Duration of Exclusive Breastfeeding - Questions and Answers for Professionals

Q1: Will exclusive breastfeeding for 6 months cause an increase in prevalence of iron deficiency anemia in Canadian healthy term infants?

A: The current evidence does not support that view. A review by Griffin and Abrams, examining current literature on the topic came to the following conclusions:

1. Exclusive breastfeeding will meet the iron needs of most healthy term infants until 6 months of age.
2. Exclusive breastfeeding is compatible with normal iron status.
3. To prevent iron deficiency, iron-fortified and vitamin C fortified complementary foods should be introduced at approximately six months of age.

The Dietary Reference Intakes (DRI) report on iron, states "For this age group (0-6 months), it is assumed that the iron provided by human milk is adequate to meet the iron needs of the infant exclusively fed human milk from birth through six months." It is also reported that "It is widely accepted that the iron intake of infants exclusively fed human milk must meet or exceed the actual needs of almost all of these infants and that the described pattern of utilization of iron stores is physiologically normal, not indicative of the beginning of iron deficiency".

It should be noted that full-term infants who are small for gestational age and those born to iron-deficient mothers may be at increased risk of iron deficiency. Health professionals should monitor iron status of these infants closely.

Griffin and Abrams, Ped. Clinics. N.A. 2001:48 (2); 401-413

Q2: Why does this document not cover the overall health benefits associated with breastfeeding?

A: The intent of this document is to provide advice on the recommended duration of exclusive breastfeeding and update the recommendation made in the 1998 document Nutrition for Healthy Term Infants. The intent is not to provide an all-inclusive document on breastfeeding.

Q3: Why was the issue of breastfeeding and reduced breast cancer risk not addressed in this document?

A: Although several studies have looked at the association between breastfeeding in general and reduced risks of breast cancer, these studies have not specifically compared four versus six months of exclusive breastfeeding.

Q4: What is meant by nutrient-rich solid foods with particular attention to iron?

A: Examples include infant cereals, chicken, pork, beef, wild meat, egg yolks and legumes. The absorption of non-heme iron (the type of iron found in non-animal food sources such as infant cereals, legumes) can be enhanced if it is consumed with foods high in vitamin C such as citrus fruits, peppers and tomatoes.

Q5: When should solids be introduced for infants fed commercial breast milk substitutes and mixed-fed babies (those who are fed breastmilk and breast milk substitutes ) ?

A: Solids should be introduced at six months of age for infants fed commercial breast milk substitutes and mixed-fed babies.

Q6. What if a mother decides not to exclusively breastfeed until 6 months?

A: Some mothers may not exclusively breastfeed to six months for personal and/or social reasons. These parents also need to be supported and given appropriate information to enable informed decisions to ensure optimal infant nutrition.

Q7: How was this recommendation on the duration of exclusive breastfeeding developed and who was involved?

A: Advice and guidance was sought from a variety of experts and stakeholders. An internal Health Canada Infant Feeding Working Group was created. The feedback and advice of the Expert Advisory Panel on Exclusive Breastfeeding was also incorporated into the present recommendation. Judy Sheeshka from the University of Guelph prepared a discussion paper to inform the work of the panel.

The draft recommendation was also posted to Health Canada's website for a comment period. Sixty-nine respondents sent in comments, representing over 368 reviewers. These comments were then reviewed by the infant feeding working group and the expert panel in finalizing the recommendation and supporting materials.