Infant Feeding Expert Advisory Group: Meeting Summary - Teleconference meeting

October 31st, 2011
2:30 - 4:00 PM (EST)

1. Meeting summary and objective

The main objective of the October 31st, 2011 teleconference meeting was to give members an opportunity to discuss proposed changes to the revised draft of Nutrition for Healthy Term Infants (NHTI) - Recommendations from Birth to Six Months of Age circulated prior to the meeting. Members of the Joint Working Group (JWG) and the Expert Advisory Group (EAG) were asked to flag inaccuracies in the draft text to the Secretariat, with supporting references, in advance of the meeting.

2. List of attendees

Members of the EAG: James Friel, Laura Haiek, Gerry Kasten, Daniel Roth, Nancy Watters

Members and alternates of the JWG: Deborah Hayward, Health Canada (HC), Julie Voorneveld, Public Health Agency of Canada (PHAC), Brenda McIntyre (HC), Tanis Fenton, Dietitians of Canada (DC), Jeff Critch, Canadian Paediatrics Society (CPS), Genevieve Courant, Breastfeeding Committee of Canada (BCC), Jennifer McCrea(HC), Hélène Lowell(HC)

Invited guests:  none

Regrets: Jack Newman (member of the EAG), Sheila Innis (member of the EAG), Christina Zehaluk (member of the JWG)

3. Welcome and introductions

The Secretariat and Chair welcomed everyone to the meeting and attendees introduced themselves during the roundtable.

4. Summary of overall input received from EAG and JWG on the revised draft Nutrition for Healthy Term Infants 0-6 months

Agenda item overview: The Secretariat indicated that the overall input received from the members of the EAG and JWG was positive but that a few issues remained outstanding. Edits for discussion were brought forward as agenda items for this meeting. Members were also asked to provide comments on other edits to the draft to the Secretariat via email.

The Chair reminded members that editorial-type comments submitted to the Secretariat would not be reviewed during the meeting but were given full consideration by the JWG.

5. Specific comments and proposals for discussion with EAG

a) Specify iron fortified cereals?

Agenda item overview: The Secretariat described the types of comments received from members of the EAG and JWG: some members advised that the text should specify 'iron fortified infant cereal', while others advised omitting 'iron-fortified cereal' as an example of iron-rich foods (and replacing the wording with 'other iron rich foods'). The Secretariat explained that the intention of not specifying 'infant' cereal was not to exclude infant cereals but to include other iron fortified cereals. The EAG was asked to advise on whether other iron-containing cereals can be recommended as a first food (i.e., are they an adequate source of iron?).

Proposal put forward for discussion: Include 'infant cereal' as an example of an iron-rich food: "…At this stage, iron rich foods, such as meat, meat alternatives and iron fortified infant cereals, are important to help meet the nutrient needs of the rapidly growing infant (ESPGHAN 2008, Yang 2009, Christofides et al 2005)."

Viewpoints expressed at the meeting: The following bullets outline the main discussion points:

• Including other iron fortified cereals gives parents options.
• Infant cereals are a refined grain, not a whole grain.
• Whole grains are not necessarily better since iron absorption can be affected by phytates.
• In terms of the examples of iron rich foods, game meats are a richer source of iron than other types of meat.
• Additional examples of iron rich foods should be included in the In Practice on texture of first foods, similar to the items that were in the table of iron containing foods in the consultation draft.

Action: The JWG will consider viewpoints expressed by members of the EAG when revising the draft statement.

b) Vitamin D for all infants

Agenda item overview: The Secretariat indicated that some members of the EAG and the JWG suggest addinga statement that "ALL infants need a source of vitamin D". The Secretariat explained that a similar principle was included in the consultation draft and contributed to significant confusion about the need for supplementation in exclusively formula fed infants. Many consultation participants objected to the verb 'NEED' and suggested 'RECOMMEND.'

Proposal put forward for discussion: No change to principle to avoid further confusion about the recommendation to supplement only breastfed infants. Include two sentences to first paragraph (see bold text): "All infants should have a source of supplemental vitamin D. A daily vitamin D supplement of 10µg (400 IU) is recommended from birth for exclusively and partially [Link to In Practice on partially] breastfed infants. Infants exclusively fed commercial infant formula obtain sufficient supplemental vitamin D from the formula."

Viewpoints expressed at the meeting: The following bullets outline the main discussion points:

• Remove the word 'supplemental' in the proposed text to reduce confusion.
• Separate the last sentence into two to communicate that: 1) formula is "supplemented" with vitamin D; 2) infants exclusively fed formula obtain sufficient vitamin D / do not require additional supplementation.
• Manufacturers are increasing the amount of vitamin D contained in formula. Additionally, the amount that is provided on the label is a minimum; overages vary but are not listed on the label.
• Is there a need to recommend supplementation to exclusively formula fed infants since they are not getting 400 IU in the first couple of years in life?
• It is more accurate to describe vitamin D as an ingredient in infant formula.

Action: The JWG will consider viewpoints expressed by members of the EAG when revising the draft statement.

c) Duration of vitamin D supplementation

Agenda item overview: The Secretariat indicated that some members of the EAG and the JWG feel that the duration of vitamin D supplementation should be included in the document. It was suggested that at about 12 months of age, most children will be approaching 400 IU per day from food sources, primarily from cow's milk.

Proposal put forward for discussion: Add duration in rationale text, not in recommendation: "…continuing until at least one year of age" and link to a new Questions and Answers (Q&A) that could be updated/removed if the recommendation is revised as part of the second phase of the project.

The Secretariat indicated that the use of the wording at least allows for individualization. Also, guidance for children 2 years and older is currently being looked at in light of the new 600 IU Recommended Daily Allowance (RDA) for children and adults. The Q and A could clarify that if vitamin D fortified foods (e.g. cow's milk) are not introduced into a child's diet by one year of age, there may be benefit to continuing with a daily vitamin D supplement beyond the first year.

Viewpoints expressed at the meeting: The following bullets outline the main discussion points:

• Timing to stop supplementation is dependent on time of weaning.
• Recommendation should be to continue supplementation until such time that the child gets enough vitamin D from other sources.
• Need to think about guidance for the child over 1 years of age since the RDA is higher after the age of 1 year (the RDA goes from 400 to 600 IU).
• If breastfeeding stops before 1 year but other milks are offered, there is no need to supplement.
• Health professionals need to offer parents specific guidance on the timing of supplementation (i.e., when to start, how much to give, when to discontinue).
• Guidance could include "until the infant is weaned from the breast".

Action: The JWG will consider viewpoints expressed by members of the EAG when revising the draft statement.

d) Iron supplementation

Agenda item overview: The Secretariat discussed the types of comments received from members of the EAG and the JWG some of whom stated that the guidance on the need for iron supplementation will be missed if left in the In Practice section. The Secretariat indicated that a frequent question from health professionals is whether breastfed infants require an iron supplement in the first 6 months. It needs to be clear that NHTI does not have a universal supplement recommendation for iron but that some groups are at risk and should be identified early.

Proposal put forward for discussion: Add a new principle/section after the Vitamin D section and before the First Foods section. The text from the In Practice would form the rationale.

Proposed new principle: Iron supplementation may be beneficial for infants at risk of iron deficiency or (a more general principle option) Iron is an important nutrient for growth and development during infancy.  Proposed new recommendation: Case-select breastfed infants who may be at risk of iron deficiency.

Viewpoints expressed at the meeting: The following bullets outline the main discussion points:

• The more general wording of the principle (Iron is important…) is preferable.
• There are issues with the guidance to 'case-select infants for testing'. Further guidance about the type of testing would be needed along with this statement.
• Current wording does not provide clear guidance on what the health professional should do.
• Many full term infants are born with a birth weight of 3000 grams are less.
• Indicate to the health professional that maternal iron status should be checked as well as the infant's birth weight.
• The issue is adequately addressed by the In Practice section.
• Leave out 'testing' part of the text, except if clear guidance can be provided.
• Include the principle about the importance of iron for growth and development in the first solid foods section.
• Being specific and recommending the case-selecting of infants is problematic since we are talking about a sub-set of the population that is heterogeneous.
• The current text covers the available knowledge on characteristics of "at risk" infants.

Action: The JWG will consider viewpoints expressed by members of the EAG when revising the draft statement.

e) Text to clarify that breastfeeding continues after 6 months

Agenda item overview: The Secretariat described the types of comments received from members of the EAG and JWG, including the need to clarify that breastfeeding is recommended to continue after six months. The Secretariat highlighted that there is a misperception that the recommendation for exclusive duration (six months) is the recommended duration for any breastfeeding. The NHTI statements are arbitrarily split at 0-6 and 6-24; however, some guidance straddles the two statements.

Proposal put forward for discussion: New text for introductory paragraph: "Breastfeeding - exclusively for the first six months with continuation along with complementary foods for two years or more - is important for the nutrition, immunologic protection, growth and development of infants and toddlers."

Viewpoints expressed at the meeting: The following bullets outline the main discussion points:

• Like the text although the wording is awkward.
• Prefer the wording of the 2004 Health Canada recommendation on exclusive breastfeeding.
• A variety of wording suggestions were proposed at the meeting.

Action: The JWG will consider viewpoints expressed by members of the EAG when revising the draft statement.

6. Next Steps

Agenda item overview: The Secretariat indicated that Health Canada will be identifying one new member for the EAG membership who will contribute the perspective/experience of a lay-person. An 'open call for candidates' will be posted on the Health Canada website following the EAG meeting and stakeholders will be notified via email of the posting. The Secretariat clarified that the JWG would be responsible for selecting a member among qualified candidates.

In terms of the second round of consultation, the Secretariat indicated that the 60-day consultation period is being planned for early January, 2012. Prior to posting the draft for consultation, it will be professionally edited and translated. The Secretariat also indicated that a comparative edit of the French text will be completed prior to the consultation.

Action: The Secretariat will draft a statement of work that will be circulated to members of the JWG and EAG.

7. Adjournment

The meeting was adjourned at 4:15 PM.