Infant Feeding Expert Advisory Group: Meeting Summary

June 28 & 29, 2011
Ottawa, Ontario

1. Meeting summary and objectives

The objectives of this meeting were the following: to share the input received during the stakeholder consultation on the draft statement Nutrition for Healthy Term Infants (NHTI) - Recommendations from Birth to Six Months of Age; to present how the Joint Working Group (JWG) proposed to address the input received; and to obtain expert advice on specific issues as outlined in the meeting agenda. The JWG received valuable input and guidance that will be considered as part of the work to revise the draft statement.

2. List of attendees

Members of the Expert Advisory Group (EAG): James Friel, Laura Haiek, Sheila Innis, Gerry Kasten, Jack Newman, Daniel Roth, Nancy Watters

Members and alternates of the JWG: Christina Zehaluk Health Canada (HC), Deborah Hayward (HC), Julie Voorneveld Public Health Agency of Canada (PHAC), Tanis Fenton Dietitians of Canada (DC), Jeff Critch Canadian Paediatrics Society (CPS), Jennifer McCrea (HC), Hélène Lowell (HC)

Invited guests:  Sandra Ace (HC), Janet Pronk (HC)

Regrets: Brenda McIntyre (member of the JWG)

3. Declaration of affiliations and interests

Janet Pronk, Director, Office of Nutrition Policy and Promotion described the concept of conflict of interest (COI) as it is described in the Health Products and Food Branch Guidance on Advisory Bodies. She clarified that not all affiliations and interests constitute a COI:

• Individuals who declare a direct financial interest are excluded from the membership of an advisory body.
• Other affiliations and interests are managed through the consistent use of mechanisms ranging from limiting participation in the work of the advisory body to public disclosure of this information.

Janet described the concerns raised during the consultation regarding the membership of the EAG, and reminded members about the need to disclose their affiliations and interests as a condition of their appointment. The Chair then requested that members identify changes to the previously disclosed affiliations and interests posted on Health Canada's Web site and circulated at the meeting. No changes were provided but minor edits were proposed to four member biographies.

Members of the EAG asked for clarification about the affiliations and interests of the members of the JWG; the possibility of collaborating with other organizations on the statement; and the options for increasing the breastfeeding/nursing expertise among the JWG membership.

Action: The JWG will consider options to broaden the membership of both committees.

4. Welcome and introductions

Janet Pronk welcomed everyone to the meeting on behalf of the JWG. Meeting participants introduced themselves during the roundtable. The Chair provided an overview of the day's agenda.

Approval of Oct. 25th meeting summary
One point of clarification was suggested for the summary of the October 25th teleconference of the EAG concerning the action for item #5. It was suggested to add that the group was to "review and discuss the recent revision by the Breastfeeding Committee for Canada of the WHO/UNICEF's Ten Steps and Seven Point Plan into the Integrated Ten Steps.

5. Consultation input overview

Agenda item overview: The Secretariat reminded everyone about the purpose and the intended audience for the statement; described the volume and level of detail of consultation submissions by stakeholders; and provided a brief overview of the main comments received. The Secretariat also described the content that the JWG was moving forward with changing based on stakeholder input and internal expert advice, and the issues that needed further guidance from the EAG. A roll-up of the consultation input was circulated prior to the meeting.

6. Questions for EAG input

a) Clarify wording of rationale for duration of exclusive breastfeeding

Agenda item overview: The Secretariat described the consultation input received on the exclusive breastfeeding section: text should focus on risks of not breastfeeding; there is a mix of evidence provided; and the evidence base for six months exclusive duration must be clear. The EAG was asked whether the recommendation's rationale should be consistent with the evidence-base presented by the WHO/UNICEF.

Viewpoints expressed at the meeting:

• Focus evidence-base on why introducing solids at six months is recommended.
• Combine recommendations on exclusive breastfeeding and introduction of solids as they are related.
• Focus on "readiness" and normal range of development.
• Provide a clear recommendation on duration with supporting text on the range of normal/variations from child to child.
• Provide a clear statement on the risks of shortened breastfeeding durations.
• Include overall statement that all Canadian infants should be breastfed.
• Explain risks of introducing foods too early and too late.
• Address inconsistency between recommendation and practice - describe recommendations in chronological order: initiation, duration, exclusivity.

Action: The JWG will consider the EAG's advice when revising the draft statement.

b) Prevention of iron deficiency/iron deficiency anaemia

Agenda item overview: An overview was provided on the content of the iron background paper commissioned by Health Canada. The paper examines the issue of iron deficiency (ID) and iron deficiency anemia (IDA) in infants and young children and the role that feeding choices play in preventing ID/IDA. Generally, the paper was well received. The EAG was asked to help clarify the guidance on first complementary foods with particular attention to iron and to provide input on the wording of a draft Questions and Answers (Q&A) on iron supplements.

Viewpoints expressed at the meeting:

• There are many determinants of iron status - breastfeeding, gestation age, birth weight
• At a population level, the recommendation in favour of exclusive breastfeeding up to six months of age is not expected to have an adverse impact on iron status
• It appears that among some parents and public health professionals the advice to offer meat as a first food is 'new' and that the labelling of infant cereal (% Daily Value of iron) contributes to confusion about recommended iron intake
• Change wording from 'infant cereal' to 'iron-fortified infant cereal'
• Wording changes were suggested for the draft Q&A (e.g., to add a statement that iron supplements are not routinely recommended in infancy, and that infants should be fed according to NHTI)

{Note: Discussion on this item was revisited and continued on Day 2. Refer to item #8}

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

c) Clarify guidance on duration of vitamin D supplementation for breastfed infants

Agenda item overview: The Secretariat provided an overview of the comments received during the consultation on the section pertaining to vitamin D supplementation. The EAG was asked to help clarify guidance on the duration of vitamin D supplementation for breastfed infants. They were also asked to comment on the need for a Q&A to address the needs of subgroups of the population.

Viewpoints expressed at the meeting:

• Recommending a vitamin D supplement from 0-12 mths is appropriate since at 1 year of age, most young children eat a variety of foods including vitamin D-fortified foods
• May need guidance for population subgroups that do not eat fortified foods
• Vitamin D is scarcely available in the diet and public health recommendations are to avoid sun exposure
• Some current recommendations limit cow's milk to 500 mL per day at 1 year of age
• There is a lack of evidence for or against supplementation for children aged one and older, particularly among those who consume vitamin D-containing foods
• Concern that foods eaten in the second year are not good sources of vitamin D
• Cannot specify a particular subgroup of the population that the current supplementation recommendation would not apply for
• Health professionals should apply greater effort to reach certain subgroups who may be at greater risk of vitamin D deficiency (e.g., infants born to women with known vitamin D deficiency) when  implementing the recommendation
• Women should be advised to consider their vitamin D intake during pregnancy and lactation
• To reduce confusion (due to differing recommendations) - clearly support supplementation of 400 IU/d for all breastfed infants everywhere in Canada but acknowledge 800 IU/d is safe

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

d) Clarify In Practice advice on how to assess breastmilk intake

Agenda overview: The Secretariat described the comments received during the consultation. The EAG was asked to confirm the appropriate techniques for assessing milk intake after the first week following birth.

Viewpoints expressed at the meeting:

• First few weeks are very important; issues can be fixed very easily in early intervention
• Focus on indicators of adequate breastmilk supply - refer to Best Start resource
• After 1st week, look to stool patterns table and urine output
• Ultimate indicator is that the baby is growing well over time
• See if the baby looks satisfied
• Need more than weight as an indicator- parents of small babies can be overly concerned about weight
• Suggest addressing overfeeding in bottle-fed babies, as suggested in the consultation comments, and including information about what hunger looks like but caution against messages that could be interpreted as controlling intake
• Encourage feeding on cues rather than based on volumes, and offering smaller amounts initially

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

7. Present illustrations for Nutrition for Healthy Term Infants

Agenda item overview: The Secretariat presented the illustrations that will be used in building the web-based content of NHTI. The EAG identified their preferences, commented on the appropriateness of the images and gave some advice on fit between certain images and the contents of the 0-6 month statement.

Viewpoints expressed at the meeting:

• Would prefer that images show skin-to-skin contact between mother and baby
• Like image of parent helping child drink from cup
• Happy to see no images with bottles
• Concern with image where baby is at the table and appears to have cups of coffee at close proximity
• White coat for health care provider is a stereotype

Action: The JWG will review the viewpoints expressed by members of the EAG when formatting the content for the final draft statement.

8. Welcome and recap of Day 1

Agenda item overview: A member of the EAG wished to revisit the agenda item on the iron background document. He expressed his concern that the document did not have the necessary data to support its conclusions and would like the JWG to reconsider recommending solid foods between four and six months.

Viewpoints expressed at the meeting:

• Concern that proposed recommendations replete iron at the stage when stores are gone (six months of age)
• There is no effective screening method for infants before six months
• The amount of iron in breastmilk is negligible and bioavailability is at 20% like all heme sources of iron
• Theory is that the iron stores are enough
• Suggest caution when looking at the amounts of nutrients in breastmilk (e.g., protein content is very low compared to other milks but babies grow nonetheless)
• Question the potential harmful effects with universal iron supplementation
• Supplementation interferes with normal physiological process of breastfeeding
• Key debate is whether a population health recommendation is needed at this time
• Unsure how big the subgroup at risk of anaemia but acknowledge it is a real concern
• The only infant meat study so far is a beef study looking at zinc
• This discussion links to when solids should be introduced
• Current wording of the recommendations can give a sense that starting solids before six months is wrong
• Some babies are ready for solid foods before six months
• Suggest a statement about not starting before four months
• Need to separate guidelines from practice - if four to six is recommended, risk increases that some will start introducing solids much sooner
• Introduction of solids is a milestone that is different for every child
• Need some flexibility in the wording about introduction of solids
• Not in agreement with the use of wording 'around' or 'about' for the range of developmental readiness
• Concern that baby will get less breastmilk if 'around' six months is advised for introducing solid foods
• Six months or earlier or later based on developmental readiness - wording 'around' can be interpreted both ways
• Risk of going too long without introducing solids
• Consider moving content between sections to discuss cue-based and 'readiness' of feeding in the first section

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

9. Questions for EAG input

Input on wording of the recommendation under Principle 2 (Referencing Ten Steps and Code)

Agenda item overview: The Secretariat provided an overview of consultation input received on recommendations contained in Section 2. The main concern raised was that the draft recommendations were somewhat different to the WHO/UNICEF Ten Steps in several ways and were incomplete. The Secretariat proposed having one recommendation that would reference use of the Ten Steps and the Code. The EAG was asked to help with the wording of that recommendation.

Viewpoints expressed at the meeting:

• Support this approach
• Refer to WHO 2009 for new interpretation of Step 4
• Suggest that information about hand expression be included in background
• Need a link to the medically indicated section
• Background should describe responsibility to support families who made an informed decision not to breastfeed and provide them with information on preparing formula (related to Step 3)
• BFI includes important points for all babies, including non-breastfed (i.e. strongest evidence is for skin-to-skin contact)
• Proposed wording for the recommendation: "Implement the policies and practices of the Baby-Friendly Initiative (BFI) for hospitals and community health services."
• Find a place in the document to describe feeding hierarchy; not sure where it fits (related to Step 6); need to avoid casual sharing of breastmilk
• Link to CPS statement on milk banks
• Suggest use wording such as 'pasteurized human donor milk.' Human donor milk is a 'food' in the Food and Drug Regulations
• See Human Milk Bank Association position statements and guidelines
• Pasteurized milk is available by prescription at BC General

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

10. Looking ahead to the final statement

Agenda item overview: The Secretariat presented information about the next steps including final review of the revised draft statement by members before the second stakeholder comment period. The EAG was asked to comment on the development of a 'promotional product' for use in disseminating the final statement.

Viewpoints expressed at the meeting:

• Adoption requires academic alignment / 'call to action'
• Talking to grass-roots and engaging academics
• Engage Canadian Institutes of Health Research (CIHR)
• Use a multidimensional approach (web seminars, conference agendas)
• Consider printed products for branding and wider recognition

Action: The JWG will consider the committee's advice when developing the dissemination strategy.

11. Second phase of update - Recommendations from 6 to 24 months

Agenda item overview: The Secretariat presented the results of the Dietitians of Canada National Conference workshop on infant feeding guidance for the 1-2 age group. The workshop participants were split about the need for qualitative messages versus a more prescriptive approach to dietary guidance (including quantity recommendations) for this age group. The Secretariat discussed the types of emerging issues that are influencing infant feeding decisions today. The EAG identified other emerging issues for consideration and proposed additional topics for the 6-24 month document.

Committee identification of emerging issues/additional topics for consideration:

• Cow's milk - cultural aspects and debate about whole milk versus lower fat milk
• Discuss formula intended for use beyond infancy, use of formula from 9-12 mths and follow-on formulas
• Daycares - issue that some centres request that infants take the bottle; and describe how centres can support breastfeeding
• Information about the division of responsibility of feeding between parents and child
• Supplements and herbal/natural products that are indicated for use in childhood
• Weaning, teething, timing of self-feeding
• Sodium
• Obesity
• Other fluids (e.g., vitamin water, raw milk, milk of other animals)
• Recognize/being sensitive to the multicultural make-up of Canada
• Discuss normal variation in number of portions and making mealtime a happy time
• Using growth charts and discussion about the normal variations in pattern of growth
• Focus on other signs that a child is healthy, not just weight (e.g., full of energy, playful)

Action: The JWG will consider the committee's advice when ready to develop an outline for NHTI 6-24 months.

12. Closing remarks

Next steps

The Secretariat indicated that the next step will be for the JWG to prepare a revised draft of Nutrition for Healthy Term Infants - Recommendations from Birth to Six Months of Age. The EAG would then have an opportunity to review and input before the second consultation draft is made public for an online comment period.

The Chair thanked everyone for their active participation at the meeting.

13. Adjournment

The meeting was adjourned at 2:30 PM.