitude towards breastfeeding had a bigger influence on breastfeeding initiation and duration than social and demographic factors.

For mothers who breastfeed, at least for a short time, the most common reason for stopping is "not enough milk" (Health Canada 2010). However, it is believed that in most cases the lack of milk is perceived rather than actual (Gatti 2008; Lewallen et al. 2006; Thulier & Mercer, 2009). Only a small percentage of women are unable to fully lactate, due to breast abnormalities, surgery, or hormonal aberrations.

Access to skilled, face-to-face support from peers, health professionals, as well as support from her partner, family, and friends can improve breastfeeding and the mothers' ability to determine whether her infant is receiving enough milk (Lewallen et al. 2006; Thulier & Mercer, 2009). It is also believed that, in most cases, supportive intervention of this kind could help to increase the duration of breastfeeding (Lewallen et al. 2006).

Breastfeeding policy and implementation

Hospital policies and practices according to the BFHI/BFI, such as early skin-to skin contact, rooming in and avoiding use of "top up" feeds, have been shown to improve the initiation and duration of breastfeeding (Moore et al. 2009, Thulier & Mercer, 2009; DiGirolamo et al. 2008, Merten et al. 2005, Pincombe et al. 2008 Declercq et al. 2009)

In hospitals that provide maternity care, supportive practices are encouraged through written breastfeeding policies and staff training (Kramer et al. 2001, Cattaneo & Buzzetti 2001). Written policy and practices should be based on the BFI.

Policy should include these elements:

• Keep mothers and infants together from birth and assist with breastfeeding in the first hour
• Ensure mothers are shown how to breastfeed
• Teach mothers how to maintain lactation should they be separated from their infant
• Ensure early, on cue, unrestricted and exclusive breastfeeding
• Ensure no supplementary feeds unless there is a documented medical indication.
• Refer mothers to professional and peer breastfeeding support in the community.

Implementation of the International Code of Marketing Breast-milk Substitutes should also be part of a written breastfeeding policy. For example, hospitals must not permit advertising or free gifts of formula, bottles, nipples, pacifiers, videos, or CDs.

In other settings, such as community and recreation centers and child care facilities, breastfeeding policy and staff training should emphasize:

• Support for mothers in initiating and maintaining breastfeeding
• A welcoming atmosphere for breastfeeding families
• Cooperation with healthcare staff, breastfeeding support groups, and the local community.
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A Canadian survey of new mothers confirms that certain practices need more attention from health care providers to better support breastfeeding (PHAC 2009). For example:

• Over a third of mothers were separated from their newborn for more than one hour in the first 24 hours after birth.
• Half of breastfeeding infants were not fed solely on cue during the first week after birth.
• Over a third of mothers were offered or given free samples of infant formula. Younger mothers and those with less education or income were more likely to be offered samples.

Pre- and postnatal counselling and assistance

Health professionals have a responsibility to promote, protect and support breastfeeding before, during and after birth. Most women report that they received the information they needed on breastfeeding during their pregnancy and that they planned to breastfed their child (PHAC 2009). After birth, most mothers say that their health professional offered help to initiate breastfeeding and guided them toward breastfeeding resources in the community (PHAC 2009). However, extending the duration of breastfeeding remains a challenge. For this reason, skilled professional support to breastfeeding mothers after discharge should be enhanced (Thulier & Mercer, 2009, Wijndaele et al. 2009).

Community supports for breastfeeding

Peer support groups and community networks, such as La Leche League, can give women and families the opportunity to share breastfeeding practices and experiences, thus enhancing each mother's knowledge and confidence about breastfeeding. (Dyson et al. 2005)

Public health department and community health centers can assist breastfeeding mothers to access local resources and programs. Public health nurses and lactation consultants can provide ongoing support to breastfeeding mothers in the community with home visits, counselling, and resource referrals.

Community programs that provide breastfeeding education and support such as those funded through the  Canada Prenatal Nutrition Program (CPNP) can help women, in particular newcomers to Canada, women who are socially or geographically isolated and Aboriginal women. These programs have been shown to improve initiation and maintenance of breastfeeding among its participants (PHAC 2009b).

Support in the workplace

In Canada, maternity/parental benefits were extended in 2000 to allow about one year of job-protected, paid leave. However, women who are self-employed, work part-time, or who have not worked long enough, may not qualify for this extended leave (Heymann & Kramer 2009). Some may not be able to afford the reduced rate of pay while on leave. Others may choose to return to work for various reasons before their child is one year old.

Some studies suggest that mothers who expect to return to full-time work earlier than one year postpartum are less likely to initiate breastfeeding (Mandal et al. 2010; Hawkins et al. 2007a). Among mothers who do initiate breastfeeding, some stop when they return to work, believing that:

• they will be unable to maintain a milk supply
• breastfeeding will take too much time or
• they will have discomfort when they are away from their infant (Johnston & Esposito 2007).

Others may cease breastfeeding due to unsupportive or hostile workplaces (Johnston & Esposito 2007, Heymann & Kramer 2009). Breastfeeding can be successfully maintained after a return to work or school with support in the workplace and appropriate child care arrangements (Johnston and Esposito, 2007; Hawkins et al, 2007b, Heymann & Kramer 2009). Factors which may increase the duration of breastfeeding include:

• the availability of nearby child care
• the use of breast pumps to express milk
• flexible work schedules
• supportive family, friends, supervisors and colleagues
• workplaces that provide a comfortable and private place to express milk and a refrigerator for storage (Johnston & Esposito 2007, Heymann & Kramer 2009).

In practice: talking to families about infant nutrition

How can I use points of contact with expectant and new mothers to educate and support them in breastfeeding?

• With prospective parents, explore their attitudes, values, and beliefs about breastfeeding.
• At the first prenatal visit, ask if the expectant mother intends to breastfeed, and provide  written information on the benefits of breastfeeding to the mother and infant. For those who say they do not intend to breastfeed, explore their attitudes and beliefs towards breastfeeding and talk about the importance of breastfeeding even for a short period.
• In hospital, ensure early skin to skin contact for as long as possible and on cue, unrestricted, and exclusive breastfeeding with no supplemental feedings unless medically indicated.
• Before discharge, ensure parents understand how they will feed their infant and receive  written information on the signs of successful breastfeeding and community breastfeeding resources. Advise mothers that feeding from bottles or using pacifiers may interfere with the establishment of breastfeeding.
• At the mother's first post-partum visit, a skilled practitioner should observe the infant breastfeeding. Anticipatory counselling should be offered about normal infant growth spurts and increases in breastfeeding demand.

Some mothers may not exclusively breastfeed for personal, medical, or social reasons. They need support to optimize their infant's nutritional well-being. Individually counsel families that have made a fully informed choice not to breastfeed. Give them information on alternate milks and safe preparation techniques.

References

Cattaneo A, Buzzetti R. 2001. Effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative. BMJ. 323:1358-62.

Declercq E, Labbok MH, Sakala C, O'Hara M. 2009. Hospital practices and women's likelihood of fulfilling their intention to exclusively breastfeed. Am J Public Health. 99: 929-35

DiGirolamo AM, Grummer-Strawn LM and Fein SB. 2008. Effect of maternity-care practices on breastfeeding. Pediatrics. 122;S43-S49

Donath SM, and Amir LH. 2008. Maternal obesity and initiation and duration of breastfeeding: data from the longitudinal study of Australian children. Maternal and Child Nutrition. 4, 163-170.

Dyson L, McCormick FM, Renfrew MJ. 2005. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001688.

Gatti L. Maternal perceptions of insufficient milk supply in breastfeeding. Journal of Nursing Scholarship. 2008. 40:4, 355-363

Hawkins SS, Griffiths LJ, Dezateux C, Law C and the Millennium Cohort Study Child Health Group. The impact of maternal employment on breast-feeding initiation in the UK Millennium Cohort Study. Paediatric and Perinatal Epidemiology. 2007a. 21: 242-247.

Hawkins SS, Griffiths LJ, Dezateux C, Law C and the Millennium Cohort Study Child Health Group. 2007b. The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study. Public Health Nutrition. 10(9): 891-896.

Health Canada. 2010. The maternal experiences breastfeeding module (MEX). Retrieved from: (IN PRESS)

Heymann J, Kramer MS. 2009.Public policy and breast-feeding: a straightforward and significant solution. Can J Public Health. Sep-Oct;100(5):381-3.

Johnston M and Esposito N. Barriers and facilitators for breastfeeding among working women in the United States. JOGNN. 2007. 36: 9-20

Kramer MS, Chalmers B, Hodnett ED et al. 2001. Promotion of Breastfeeding Intervention Trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA. 285(4):413-420

Kramer M., Fombonne E., Igumnov S., Vanilovich I., Matush L., Mironova E., Bogdanovich N., Tremblay R., Chalmers B., Zhang X., Platt R., and for the promotion of breastfeeding intervention trial (PROBIT) Study group. 2008. Effects of Prolonged and Exclusive Breastfeeding on Child Behavior and Maternal Adjustment: Evidence from a Large, Randomized Trial. Pediatrics. 121: e435-e440.

Lewallen LP, Dick MJ, Flowers J, Powell W, Zickefoose KT, Wall YG, Price ZM. 2006. Breastfeeding support and early cessation. J Obstet Gynecol Neonatal Nurs. Mar-Apr; 35(2):166-72.

Mandal B, Roe BE, Fein SB. 2010. The differential effects of full-time and part-time work status on breastfeeding. Health Policy. 97(1): 79-86

Merten S, Dratva J and Ackermann-Liebrich U. 2005. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics. 116: e702-e708

Millar WJ, Maclean H. 2005. Breastfeeding Practices. Health Reports. 16(2): 23-31.

Moore ER, Anderson GC, Berman N. 2009. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2007. Issue 3.Art. No.:CD003519.

Pincombe, J, Baghurst, P, Antoniou, G, Peat, B, Henderson, A & Reddin, E. 2008. 'Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia', Midwifery. 24 (1): 55-61.

Public Health Agency of Canada. 2009a. What mothers say: The Canadian maternity experiences survey. Ottawa. PHAC.

Public Health Agency of Canada. 2009b. Summative evaluation of the Canada prenatal nutrition program 2004-2009

Rebhan B, Kohlhuber M, Schwegler U, Fromme H, Abou-Dakn M, Koletzko BV. 2009. Breastfeeding duration and exclusivity associated with infants' health and growth: data from a prospective cohort study in Bavaria, Germany. Acta Paediatr.98(6):974-80.

Scott et al. 2006. Predictors of Breastfeeding Duration: Evidence from a Cohort Study. Pediatrics. 117: e646-e655.

Scott JA, Shaker I, Reid M. Parental attitudes toward breastfeeding: their association with feeding outcome at hospital discharge. Birth. 2004 Jun; 31(2):125-31.

Statistics Canada. 2010.  Breastfeeding, 2009. Retrieved on June 15, 2010

Thulier D and Mercer J. 2009.Variables associated with breastfeeding duration. JOGNN. 38, 259-268

UNICEF & World Health Organization. 2009. Baby-friendly hospital initiative: revised, updated and expanded for integrated care. Section 4:  Hospital self-appraisal and monitoring.

Weiser TM, Lin M, Garikapaty V, Feyerharm RW, Bensyl DM, Zhu BP. 2009. Association of maternal smoking status with breastfeeding practices: Missouri, 2005. Pediatrics. 124(6):1603-10.

Wijndaele K, Lakshman R, Landsbaugh JR, Ong KK, Ogilvie D. 2009. Determinants of early weaning and use of unmodified cow's milk in infants: a systematic review. J Am Diet Assoc. 109(12):2017-28.

3. Breastfeeding is rarely contraindicated. - DRAFT

3.1 Recommend an acceptable alternative to breastfeeding for mothers who are HIV infected. Very few other maternal infections contraindicate breastfeeding.

3.2 Take a case-by-case approach when a mother is using drugs. Most medications are compatible with breastfeeding.

3.3 Advise mothers to limit their alcohol intake. Mothers, who drink once in a while, in moderation, should continue to breastfeed.

3.4 Encourage mothers who smoke to stop or reduce smoking. However, even if they keep smoking, breastfeeding is still the best choice.

For the healthy term infant, there are very few situations when stopping or interrupting breastfeeding is indicated. Rare maternal contraindications include when the mother:

• is HIV-infected
• has herpes lesions on both breasts
• has untreated infectious tuberculosis
• has a severe illness that prevents her from caring for her infant (WHO/UNICEF 2008).

Some examples of the rare infant conditions when breastmilk should not be given are mentioned in Section 5.

• Maternal infections
• Medications and illicit drugs
• Alcohol
• Smoking
• In practice: Talking with families about infant nutrition
• References

Maternal Infections

HIV can be transmitted from an infected mother to her infant during breastfeeding (WHO 2008). The risk of HIV transmission continues as long as the infant is breastfed (WHO 2009). Current recommendations are that breastfeeding should be avoided, even if the HIV-positive mother is receiving antiretroviral therapy. This is consistent with the WHO's recommendation in countries where suitable alternate milks are available (WHO 2009).

Counselling about the risks HIV transmission during pregnancy and lactation are an important part of early prenatal care. Women should be urged to access this care (Lawrence & Lawrence 2001).

Tuberculosis is rarely transmitted through breastmilk, but can be transmitted by exposure to sputum from an infected mother or other caretaker (CPS Infectious Diseases and Immunization Committee 2006). If a woman must temporarily isolate herself due to infection, for example untreated infectious tuberculosis, she should receive support and help with maintaining her milk supply. She can resume breastfeeding when she is no longer infectious.

Herpes can be transmitted from lesions on the breast. It is possible for Hepatitis C to be transmitted from cracked and bleeding nipples. When breastfeeding is interrupted to protect the infant, advise the mother to express and discard her breastmilk. This enables her to resume breastfeeding when the breasts have healed (CDC 2009, CPS Infectious Diseases and Immunization Committee 2006).

Hepatitis B virus may be found in breastmilk, but with proper care and treatment of mother and child pre- and post-natally, breastfeeding can be safely recommended. [CDC 2009, CPS Infectious Diseases and Immunization Committee 2006]

Medications and illicit drugs

Prescription and over-the-counter medications
Most common prescriptions, such as most medications for diabetes (Feig et al 2007), and over-the-counter drugs such as acetaminophen are minimally excreted through breastmilk. They are pharmacokinetically benign to the infant (AAP Committee on Drugs 2001).

Medications or therapies such as cytotoxic chemotherapy may indicate temporary avoidance of breastfeeding if safer alternatives are not available (AAP Committee on Drugs. 2001). The AAP has a statement on the transfer of drugs to breastmilk and their potential effects on milk supply or on infant health (AAP Committee on Drugs 2001).

Natural remedies
Natural health products (NHP) and herbal remedies may contain pharmacologically active substances. They should only be used with caution by breastfeeding women. Refer to Health Canada's NHP Monograph for contraindications of specific substances.

Illicit drugs
Women should be encouraged not to use illicit drugs, and given support to abstain during pregnancy and breastfeeding. Illicit drugs can have harmful effects on breastfed infants and impair the mother's ability to care for her infant. If the mother is unable or chooses not to stop illicit drug use, advise her of the benefits of breastfeeding and the risks the drug use poses, based on her circumstances.

The  Motherisk website, and the French language website for the  centre IMAGe (en français seulement) are other useful sources of information on drugs, health products and breastfeeding.

Alcohol

Alcohol can alter the milk let-down reflex and decrease the amount of milk consumed by the infant (Giglia & Binns 2006, Chien et al. 2009, Mennela 2001-A). With daily exposure, it may also affect the infant's short-term sleep patterns (Giglia & Binns 2006, Mennela & Garcia-Gomez 2001) and gross-motor development (Mennela 2001-B). Concentrations of alcohol in breastmilk approximate the levels in the mother's blood. Frequent or heavy drinking can impair the mother's judgment and functioning.

Although there is no known "safe" amount of alcohol in breastmilk, an occasional drink is unlikely to harm the breastfed infant. The benefits of breastfeeding outweigh the risks of occasional moderate alcohol intake (Koren 2002).

Smoking

Smoking can affect milk production (Friguls et al 2010) and may impact infant growth (Little et al 1994, Boshuizen et al 1998) and infant sleep patterns in the short-term (Mennela et al 2007). Exposure to tobacco smoke in the environment also carries risks to the infant (Ladomenou et al, 2009).

Encourage breastfeeding mothers to stop or reduce smoking. However, even if smoking continues, breastfeeding is still the best choice. Advise parents who smoke that breastfeeding may mitigate some of the negative effects of smoking on the health of their infant (Chatzimichael et al 2007, Woodward et al, 1990). Smokers in the household should go outside to smoke, but always ensure the infant is supervised in their absence.

In practice: Talking with families about infant nutrition

How can a mother maintain her milk supply, if she needs to temporarily stop breastfeeding because of medical condition or treatment?
During a temporary interruption, mothers can express milk manually or with a breast pump every three to four hours to prevent engorgement and maintain milk supply. Once the mother is off the unsafe medications and feels she is ready to breastfeed, she can resume.

References

Boshuizen HC, Verkerk PH, Reerink JD, Herngreen WP, Zaadstra BM, Verloove-Vanhorick SP. 1998. Maternal smoking during lactation: relation to growth during the first year of life in a Dutch birth cohort. Am J Epidemiol. 15;147(2):117-26.

AAP (American Academy of Pediatrics) Committee on Drugs. 2001. The transfer of drugs and other chemicals into human milk. Pediatrics Vol 108(3).

CDC (Centers for Disease Control and Prevention). 2009.  Breastfeeding: Disease and conditions - Hepatitis B and C Infections.

Chatzimichael et al. 2007. The role of breastfeeding and passive smoking on the development of severe bronchiolitis in infants. Minerva Pediatr. 2007 Jun;59(3):199-206.

Chien et al. 2009 Maternal lactation characteristics after consumption of an alcoholic soup during the postpartum 'doing-the-month' ritual. Public Health Nutr. 2009 Mar; 12(3):382-8. Epub 2008 Apr 22.

CPS Infectious Diseases and Immunization Committee. 2006. Maternal infectious diseases, antimicrobial therapy or immunizations: Very few contraindications to breastfeeding. Canadian Paediatric Society. Pediatrics and Child Health. 11(8) 489-491.

Feig DS, Briggs GG, Koren G. 2007 Oral antidiabetic agents in pregnancy and lactation: a paradigm shift? Annals of Pharmacotherapy. 41(7):1174-1180.

Fríguls B, Joya X, García-Algar O, Pallás CR, Vall O, Pichini S. 2010. A comprehensive review of assay methods to determine drugs in breast milk and the safety of breastfeeding when taking drugs. Anal Bioanal Chem. 397(3):1157-79.

Giglia and Binns. 2006. Alcohol and lactation: A systematic review. Nutrition & Dietetics: 63:103-116.

Koren G. 2002. Drinking alcohol while breastfeeding - Will it harm my baby? Canadian Family Physician. 48:39-41.

Lawrence & Lawrence. 2001. Given the benefits of breastfeeding, what contraindications exist? Pediatr Clin North Am 48(1):235-51.

Little R. E, Lambert M. D, Worthington-Roberts B, Ervin C. H. Maternal smoking during lactation: Relation to infant size at one year of age. American Journal of Epidemiology. 1994;140:544-554

Mennela and Garcia-Gomez 2001. Sleep disturbances after acute exposure to alcohol in mothers' milk. Alcohol. 25(3):153-8.

Mennela et al. 2007. Breastfeeding and smoking: Short-term effects on infant feeding and sleep. Pediatrics 120 (3):497-502

Mennela J. 2001-B. Alcohol's effect on lactation. Alcohol Res Health. 25(3):230-4.

Mennela JA. 2001-A. Regulation of milk intake after exposure to alcohol in mothers' milk. Alcohol Clin Exp Res. 25(4):590-3.

WHO. 1998. Breastfeeding and Maternal tuberculosis. WHO Geneva (Update No. 23)

WHO. 2008. HIV Transmission through breastfeeding - A review of available evidence, 2007 update. France. World Health Organization.

WHO. 2009. HIV and infant feeding - revised principles and recommendations.

WHO/UNICEF. 2008. Acceptable medical reasons for use of breast-milk substitutes. Geneva. World Health Organization.

Woodward, A.; Douglas, R.M.; Graham, N.M.H.; Miles, H. (1990) Acute respiratory illness in Adelaide children: breast feeding modifies the effect of passive smoking. J. Epidemiol. Community Health 44:224-230.

4. In Canada, all infants need supplemental vitamin D. - DRAFT

4.1 Give a daily vitamin D supplement of 10 µg (400 IU) to breastfed infants, starting at birth.

Infants fed commercial infant formula get sufficient supplemental vitamin D from the formula.

• Dosages for infants
• Role of vitamin D
• In practice: Talking with families about infant nutrition
• References

Dosages for infants

All infants in Canada should receive a daily supplemental source of vitamin D. Without supplementation, an infant's vitamin D stores will be depleted (Butte 2002), particularly if the mother's stores are low (Salle et al 2000), leading to potential adverse effects.

Sunlight, which stimulates the formation of vitamin D in the skin, is the main source of vitamin D for humans. In Canada, for a large part of the year (October to March, and longer in the far North), the angle of the sun is too low to stimulate the synthesis of vitamin D. For this reason, recommendations for vitamin D intake are set assuming only minimal sun exposure.

The current level of adequate intake of vitamin D recommended for infants from birth to six months is 10 µg (400 IU) based on intakes consistent with desirable serum 25OHD concentrations (IOM 2011). For infants six months and younger, intake of vitamin D should not exceed 25 µg (1000 IU) per day, which is the highest average daily nutrient intake level likely to pose no risk of adverse health effects (IOM 2011).

Breastfed infants should be given a daily supplement of 10µg (400 IU) from birth. Infants fed commercial infant formula get sufficient supplemental vitamin D from the formula, which is fortified at a level of 1 µg or 40 IU per 100 ml. Infants who are partially breastfed also need a daily supplement of vitamin D.

Canadian survey data suggests only two thirds of breastfed infants receive supplements containing vitamin D. (Health Canada 2010). The frequency and quantity of vitamin D supplementation is not known. The percentage of breastfed infants receiving supplements varies by socio-demographic characteristics. Health professionals should work to increase rates of supplementation among:

• younger parents
• those with a lower household income
• those with a lower education level.

Daily vitamin D supplements have been recommended for breastfed infants in Canada since 1967. Before that, there was a recommendation to supplement with cod liver oil (a source of vitamin D), which goes back to 1927.

The evidence available at this time shows that a supplement of 10 µg (400 IU) of vitamin D is adequate for all infants living in any part of Canada. However, there is a need for further surveillance and research, particularly in high risk populations.

Role of vitamin D

Vitamin D has an essential role in calcium absorption, maintenance of calcium and phosphate levels in the blood, and normal bone mineralization (IOM. 2006).

Rickets is the inadequate mineralization and deformation of the bones, which can be due to vitamin D deficiency. Evidence consistently links low serum 25(OH) D concentrations to confirmed cases of rickets in infants (Chung et al. 2009). Serum levels below 27.5 nmol/liter (11 ng/ml) are associated with rickets (IOM 1997). Vitamin D supplementation of infants is an effective preventative measure against rickets (Lerch & Meissner 2007).

Cases of vitamin D deficiency still occur in Canada among unsupplemented infants (Ward et al. 2007). Vitamin D deficiency rickets remains a public health concern. Infants at risk without supplementation include:

• those living at extreme Northern latitudes
• dark-skinned infants
• infants born to mothers who are themselves deficient in vitamin D (Ward et al 2007).

Vitamin D deficiency in the mother may be due to:

• insufficient intake from the diet
• limited sun exposure (due in part to increased use of sunscreens or extensive covering of skin).
  Top of Page

In practice: Talking with families about infant nutrition

If an infant is still breastfeeding, but also gets some formula, should he or she be given the vitamin D supplement?

An infant who is partially breastfed and receives some infant formula will likely still need supplemental vitamin D. Commercial infant formulas contain vitamin D at a level of 1 µg or 40 IU per 100 ml. If an infant is taking in less than 1000 ml (or 4 cups) of formula per day he or she needs a vitamin D supplement of 10µg (400 IU).

Can the mother take a vitamin D supplement while she is breastfeeding instead of giving the supplement to her infant?

Women of childbearing age are advised to take a daily multivitamin, which generally provides between 5-20µg (200 - 800 IU) of vitamin D. However, this level of supplementation is unlikely to sufficiently increase the concentration of vitamin D in the mother's breastmilk to meet the needs of the infant. Recent studies have investigated the efficacy of supplementing breastfeeding mothers with high doses of vitamin D to prevent rickets in their infants. More research is needed on the efficacy and the safety of this approach before making a change to the practice recommendations.

What should parents and caregivers look for when buying the vitamin D supplement?

A single vitamin D₃ supplement (without other vitamins) in a liquid (drop) format is recommended for infants. Other vitamin D products such as vitamin D₂ or a multivitamin, which contains vitamin D, are not suggested.

Vitamin D supplements are sold in pharmacies and some grocery stores, over-the-counter, without a prescription. Some families may qualify for subsidized supplements. First Nations or Inuit people may also be eligible to receive vitamin supplements through the Non-Insured Health Benefits Program.

References

Butte N, Lopez-Alarcon M, Garza C. 2002. Nutrient Adequacy of Exclusive Breastfeeding for the Term Infant during the First Six Months of Life. World Health Organization. Geneva

Chung M, Balk EM, Brendel M, Ip S, Lau J, Lee J, Lichtenstein A, Patel K, Raman G, Tatsioni A, Terasawa T, Trikalinos TA. 2009. Vitamin D and calcium: Systematic review of health putcomes. Evidence Report/Technology Assessment No. 183. AHRQ Publication No. 09-5015, Rockville, MD. Agency for Healthcare Research and Quality.

Health Canada. 2010. The maternal experiences breastfeeding module (MEX). Retrieved from: (IN PRESS)

IOM (Institute of Medicine). 1997. Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride. Washington DC: The National Academies Press.

IOM (Institute of Medicine). 2006. Dietary Reference Intakes - The Essential Guide to Nutrient Requirements. Washington DC. National Academies Press.

IOM (Institute of Medicine). 2011. Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: The National Academies Press.

Lerch C, Meissner T. 2007. Interventions for the prevention of nutritional rickets in term born children. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD006164.

Salle B et al. Perinatal metabolism of vitamin D. Am J of Clin Nutr 2000; 71: 1317S-24S.

Statistics Canada 2009.  Canadian Community Health Survey (CCHS) 2007-2008.

Ward LM et al. 2007. Vitamin D-deficiency rickets among children in Canada. CMAJ.177 (2): 161-6.

5. Commercial infant formulas are the only acceptable alternative to breastmilk. - DRAFT

5.1 If an infant is not breastfed or is only partially breastfed, recommend cow's milk-based formulas.

5.2 Limit the use of soy-based formulas to infants who have galactosemia or cannot consume dairy-based products for cultural or religious reasons.

5.3 Recommend formulas for special medical purposes only when you detect or suspect pathology in the infant.

5.4 Cow's milk, evaporated milk formula, goat's milk, soy beverage, rice beverage, and all other beverages are inappropriate alternatives to breastmilk.

Infant formulas are designed to meet the nutritional requirements of the infant for whom they are intended. The  Canadian Food and Drug Regulations regulate the nutritional composition, packaging, and labelling of all infant formulas sold in Canada. The Regulations also restrict the food additives that may be used.

All new infant formulas, as well as formulas that undergo a change in formulation, processing, or packaging, are subject to a premarket notification. Health Canada requires the manufacturer to submit details of the formulation, ingredients, processing and packaging for review. Manufacturers must also submit evidence that the formula is nutritionally adequate to support growth and development.

While manufacturers vary their formula recipes, due to the regulation of nutritional requirements, nutrient differences among formulas are minimal. Human breast milk is a complex biological fluid with many nutrients and biologically active factors that contribute to healthy infant growth and development. No formula is equivalent to breastmilk.

• Cow's milk protein-based formulas
• Soy protein-based formulas
• Formulas based on partially hydrolyzed cow's milk protein
• Formulas for special medical purposes
• Issues in the composition of infant formulas
• Inappropriate alternatives
• References

Cow's milk protein-based formulas

Cow's milk protein-based formulas are the standard product for healthy term infants who are not breastfed. All are designed to meet the known nutritional requirements of the healthy term infant. The protein in these formulas may be entire milk protein, or a combination of casein and whey proteins, or just one of these proteins. Some or all of the protein may be hydrolyzed.

The iron content of the milk protein based-infant formulas currently on the market varies from 0.4 mg per 100 mL to 1.2 mg per 100 mL. The lower iron formulas (0.4 mg per 100 mL) provide sufficient iron for the healthy term infant. Higher iron formulas may be recommended for infants at risk of iron deficiency.

Infant formulas may also contain a number of nutritive substances that are not required under the regulations. Most cows' milk protein infant formulas are supplemented with the long chain fatty acids DHA (docosahexaenoic) and ARA (arachidonic). Many infant formulas on the market contain added nucleotides and some may also contain an added bacterial culture.

Soy protein-based formulas

About 10% of infants in Canada are given soy protein-based formulas. However, the indications for the use of these formulas are limited to galactosemia and a vegan diet.

A cow's milk protein allergy (CMPA) is sometimes perceived to be an indication to use a soy-based formula. However, the use of soy-based formulas is only contraindicated for non-immunoglobulin E (IgE)-mediated CMPA. This contraindication stems from the high rate of coincident soy allergies in these patients. While not all CMPA requires a formula based on extensively hydrolyzed protein, it is often impractical to distinguish IgE- versus non IgE-mediated CMPA. Therefore, it is safer and more appropriate from a public health standpoint to recommend an extensively hydrolyzed formula for infants with CMPA (Nutrition Committee, Canadian Paediatric Society 2009). In the case when a diagnosis of non-IgE-mediated CMPA can be satisfactorily ruled out, then the use of soy formula is not contraindicated.

Currently available soy-based formulas support normal growth and nutritional status for the first year of life. No overt toxicities have been observed in healthy infants fed these formulas as their sole source of nutrition (Nutrition Committee, CPS 2009, Badger et al. 2009).

Soy proteins contain phytoestrogens. Phytoestrogens are plant-derived substances with estrogenic activity. Concern has been raised from research carried out in vitro and in animal studies about the suitability of soy products for infants. Although a report (Setchell et al., 1997) demonstrated that the levels of phyto-oestrogens in the plasma of infants fed soy-based formulas are much higher than those of infants consuming cow's milk or breastmilk, these levels have not been found to affect the growth or development of healthy term infants.

The National Toxicology Program, Board of Scientific Counsellors has concluded that there is minimal concern regarding adverse developmental effects in humans due to the presence of estrogenic isoflavones (phytoestrogens) in soy infant formulas (National Toxicology Program 2009). They found there was insufficient information from studies in humans to reach a conclusion on potential adversity. Findings from laboratory studies, which demonstrated clear adverse effects on the female reproductive system in rodents, could not be extrapolated to human infants. The animals in the study had been treated with only one component of soy protein-based infant formula at a high dose.

Formulas based on partially hydrolyzed cow's milk protein

These widely available formulas contain protein that has been partially hydrolyzed. The degree of hydrolysis varies from product to product. Some formulas contain a combination of partially hydrolyzed and intact proteins. Currently, there is little evidence to support any benefit to the digestive system of infants compared to standard cow's milk protein-based formulas. All infant formulas are "easy to digest" and "well tolerated", mainly due to heat processing, which decreases the protein curd tension.

The only acceptable claim for formulas where partially hydrolyzed protein is the sole source of protein may be a reduced risk of an allergic reaction to whole cow's milk protein. Parents and caregivers should be advised that partially hydrolyzed formulas may also contain some whole (intact) cow's milk protein. This can be checked by reading the ingredients list on the label.

Thickened infant formulas
Infant formulas are available which have been slightly thickened with rice starch. They may be labelled as suitable for infants who spit up frequently. It should be noted that spitting up is usually normal in infancy and only very rarely leads to health problems such as failure to thrive. These formulas are not suitable for infants with severe reflux, such as that which may occur in gastro-oesophageal reflux disease (O'Connor 2009). Further assessment is warranted if spitting-up persists or increases in severity.

Formulas for special medical purposes

Formulas for special medical purposes that are available at the retail level are intended for the small number of infants who cannot tolerate formulas for healthy term infants which are based on intact cow's milk protein or soy protein. Most often, these infants have physician-confirmed food allergies or malabsorption syndromes. The choice of formula for special medical purposes should be individualized and based on the diagnosis of a physician.

Some formulas are intended for use only under medical supervision. They include formulas for the dietary management of conditions, such as aminoacidurias and severe malabsorption syndromes. Since these products are not generally available at the retail level they will not be discussed in this statement.

Formulas for preterm infants on discharge from hospital may be available at the retail level and parents should be advised that they are not appropriate for the healthy term infants.

Infant formulas with extensively hydrolyzed protein
The protein in these formulas has been extensively broken down to the small peptide and amino acid level. Currently, the protein source is casein. These formulas are considered "hypoallergenic". They are intended for :

• infants with a confirmed allergy to cow's milk or soy proteins
• the prevention of atopic disease in high risk infants
• the dietary management of inflammatory bowel diseases. (Committee on Nutrition, American Academy of Paediatrics 2000).

In addition, some infants with severe colic may benefit from a 1-2 week trial of these formulas.

"Hypoallergenic" does not mean "non-allergenic." Formulas based on extensively hydrolyzed protein have provoked allergic reactions in highly allergic infants. For these infants, an amino acid-based infant formula may be recommended (Hill et al. 1995, Saylor et al. 1991).

Lactose-free, cow's milk protein based formulas
In these formulas glucose polymers, usually from corn syrup solids, replace lactose. They may be useful during periods of secondary disaccharidase deficiency due to acute enteritis or chronic conditions affecting the integrity of the small intestine such as diarrhea and enteropathies (Committee on Nutrition, American Academy of Paediatrics 2006). It has been reported that in developed countries, even in the case of acute gastroenteritis, enough lactose digestion and absorption are preserved. This means that lactose free formulas have no clinical advantages compared to the usual cow's milk formula (Committee on Nutrition, American Academy of Paediatrics 2006).

Because these formulas contain small amounts of residual galactose from their cow's milk protein component, they are contraindicated for infants with galactosemia and congenital lactase deficiency. In addition, these formulas are unsuitable for infants with confirmed cow's milk protein allergy and are ineffective in the dietary management of infant colic.

Issues in the composition of infant formulas

Addition of the fatty acids DHA (docosahexaenoic acid) and ARA (arachidonic acid)
Although the addition of DHA and ARA to infant formulas is not currently mandatory in Canada, infant formulas with DHA and ARA have become widely available. Other jurisdictions, as well as the international infant formula standard, lists DHA as an optional ingredient and recommend that if DHA is added to infant formula, ARA should reach at least the same concentration as DHA (ESPGHAN Committee on Nutrition 2005, United Nations FAO/WHO 2007).

Formulas with added DHA and ARA are labelled as "with Omega-3 (DHA) and Omega-6 (ARA)" or "with DHA and ARA", or similar phrases. They have been marketed with the label claim "DHA and ARA promote normal brain and eye development."

All infant formulas sold in Canada contain adequate amounts of the essential fatty acids linoleic and alpha-linolenic, which are the precursors of the long-chain polyunsaturated fatty acids ARA and DHA. Breastmilk contains all of these fatty acids (i.e., the precursors as well as their derivatives).

The infant's conversion of linoleic and alpha-linolenic acids to their long chain derivatives is still being investigated (Hoffman et al 2000). Clinical trials on the effects of ARA and DHA in infant formula on cognitive, social, and motor development have shown both positive results and no effect. . Although no harm has been demonstrated, several randomized trials comparing term infants fed formula with and without ARA and DHA or with DHA alone have found no difference in average test scores of the groups. This led a recent Cochrane review to conclude that current weight of evidence did not support a conclusion that feeding formula with ARA and DHA improve infant development (Simmer et al., 2008). However, infant development is complex with variability among healthy infants in the age at which different skills develop. This contributes to the difficulties in interpreting multi-centre studies with boys and girls and with small sample sizes. Improved visual acuity has been shown in infants fed formulas with DHA in several studies (Birch et al 2010)

The American Dietetic Association and Dietitians of Canada (2007) recommend that infant formulas contain DHA at a level of at least 0.2% of total fatty acids and that the level of ARA should not be lower than DHA. The Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition (2008) has recommended an AI (adequate intake) for DHA for infants 0 to 6 months of age of 0.20 to 0.36% of total fatty acids.

The term infant formulas with added DHA and ARA sold in Canada contain between 7.4 to 19 mg DHA per 100 kcal of formula (0.14% to 0.35% of total fat), and between 14.6 to 34.8 mg ARA (0.27 to 0.66 % of total fat) per 100 kcal of formula and the levels of ARA are not lower than DHA for any product.

Each potential new source of DHA or ARA must be thoroughly tested to ensure its safety for use in infant formulas. It has been established that the use of ARA and DHA from certain fungal and algal oils is safe. This decision and a summary of the information reviewed are available on Health Canada's website.

Nucleotides
Some infant formulas on the Canadian market contain added nucleotides+. Formulas may be labelled "with nucleotides" for ease of identification. Products containing added nucleotides must list these as well as their amounts. There are no health claims for nucleotides permitted for use on infant formula.

There are data from in vitro and animal studies that demonstrate potential benefits of nucleotides to the immune and gastrointestinal systems, the fatty acid composition of serum lipids and erythrocyte membranes. Definitive human data, however, are lacking (Uauy et al. 1994, Carver et al.1990, Delucchi et al. 1987). The Life Sciences Research Office of the American Society for Nutritional Sciences (1998) found no compelling reason to require the addition of nucleotides to infant formula. However, a recent randomized controlled trial showed that nucleotide supplementation increased weight gain and head circumference compared to unsupplemented infants (Singhal et al. 2010). This result requires confirmation in other trials.

Parents and caregivers should be advised that the use of a formula with nucleotides is optional (ESPGHAN Committee on Nutrition 2005, United Nations FAO/WHO 2007)

Live microorganisms and probiotics
Probiotics have been defined (FAO/WHO, 2006) as "live microorganisms which when administered in adequate amounts confer a health benefit to the host." Live microorganisms may be added to infant formula in Canada if the microorganism has been assessed as safe for infant use.

The addition of probiotics is proposed to mimic the effects of breastmilk on the infant's gastrointestinal system. However, to date, there is no unequivocal evidence for long-term clinical benefits from infant formulas supplemented with probiotic bacteria (Lee & Seppo 2009). Parents and caregivers should be advised that this addition to infant formula is optional. They should also be informed that powdered infant formulas should be prepared as recommended on the product label to ensure the viability of the live microorganisms.

Health Canada (2009) issued a Guidance Document, "The Use of Probiotic Microorganisms in Food" which states that the term "probiotic" may be used on food labels and in advertising only when accompanied by specific, validated statements on the benefits or effects of the probiotic microorganism contained in the food. Claims about the nature of certain microorganisms are permitted (for example, "Provides live microorganisms that naturally form part of the gut flora") provided the microorganism is listed and the food contains a specified amount of it.

Palmitic Acid
A large portion of the saturated fatty acid in breastmilk is esterified on the centre position of the human milk triglyceride. Unlike human milk, palmitic acid in vegetable oils is esterifed almost exclusively on the outer 1,3 positions of the oil triglceride. Sources of palmitic acid, like palm olein used as part of the fat in most infant formulas provides palmitic acid but in a different way to breastmilk. Claims have been made that formulas with lower palmitic acid result in improved fat absorption and bone mineralization compared to formulas with higher palmitic acid from vegetable oils. To date, the scientific literature does not support any long term benefits of higher fat absorption or bone mineralization in infants fed low palmitic acid formula (Young et al. 2005). The effects of varying palmitic acid, which represent about 20 to 25% of breast milk fatty acids are poorly understood. Parents and caregivers should be advised that there are no proven benefits to using formula that is low in palmitic acid from palm olein or any other vegetable oil.

Inappropriate alternatives

Cow's milk differs greatly from human breastmilk. It lacks many of the growth and immunological factors found in breastmilk. Nutritionally, cow's milk:

• is low in iron
• is low in essential fatty acids and other essential nutrients
• has a less-digestible form of protein
• has a high renal solute load (Prentice 1996).

In infants under six months, the use of cow's milk is associated with occult blood loss in stool, which can contribute to iron deficiency anaemia (WHO 2009).

Cow's milk and other animal milks, including goat's milk, are not appropriate alternatives to breastmilk in the first six months of life (WHO 2009).

Formulas made from non-pasteurized cow's or goat's milk (raw milk) should never be offered to infants and children, due to the risk of food-borne illness from pathogens such as, Salmonella, Escherichia. coli, Campylobacter and Listeria monocytogenes (Health Canada 2010, Infectious Diseases and Immunization Committee 2008).

Homemade formulas made from canned evaporated whole milk (cow or goat), are not recommended as an alternative to breastmilk because they are nutritionally incomplete (Briend 2006). These formulas should only be considered for emergency, short-term use and prepared safely following directions from  WHO's Guidelines for Use of Breast-milk Substitutes in Emergency Situations (WHO 2005).

Soy, rice and other vegetarian beverages, even when they are fortified, are not appropriate alternatives to breastmilk because they are not nutritionally complete for infants. Consumption of these beverages by young infants may result in failure to thrive (Skypala & Venter 2009).

Families who have made a fully informed choice not to breastfeed should be given appropriate information on acceptable alternate milks.

References

American Dietetic Association and Dieticians of Canada: Position Statement on Dietary Fatty Acids, Sept 2007, JADA, 107 (9), 1599-1611.

Badger, T.M. et al. 2009. The health implications of soy infant formula. Am J Clin Nutr. 89(suppl): 1668S-72S.

Birch EE, Carlson SE, Hoffman DR, Fitzgerald-Gustafson KM, et al. 2010. The DIAMOND (DHA Intake And Measurement Of Neural Development) Study: a double-masked, randomized controlled clinical trial of the maturation of infant visual acuity as a function of the dietary level of docosahexaenoic acid. Am J Clin Nutr. 91: 848-859.

Briend A. 2006. Home-modified animal milk for replacement feeding: Is it feasible and safe?
 Discussion paper for technical consultation on HIV and infant feeding.

Carver, J. D. et al. 1990. Dietary nucleotide effect upon murine natural killer cell activity and macrophage activation. J. Parenteral Enteral Nutr. 14:18-22.

Committee on Nutrition, AAP (American Academy of Paediatrics). 2006. Lactose Intolerance in Infants, Children, and Adolescents. Pediatrics. 118(3).

Committee on Nutrition, AAP (American Academy of Paediatrics). 2000. Hypoallergenic Infant Formulas. Pediatrics. 106(2).

Delucchi, C. et al. 1987. Effects of dietary nucleotides on the fatty acid composition of erythrocyte membrane lipids in term infants. J. Pediatr. Gastroenterol. Nutr. 6:568-74.

ESPGHAN (European Society of Pediatric Gastroenterology, Hepatology and Nutrition) Committee on Nutrition. 2005. Global standard for the composition of infant formula: recommendations of an ESPGHAN coordinated international expert group. J. Pediatr. Gastroenterol. Nutr. 41:584-599.

FAO/WHO. 2006. Probiotics in Food, Health and Nutritional Properties and Guidelines for Evaluation.

FAO/WHO. 2008.  The Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition.

Health Canada. 2010. Tip sheet for raw milk.

Hill, D.J. et al. 1995. Challenge confirmation of late-onset reactions to extensively hydrolyzed formulas with multiple food protein intolerance. Allergy Clin Immunolo. 96:386-394.

Hoffman, D. et al. 2000. Impact of early dietary intake and blood lipid composition of long-chain polyunsaturated fatty acids on later visual development. J. Pediatr. Gastroenterol. Nutr. 31(5): 540-553.

Infectious Diseases and Immunization Committee, CPS (Canadian Paediatric Society). 2008. Foodborne infections. Paediatr Child Health. 14(6): 779-82.

Lee, Y.K. and Seppo, S. (Eds) 2009. Handbook of Probiotics and Prebiotics (2^nd Edt). Chapter 1. pp. 94-95. John Wiley & Sons Inc.

National Toxicology Program. 2009. Draft CERHR (Center for the Evaluation of Risks to Human Reproduction) expert panel report on soy formula. U.S. Department of Health and Human Services.

Nutrition Committee, CPS (Canadian Paediatric Society). 2009. Concerns for the use of soy-based infant formulas in infant nutrition. J Paediatr Child Health. 14(3): 109-13.

O'Connor, N. 2009. Infant Formula. Am Fam Physician. 79(7): 565-570.

Prentice A. 1996. Constituents of human milk. Food and Nutrition Bulletin of the United Nations University Press. 17(4).

Saylor, J.D. et al. 1991. Anaphylaxis to casein hydrolysate formula. J Pediatr. 118: 71-74.

Setchell, K.D.R. et al., 1997. Exposure of infants to phyto-estrogens from soy-based infant formula. Lancet. 350:23-27.

Simmer K, Patole D, Rao SC. 2008. Long chain polyunsaturated fatty acid supplementation in infants born at term. Cochrane Database of Systematic Reviews. Issue 1. Art. No.: CD00376.

Singhal et al. 2010 Singhal, A. et al. 2010. Dietary nucleotides and early growth in formula-fed infants: a randomized controlled trial. Pediatrics. 126(4):946-53.

Skypala I and Venter C. 2009. Food hypersensitivity: Diagnosing and managing food allergies and intolerance. Blackwell Publishing Ltd. Ox ford UK. pp 247-249.

Uauy, R. et al. 1994. Role of nucleotides in intestinal development and repair: implications for infant nutrition. J. Nutr. 124:1436S-41S.

United Nations FAO/WHO Codex Alimentarius Standard for Infant Formulas. 1981. Codex Standard 72. Standard for infant formula and formulas for special medical purposes intended for infants. (Revised 2007).

WHO. 2005.  Guidelines for use of breast-milk substitutes in emergency situations.

WHO. 2009. Infant and young child feeding (model chapter for textbooks for medical students and allied health professionals). World Health Organization. Geneva. pp 9-17.

Young, R.J. et al. 2005. Neonatal and infant feeding: effect of bone density at 4 years. J. Pediatr. Gastroenterol. Nutr. 41(1):88-93.

6. Milk provided to infants must be free of pathogens and fed safely. - DRAFT

6.1 Advise parents and caregivers to use proper preparation and storage practices to reduce the risk of bacteria-related illness.

6.2 Warn of the risk of choking if infants are left alone while feeding. Explain the dangers of "propping" a bottle.

• Safe preparation and storage
• Supervision of a feeding infant
• In practice: Talking with families about infant nutrition
• References

Safe preparation and storage

Young infants are vulnerable to food borne illness. Infants who are breastfed always have access to safe milk that is pathogen-free and at the right temperature.

Expressed milk
During temporary separation of a mother from her infant, expressing breastmilk maintains the mother's milk supply and exclusive breastfeeding for infant. Milk can be expressed by hand directly into a clean wide-necked container or with the aid of a breast pump.

• Advise mothers to follow the instructions for sanitary use provided with manual or electric breastmilk pumps.
• Expressed milk should be stored in covered sterilized containers labelled with the time and date.
• Expressed milk can be kept in the refrigerator for up to three days, or frozen for up to three months in fridge freezer, or up to six months in a deep freezer.

When an infant is not breastfed, liquid infant formula or powdered infant formula are the only nutritionally acceptable alternatives. However, they must be prepared and stored safely to reduce the risk from bacteria.

Feeding equipment
Sterilization of all infant feeding equipment is recommended until the time that the infant is introduced to other foods. Instruct parents and caregivers to:

• Thoroughly wash bottles, nipples, caps, tongs, measuring cups or other containers, and breast pump components.
• Sterilize the washed equipment by boiling in a pot of clean water for two minutes (Health Canada 2010).
• Avoid cross-contamination from other foods prepared in the kitchen.

Liquid formula
Liquid infant formula is heat treated to be sterile and is available in ready-to-feed formats or as a liquid concentrate. Ready-to-feed infant formula is available in cans or in plastic bottles and is the safest choice of formula for higher-risk infants including low birth weight and immno-compromised infants. Although liquid formulas are sterile, it is important that the parents and caregivers follow the manufacturer's directions for preparation and use safe practices to avoid cross-contamination. For example:

• Opened cans of liquid formula should be covered and refrigerated immediately and used within 48 hours or according to manufacturer's directions.
• Liquid concentrate infant formula must be prepared by adding water according to manufacturer's directions.

Powdered formula
Powdered infant formula is not sterile. It has been linked to outbreaks of Cronobacter sakazakii and Salmonella spp, mainly in high-risk infants (WHO 2006). If liquid formula is not available, powdered infant formula can be used if it is properly prepared.

Advise parents that if the powdered formula will be fed immediately after preparation, it is safe to mix the powder with previously boiled water that has been cooled to body temperature.

If they are preparing more than one bottle in advance, advise parents and caregivers to follow the guidelines for Preparation, Storage and Handling of Powdered Infant Formula. Formula prepared in this manner can be stored in the refrigerator for up to 24 hours.

Water
Municipal tap water and commercially bottled water (except carbonated or mineral water) are suitable for preparing powdered or concentrated infant formulas. Well water that is regularly tested and meets standards of safety for chemical composition and lack of microbial contamination is also suitable. However, the nitrate concentration of well water should be monitored to ensure it is below 10 ppm, since methaemoglobinaemia is a risk for infants younger than six months.

Tap water, well water, and commercially bottled water are not sterile. Home water treatment equipment does not replace the need to sterilize water for infants. To ensure water for infants is safe and pathogen-free, advise parents and caregivers to:

1. Use cold tap water. Hot tap water may contain more metal contaminants from the pipes such as copper or lead.
2. Bring water to a rolling boil.
3. Continue to boil for 2 minutes.
4. Let cool.

Supervision of a feeding infant

Breastfeeding allows close contact and constant supervision of infants during feeding. When an infant is not breastfed, feeding from a bottle or cup must always be supervised. Strongly discourage parents and caregivers from:

• Using a propped bottle to feed an unattended infant: There is a danger of choking or aspiration, because the flow of milk into the mouth may be too rapid. Even older infants who are able to hold a bottle benefit from being held when feeding.
• Using a propped bottle as a pacifier, particularly at bedtime: Prolonged use of a bottle as a pacifier increases the risk of "nursing bottle syndrome" and early childhood tooth decay in older infants (Health Canada 2009) as well as feeding difficulties.

In practice: Talking with families about infant nutrition

What steps should parent and caregivers follow to safely prepare and store powdered formula?

Recommend liquid formula if it is available. If powdered formula is used, offer the following guidance:

Preparing your space and equipment:

1. Clean your countertops and hands with soap and warm water and a clean cloth or paper towel.
2. Sterilize bottles, nipples, and spoons by boiling in an open pan of water for two minutes.
3. Allow them to air dry and cool. Cover them with a clean tea towel if you're not going to use them right away.

Preparing formula to use right away:

1. Use previously boiled water that has cooled to body temperature.
2. Add the powder and mix thoroughly.
3. Use the formula right away.

Storing formula for later use:

1. Store the prepared formula in the fridge. You can store it for up to 24 hours at 4°C.

Re-warming stored formula

1. Remove the formula from the fridge. Re-warm and use it right away, because bacteria can grow at temperatures above 4°C.
2. Place the formula in a bottle warmer or a pan of warm water for no more than 15 minutes. The longer you warm it, the greater the chances that bacteria might grow.
   Note: Do not use a microwave oven. The uneven heat can create "hot spots" that can burn your infant's mouth.
3. Always check the temperature of the formula on the inside of your wrist to make sure it isn't too hot.
4. Within two hours, always discard any unused portion of your infant's prepared formula left after a feeding. However, do not encourage an infant who is not hungry to finish a bottle. This will encourage overfeeding. Discard the leftover formula.

References

Health Canada. 2010. Recommendations for the preparation and handling of powdered infant formula.

Health Canada. 2009. Caring for your teach and mouth - Early Childhood Tooth Decay.

WHO. 2006. Safe preparation, storage and handling of powdered infant formula guidelines. World Health Organization. Geneva.

7. Routine growth monitoring is important for assessing infant health and nutrition. - DRAFT

7.1 Use the World Health Organization (WHO)  Growth Charts for Canada for optimal monitoring of infant growth.

In infancy, routine growth monitoring can help to identify nutritional or health problems in their early stages, when corrective action is most effective. Growth monitoring should be part of both well-baby visits and "unwell" visits.

• Basis for growth standards
• Interpretation of the growth pattern
• Accurate measurements and plotting
• In practice: Talking with families about infant nutrition
• References

Basis for growth standards

The WHO Child Growth Standards are based on the growth of healthy breastfed infants in multi-ethnic populations. Healthy breastfed infants born to non-smoking women with access to health care are the normative model for growth and development (Collaborative Statement 2010).

WHO's standards for monitoring and assessment have been promoted for use in Canada by the Dietitians of Canada, the Canadian Paediatric Society, the College of Family Physicians of Canada, and Community Health Nurses of Canada (Collaborative Statement 2010). Growth charts are available from the  Dietitians of Canada and the  Canadian Paediatric Society.

Interpretation of the growth pattern

The spectrum of 'normal' size measurements for infants can be anywhere within the 3^rd and 97^th centiles of the growth curves for weight, length and head circumference. Health professionals should take time to show parents how to interpret their infant's growth chart. There is a tendency for both parents and health professionals to favour sizes to be around the 50^th percentiles and above. Explain that the 50th percentile is not the goal for each child (Ben-Joseph et al. 2009). A range of sizes is expected and physiological.

Plotted measurements tracking along the growth curves indicate normal growth. Crossing the centiles downwards or upwards may indicate slow or rapid growth (Collaborative Statement 2010). Further assessment is also appropriate when length and weight percentiles are substantially disproportional, or when length and or weight cross percentiles downwards or upwards substantially.

However, in infancy, some shifts in growth are normal. Infants can often shift one to two major centiles (i.e. 5th, 10th, 25th, 50th, 75th, 90th, and 95th) for both length and weight, especially in the first six months (Mei 2004). In general, infants will settle into a channel towards their genetic potential.

Slight differences should be anticipated when assessing growth of formula-fed infants against standards based on breastfed infants. Formula-fed infants tend to be lighter than breastfed infants in the first three to four months of life. Then formula-fed infants tend to be slightly (up to 1 kg) heavier compared to breastfed infants after four to six months (Dewey 1995).

Accurate measurements and plotting

To obtain the weights and measures, use calibrated, well-maintained, high quality weighing and measuring equipment and standardized measurement techniques.

For infants from birth to six months of age, record and plot the following size measurements:

• weight for age
• length for age
• weight for length
• head circumference.

Assessment of infant growth requires that several measurements be taken over time. Interpretation of the growth pattern should include clinical, developmental and behavioural assessments as well as an assessment of feeding, and consider a number of factors such as:

• parental size
• growth trajectory
• birth weight
• any problems with lactation
• any acute or chronic illness

All of these factors should be taken into account before suggesting dietary modification or invasive investigation.

In practice: Talking with families about infant nutrition

How can parents and caregivers be reassured that the infant is getting enough milk?

Parents need reassurance and confidence that their infant is receiving adequate nutrition and is growing well. Although mothers give "not enough milk" as the most common reason for stopping breastfeeding (Health Canada 2010), insufficient breastmilk production is rare.

An infant's steady weight gain can be monitored and assessed after the first weeks of life as an indication of the adequacy of the mother's milk supply and the infant's intake. Breastfed infants gain weight at rate of about 0.6 to 1.4 kg per month for the first three months, and at a slower rate of about 0.3 to 0.7 kg per month from three to six months of age.

In the first two weeks, when newborns experience normal weight decline and recovery, observation of breastfeeding technique is essential to assess suspected problems with milk intake. For health professionals with the proper training, observation and assessment of breastfeeding can reassure mothers that the infant's latch is good and that he or she is receiving enough milk.

Parents can be given advice on how to assess if their infant is getting enough milk from breastfeeding. When an infant is getting milk, he or she will suck in a specific way (open mouth wide > pause > close mouth) similar to the action of sucking on a straw. Parents can observe the infant's chin while feeding, watching for the pause that represents a mouthful of milk. The longer the pause, the more milk has been ingested.

References

Ben-Joseph et al. 2009. Do parents understand growth charts? A national, Internet-based survey. Paediatrics. 124(4):1100-1109.

Dewey et al. 1995. Growth of breastfed infants deviates from current reference data: A pool-analysis of US, Canadian, and European data sets. WHO Working Group on Infant Growth. Pediatrics. 96. 495-593.

Collaborative Statement(of Dietitians of Canada, Canadian Paediatric Society, the College of Family Physicians of Canada, Community Health Nurses of Canada). 2010. Promoting optimal monitoring of child growth in Canada: Using the new WHO growth charts.

Health Canada. 2010. The Maternal Experiences Breastfeeding Module (MEX). Retrieved from (IN PRESS)

Mei Z. et al. 2004. Shifts in percentiles of growth during early childhood: Analysis of longitudinal data from California Child Health and Development Study. Pediatrics. 113: e617-e627.

8. Avoid unnecessary interventions for common infant health conditions and illnesses. - DRAFT

8.1 Explain that feeding changes do little to manage infantile colic.

8.2 Educate about the wide variation in normal bowel function in infants to avoid unnecessary interventions.

8.3 Provide reassurance that gastroesophageal reflux (regurgitation or 'spitting up') is common in healthy infants and rarely needs treatment.

8.4 Manage mild to moderate dehydration from acute gastroenteritis with continued feeding and an oral electrolyte solution.

During the first six months of life, infants frequently experience conditions such as infantile colic, constipation, gastroesophageal reflux (regurgitation) and acute gastroenteritis. These may lead to unnecessary interventions that can compromise their nutrition. Altering feeding practices (for example, switching from breastfeeding to formula feeding or from one formula type to another) is generally not beneficial in managing these problems.

Health care providers should be knowledgeable about the wide variations in normal infant behaviours, such as crying time, frequency and consistency of bowel movements and amount of regurgitation. Knowledge of normal variations of infant behaviours will help ensures that they do not misinterpret normal variants.

• Infantile colic
• Constipation
• Gastroesophageal reflux
• Acute gastroenteritis
• In practice: Talking with families about infant nutrition
• References
  Top of Page

Infantile colic

Infantile colic occurs in both breastfed and formula-fed infants. Typically, colic starts before three to four weeks of age and resolves by four months. Infants with colic have periods of irritability, fussiness, or crying that start and stop without obvious cause and with no evidence of failure to thrive. A commonly used definition of colic is that the episodes last three or more hours per day and occur at least three days per week for at least one week (Hyman et al. 2006). The symptoms appear to be common. Depending on the definition, the reported cumulative incidence varies between 5% - 19% (Lucassen et al. 2001).

The etiology of infantile colic is unknown. Current hypotheses suggest that it may have several independent causes. These include:

• immaturity of gut function
• altered visceral perception
• (rarely) protein hypersensitivity (Savino 2007).

While infantile colic is a self-limiting condition, it is usually very stressful for caregivers. This often results in a variety of behavioural, nutritional, and pharmacological interventions. Unfortunately, few of these interventions have been subjected to appropriately designed trials.

Managing infantile colic
Health professionals should first reassure caregivers that colic usually resolves by itself around four months. They should also provide counselling and encouragement and check that caregivers have sufficient supports are in place. Cuddling, rocking, stroking, and massaging are common ways to soothe an infant. It may prove helpful to examine the feeding technique to ensure that the infant has a good latch, and is not swallowing too much air. Advise continued breastfeeding on demand (i.e. avoid timed feedings or delaying feedings) and consider referral to an experienced breastfeeding specialist.

Cow's milk protein hypersensitivity
There is evidence that a small minority of infants suffering from colic have a cow's milk protein hypersensitivity (CPS colic statement - in press). For breastfed infants, a dairy-free maternal diet may help. An extensively hydrolyzed formula may be beneficial for formula-fed infants. However cow's milk protein hypersensitivity appears to be a relatively infrequent cause of infantile colic. For this reason such interventions should be reserved for more severe cases and for infants showing other signs of the allergy, such as blood in the stools and atopy. Health professionals should consult with colleagues experienced in the management of infantile allergies before performing nutritional interventions.

Other hypotheses
It has been proposed that relative lactase deficiency may contribute to infantile colic. However, the poor quality of the published studies does not add support for recommending the use of lactase or low lactose formula in its treatment. Others have proposed that abnormal gut microflora may lead to the development of colic through its effect on intestinal fatty acids. While there have been several studies using probiotics, there is insufficient evidence to justify recommending their use for colic (CPS colic statement - in press).

Herbal remedies
Herbal teas have reportedly been used to treat infantile colic. Weizman et al reported a decrease in crying time after using a product containing a mixture of vervain, camomile, fennel, liquorice and lemon (Weizman et al. 1993). It is important to note that the composition of herbal teas varies considerably among products.

The use of these products is not without risk, as they may have pharmacologic actions, frequently contain sugar and alcohol, and interfere with breastfeeding. At this time, there is insufficient evidence on efficacy and safety to warrant their use during infancy.

Constipation

Parents frequently express concern over their infants' bowel habits. The frequency of bowel movements varies widely during infancy. There is greater variability in breastfed infants, who may pass soft bowel movements as often as 12 times a day and as seldom as once every three or four weeks (Baker et al. 2006).

In formula fed infants, firm stools may occur from the first weeks of life. Normal bowel function occurs even when an infant appears to be in pain, showing straining and reddening of the face. Unfortunately, this wide range of 'normal' in infant stooling frequency and consistency are often misinterpreted, leading to an erroneous diagnosis of constipation.

For breastfed infants who are receiving adequate milk, stools may be infrequent but constipation is extremely rare. For formula fed infants, it is important to ensure that formula is being properly diluted. Reassurance can be given to the caregiver that bowel function is within normal variants if the infant is growing normally and there are no signs of obstruction or enterocolitis (Baker et al. 2006).

The use of prune juice and corn syrup or other home remedies (e.g. brown sugar water) are not recommended for infants younger than six months.

Gastroesophageal reflux

Gastroesophageal reflux is defined as the passage of gastric contents into the esophagus, with or without regurgitation. This normal physiologic process can occur several times a day in healthy infants, children, and adults. About half of healthy three to four-month old infants regurgitate at least once daily (Nelson et al. 1997, Martin et al. 2002) among both breastfed and formula fed infants (Vandenplas et al. 2009).

Gastroesophageal reflux disease (GERD) occurs only when gastric reflux leads to troublesome symptoms or complications. Most infants who regurgitate have no symptoms or complications and require no treatment except parental education and reassurance. Most importantly, breastfeeding should not be discontinued for uncomplicated regurgitation in a thriving, healthy infant. For formula fed infants, ensure there is no overfeeding and that burping technique is effective.

Thickened formulas
Thickening formulas with the addition of rice cereal has been shown to reduce the frequency of vomiting. However, adding rice cereal will dramatically increase the caloric density of the formula and may lead to inappropriate weight gain. Furthermore, the implications of the early introduction of rice protein into the diet are unknown. This intervention should not be used in the management of healthy infants with gastroesophageal reflux.

Commercial antiregurgitant formulas containing processed rice starch are also associated with a decrease in regurgitation. However, the impact of these products on the natural history of gastroesophageal reflux or GERD has not been studied. Furthermore, their allergenicity is unclear. Further research is needed to assess possible nutritional risks of long-term use (Vandenplas et al. 2009).

If there is concern that an infant is suffering from GERD, they should be referred to a physician experienced in its diagnosis and management.

Acute gastroenteritis

Acute gastroenteritis is defined as diarrhea with or without fever or vomiting (Guarino et al. 2008). It is a common problem in infancy and early childhood, usually secondary to viral infections. Rotavirus is the most common cause of severe gastroenteritis.

Dehydration is the main clinical concern of acute gastroenteritis and generally reflects disease severity. Infants with severe dehydration must be managed in a hospital setting with intravenous rehydration.

For minimal to moderate dehydration in both breastfed and formula fed infants, rehydration is the primary goal of treatment. It should start as soon as possible using oral rehydration therapy.

Gastrointestinal infections are very rare in exclusively breastfed infants (Guarino et al. 2008; Bahl et al. 2002; Ribeiro et al. 1994). Breastfeeding should continue during rehydration, as it has also been shown to reduce the severity and the duration of diarrhea from rotavirus (Guarino et al. 2008; Khin et al. 1985; Haffejee 1990).

For infants who are not breastfed, formula feeding should continue. If it has been interrupted, it should start again no later than four to six hours after the onset of rehydration. Meta-analyses (Brown et al. 1994) do not support diluting formula or the gradual reintroduction of feeding. The majority of infants should continue to receive lactose-containing formula (Brown et al. 1994). There is no evidence to support a switch to soy or hydrolysate formula (Guarino et al. 2008).

In practice: Talking with families about infant nutrition

Many products and common practices aim to alleviate infant discomfort. What advice should parents or caregivers be given about their effectiveness and safety?
Infantile colic, constipation, regurgitation (spitting up) and acute gastroenteritis are common problems in early infancy. Changing feeding regimens (for instance, switching from breastfeeding to bottle feeding or changing formulas) are not effective ways to manage these problems for most infants. Changing feeding may also interfere with good nutrition.

Health care providers should be knowledgeable about the wide range of normal behaviour in infants. Unfortunately, many practices still in use to manage these problems are not evidenced based and may be harmful. Any nutritional interventions should be performed under the direction of a health care professional who is well-informed of the risks and benefits.

References

Bahl R, Bhandari N, Saksena M, et al. 2002. Efficacy of zinc-fortified oral rehydration solution in 6- to 35-month-old children with acute diarrhea. J Pediatr.141:677-82.

Baker et al. 2006 Journal of Pediatric Gastroenterology and Nutrition 43:e1-e13. Clinical Practice Guideline NASPGHAN.

Brown KH, Peerson JM, Fontaine O. 1994.Use of nonhuman milks in the dietary management of young children with acute diarrhea: a meta analysis of clinical trials. Pediatrics. 93:17-27.

CPS Nutrition Committee. 2009 (In Press). Is there a role for dietary manipulations in infantile colic?

Guarino et al. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases. 2008. Evidence-based guidelines for the management of acute gastroenteritis in children in Europe. Journal of Pediatric Gastroenterology and Nutrition 46:S81-S122.

Haffejee IE. 1990. Cow's milk-based formula, human milk, and soya feeds in acute infantile diarrhea: a therapeutic trial. J Pediatr Gastroenterol Nutr. 10:193-8.

Hyman PE, Milla PJ, Benninga MA, Davidson GP, Fleisher DF, Taminiau J. 2006. Childhood functional gastrointestinal disorders: Neonate/toddler. Gastroenterology. 130(5):1519-26.

Khin MU, Nyunt NyuntW, Myo K, et al. 1985. Effect on clinical outcome of breastfeeding during acute diarrhoea. Br Med J (Clin Res Ed). 290:587-9.

Lucassen PL, Assendelft WJ, van Eijk JT, Gubbels JW, Douwes AC, van Geldrop WJ. 2001. Systematic review of the occurrence of infantile colic in the community. Arch Dis Child. 84:398-403.

Martin AJ, Pratt N, Kennedy JD, et al. 2002. Natural history and familial relationships of infant spilling to 9 years of age. Pediatrics.109:1061-7.

Nelson SP, Chen EH, Syniar GM, et al. 1997. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 151:569-72.

Ribeiro Junior H, Ribeiro T, Mattos A, et al. 1994. Treatment of acute diarrhea with oral rehydration solutions containing glutamine. J Am Coll Nutr. 13:251-5.

Savino F. 2007. Focus on infantile colic. Acta Paediatr. 96(9):1259-64.

Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenzl TG. 2009. Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 49(4):498-547.

Weizman Z, Alkrinawi S, Goldfarb D, Bitran C. 1993. Efficacy of herbal tea preparation in infantile colic. J Pediatr. 122:650-2.

9. At six months, infants need complementary foods along with continued breastfeeding to meet their nutrient needs. - DRAFT

9.1 Recommend complementary feeding beginning at six months with continued breastfeeding.

9.2 Recommend nutrient-rich foods with iron as the infant's first complementary foods.

At about six months of age, infants are developmentally ready for other foods (Naylor & Morrow 2001). Infants should start to receive nutritionally adequate and safe complementary foods at this stage (PAHO/WHO 2002).

Use of complementary foods before six months may interfere with an infant's total milk intake (Dewey et al. 1999). During the transition to complementary feeding, it is essential that an infant also continue to get enough breastmilk or formula.

• Iron
• First foods
• Allergies
• In practice: Talking with families about infant nutrition
• References

Iron

Most healthy term infants are born with sufficient iron stores to meet their iron needs until they are about six months (Butte 2002). At that age, breastmilk alone can no longer meet their need for iron (Butte 2002, IOM 2001).

Infants who are at risk of iron deficiency include those who are small for gestational age, those born to iron-deficient mothers, and women with diabetes. These infants need close monitoring of their iron status (Savoie 2002, Innis 1997, Yang 2009, Georgieff et al 1990). Iron supplementation prior to six months, rather than early introduction of iron-containing foods, may be needed for these at-risk infants (AAP, 2005, Dewey et al 1998, Friel et al. 2003).

Iron containing foods are recommended as the first foods to help meet the nutrient requirements of the rapidly growing infant (ESPGHAN 2008). Iron from meat sources is better absorbed than iron from non-meat sources (Health Canada 2009). Meat is also an important source of zinc in the diet of older infants (Krebs et al. 2006, Krebs & Hambidge 2007).

First foods

In North America, there is evidence that some of the common first foods are not particularly iron-rich and at six months many infants do not consume iron-containing foods with sufficient frequency (Friel 2010, Dee et al. 2008). This table compares suggested, iron-rich first foods to popular first foods offered to infants in Canada.

In Canada, the most common first food has been iron-fortified infant cereal. Semi-liquid solids, like infant cereals, were necessary when introduction of solids was recommended from four months of age. A 2006 survey showed the average age for introducing solids was 4.8 months (PHAC 2009).

At about six months, infants are ready for foods with more semi-solid texture. First foods should include iron-rich meat such as beef, fish, and poultry and alternatives such as cooked egg yolks, cooked legumes, and tofu. Advice to parents should emphasize the best first foods to achieve a regular and adequate source of iron with an emphasis on more absorbable (heme) sources.

Allergies

The relationship between the timing of starting an infant on solid foods and the development of allergies remains inconclusive (Greer et al. 2008, EFSA 2009). Experts suggest, however, that introducing solid foods too early or too late has more risks than benefits (Greer et al. 2008, ESPGHAN 2008). For example, increased risk of celiac disease has been associated with both early (less than 4 months) and late (7 months or later) introduction of foods containing gluten (ESPGHAN 2008). Introducing solids later than four to six months has not been shown to protect against the development of allergies (Greer et al. 2008, ESPGHAN 2008).

Delaying the introduction of common allergens is not currently recommended as a way to prevent allergies (Greer et al. 2008). The timing of introduction of common allergenic foods (milk and milk products, eggs and peanuts), particularly for infants with a family history of allergies continues to be investigated (Sicherer et al. 2010).

In practice: Talking with families about infant nutrition

What if the infant still seems hungry after feedings or shows signs of being ready for solid food earlier than six months?

Infants will be hungrier during growth spurts. Recommend more frequent feeding in response to increased hunger rather than introducing other foods too soon. Complementary foods are not usually needed before six months, and emphasis should be placed on breastmilk or formula to provide nutrition.

If parents do introduce solid foods before six months, they should ensure the infant is showing signs of being physiologically and developmentally ready. These signs include:

• Gradual disappearance of the "extrusion reflex," which is used for sucking
• 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).

Parents must ensure that the first foods introduced are iron-rich. Solid foods should be given in limited quantities after milk feedings, to avoid interfering with the infant's milk intake. A puree texture may be needed, at least temporarily, before six months.

What advice can be offered on serving meat and alternatives as a first food to a six month-old infant?

At six months, infants can be served:

• thick purees
• food that is well mashed with a fork
• soft finger foods.

The texture of the food should be gradually increased over the next few months.

Here are some examples of how to serve meat and alternatives:

• lean meat, braised or boiled until well-cooked and minced finely
• lean poultry (i.e. skin removed), boiled, and minced finely
• fresh or frozen plain fish, baked, broiled or poached, all bones removed, and mashed with a fork
  Note: Do not feed infants predatory fish such as tuna, shark, swordfish, marlin, orange roughy and escolar. Predatory fish contain higher levels of mercury.
• well cooked eggs, either scrambled or hard boiled and mashed with a fork.
• well cooked or canned legumes, well-rinsed, and mashed with fork or potato masher.

References

AAP (American Academy of Pediatrics). 2005. Breastfeeding and the use of human milk. Pediatrics Vol. 115 No. 2.496-506.

Butte N, Lopez-Alarcon M, Garza C. 2002. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva. World Health Organization.

Dee et al. 2008. Sources of supplemental iron among breastfed infants during the first year of life. Pediatrics. 122. S98-104.

Dewey KG et al. 1998. Effects of the age of introduction of complementary foods on iron status of breastfed infants in Honduras. AJCN.67:878-884.

Dewey KG et al. 1999. Age of introduction of complementary food and growth of term, low birth weight breastfed infants: a randomized intervention study in Honduras. AJCN.69:679-686.

EFSA Panel on Dietetic Products, Nutrition and Allergies. 2009. Scientific opinion on the appropriate age for introduction of complementary feeding of infants. EFSA Journal; 7(12): pp 1423-1438.

ESPGHAN Committee on Nutrition. 2008. Complementary feeding: A commentary by the ESPGHAN. J Pediatr Gastroenterol Nutr 2008 46:99-110.

Friel JK, Aziz K, Andrews WL, Harding SV, Courage ML, Adams RJ. 2003. A double-masked, randomized control trial of iron supplementation in early infancy in healthy term breast-fed infants. J Pediatr. 143: 582-6.

Friel JK, Hanning RM, Isaak CA, Prowse D, Miller AC. 2010. Canadian infants' nutrient intakes from complementary foods during the first year of life. BMC Pediatrics.

Georgieff MK, Landon MB, Mills MM, Hedlund BE, Faassen AE, Schmidt RL, Ophoven JJ, Widness JA. 1990. Abnormal iron distribution in infants of diabetic mothers: spectrum and maternal antecedents. J Pediatr. 117(3): 455-61.

Greer et al. 2008. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Pediatrics. 121: 183-191.

Health Canada. 2009. Prenatal Nutrition Guidelines for Health Professionals, Iron Contributes to a Healthy Pregnancy. Ottawa.

Innis SM, Nelson CM, Wadsworth LD, MacLaren IA, Lwanga D. 1997. Incidence of iron-deficiency anaemia and depleted iron stores among nine-month-old infants in Vancouver Canada. CJPH. 88(2): 80-4.

Institute of Medicine. 2001. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington DC. National Academy Press.

Krebs NF, Hambidge KM. 2007. Complementary feeding: clinically relevant factors affecting timing and composition. Am J Clin Nutr. 85(suppl):639S-645S.

Krebs NF, Westcott JE, Butler N, Robinson C, Bell M, Hambidge KM. 2006. Meat as a first complementary food for breastfed infants: Feasibility and impact on zinc intake and status. JPGN. 42:207-214.

Naylor AJ, Morrow AL. 2001. Developmental readiness of normal full term infants to progress from exclusive breastfeeding to the introduction of complementary foods. Washington DC. LINKAGES/Wellstart International.

PAHO/WHO. 2002. Guiding principles for complementary feeding of the breastfed child. Washington DC. Pan American Health Organization/World Health Organization.

PHAC (Public Health Agency of Canada). 2009. What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa.

Savoie N & Rioux FM. 2002. Impact of maternal anemia on the infant's iron status at 9 months of age. CJPH. 203-7.

Sicherer SH et al. 2010. Maternal consumption of peanut during pregnancy is associated with peanut sensitization in atopic infants. J Allergy Clin Immunol. IN PRESS.

Statistics Canada. 2004. Canadian Community Health Survey 2.2. Detailed food/recipe file.

Yang Z, Lönnerdal B, Adu-Afarwuah S, Brown KH, Chaparro CM, Cohen RJ, Domellöf M, Hernell O, Lartey A, Dewey KG. 2009. Prevalence and predictors of iron deficiency in fully breastfed infants at 6 months of age: Comparison of data from 6 studies. Am J Clin Nutr. 89(5):1433-40.

Appendix

THE WHO/UNICEF Ten Steps to Successful Breastfeeding (Global Criteria)

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 skills necessary to implement this 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.

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.

Source: WHO & UNICEF. 2009.  Baby-Friendly Hospital Initiative. Revised, Updated and Expanded for Integrated Care. Section 1 Background and Implementation.

The Breastfeeding Committee for Canada's Integrated Ten Steps for Hospitals and Community Health Services (BCC Summary List of the Interpretation for Canadian Practice)

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 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 Infants are not offered food or drink other than human milk for the first 6 months, unless medically indicated.

Step 7 Facilitate 24 hour rooming-in for all mothers: 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.

Source: BCC (Breastfeeding Committee for Canada). 2010.  The Breastfeeding Committee for Canada's Integrated Ten Steps & WHO Code Practice Outcome Indicators for Hospitals and Community Health Services.

WHO International Code of marketing Breast-milk Substitutes

Summary of the main points:

1. No advertising of these products (i.e., formula, bottles, nipples, pacifiers) to the public.
2. No free samples of these products to mothers
3. No promotion of artificial feeding products in health care facilities, including the distribution of free or low-cost supplies.
4. No company representatives to advise mothers.
5. No gifts or personal samples to health workers.
6. No words or pictures idealizing artificial feeding, including pictures of infants on the labels of products.
7. Information to health workers should be scientific and factual.
8. All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and the cots and hazards associated with artificial feeding.
9. Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
   

Adapted by BCC from: WHO/UNICEF. 2009. .Section 1: Background and Implementation. Section 1.4: Compliance with the International Code of Marketing of Breast-milk Substitutes