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Breastfeeding

Breastfeeding is the optimal method of feeding infants.

Recommendation:

1. Encourage exclusive breastfeeding for the first 6 months of life, as breast milk is the best food for optimal growth. Breastfeeding may continue for up to 2 years and beyond.

For more details concerning this recommendation, consult the following document: "Exclusive Breastfeeding Duration, 2004 Health Canada Recommendation".

Active public health, hospital, community and workplace support of breastfeeding will increase initiation rates and duration of breastfeeding.

Recommendations:

2. Provide antenatal and postnatal counselling about the principles and practice of breastfeeding.

3. Encourage frequent feeds during the early postnatal period.

4. Provide more community-based programs supporting breastfeeding families as the length of hospital stays decreases.

5. Provide support in the community and workplace for flexible work schedules, part-time nursing and the use of expressed breast milk.

Breastfeeding is rarely contraindicated. Neither smoking nor environmental contaminants are necessarily contraindications to breastfeeding. Moderate, infrequent alcohol ingestion, the use of most prescription and over-the-counter drugs and many maternal infections do not preclude breastfeeding.

Recommendations:

6. Encourage women who smoke to stop or reduce smoking; however, even if smoking is continued, breastfeeding is still the best choice.

7. Limit intake of alcohol.

8. Whenever drugs are prescribed or infection detected, assess each case on an individual basis.

9. When the mother is known to be HIV antibody positive, alternatives to breastfeeding are indicated.

Vitamin D deficiency is a health concern in Canada. Infant formulas and milks are fortified with vitamin D. Breastfed infants should also receive extra vitamin D in the form of a supplement.

Recommendation:

10. Provide a daily 10µg (400 IU) vitamin D supplement to all breastfed infants starting at birth and until the diet includes at least 10 µg (400 IU) per day of vitamin D from other dietary sources, or until the breastfed infant reaches 1 year of age. After 1 year, all children should have a daily intake of 5 µg (200 IU) of vitamin D.

Benefits of breastfeeding to infants in Canada

Breastfeeding is recommended for all infants, with very few exceptions. Exceptions include infants with galactosemia, or infants of mothers who are HIV antibody positive or have untreated, active tuberculosis.

(i) Reduced incidence of infection. Recent studies have provided evidence that, in developed countries, breastfeeding protects against gastrointestinal and respiratory infections and decreases the risk of otitis media (Beaudry et al., 1995; Duncan et al., 1993; Howie et al., 1990; Boucher et al., 1986). Newborn infants breastfed for 13 weeks or more had significantly fewer gastrointestinal and respiratory illnesses during the first year of life when compared to formula-fed infants (Howie et al., 1990). In comparison to formula-fed infants, infants exclusively breastfed for a minimum of 16 weeks had fewer episodes of single and recurrent otitis media during the first year of life (Duncan et al., 1993). Breastfed infants supplemented with formula or food before 4 months were more likely to develop otitis media (Duncan et al., 1993). A recent meta-analysis of the risk factors for acute otitis media showed that the risk decreased with breastfeeding for at least 3 months (Uhari et al., 1996). Thus, exclusive breastfeeding seems to have a protective effect.

(ii) Prevention of SIDS. Although a number of studies have suggested an association between breastfeeding and protection against sudden infant death syndrome (SIDS), none has controlled for infant sleeping position and household smoke exposure, two important risk factors; thus, a causative protective relationship remains unproved (Ford et al., 1993; Bernshaw, 1991; Kraus et al., 1989). Nevertheless, breastfeeding may give some protection against SIDS.

(iii) Prevention of allergies. Atopic disease in infants is frequently reported. Its incidence has been estimated at 10%, but is likely closer to 2% (Falth-Magnusson et al., 1987; Van Asperen et al., 1983, 1984). The wide range of reported incidence is due to variable diagnostic criteria and techniques, and the high incidence of self-diagnosis. Poor study designs have contributed to the controversy regarding the protective effect of breastfeeding against atopic disease (Kramer, 1988). Breastfeeding compared to formula feeding does not appear to decrease the incidence of atopy in infants with no genetic predisposition to atopy (Lucas et al., 1990). For infants at increased risk because of a positive family history (one or both parents, or a sibling with atopy), exclusive breastfeeding for at least 4 months does appear to have a protective effect (Chandra, 1997; Saarinen and Kajosaari, 1995; Burr et al., 1993; Lucas et al., 1990).

For infants with a family history of atopy, maternal avoidance of specific foods (e.g. milk and dairy products, eggs, peanuts) during pregnancy and lactation has not been proven to be more effective in reducing the incidence and severity of atopy throughout the first year of life than exclusive breastfeeding without maternal food restriction (Falth-Magnusson, 1994; Zeiger et al., 1989). Risk of reduction in third trimester maternal weight gain and lower infant birth weight in the women avoiding potentially allergenic food during pregnancy illustrate the need for close nutritional monitoring. Until the efficacy of a restricted diet during pregnancy and lactation is known, routine restriction of diets of mothers of infants at risk for allergy is not recommended.

A small number of exclusively breastfed infants may develop allergic responses due to the passive transfer of food antigens from the mother's diet through breast milk. Two protein food antigens, bovine IgG (Clyne and Kulczycki, 1991) and ß-lactoglobulin (Jakobsson et al., 1985) have been detected in breast milk. If exclusively breastfed infants present with clinical signs of atopy, a trial elimination-challenge of suspect foods in the mother's diet is recommended to determine whether or not the infant's reaction is to foods eaten by the mother. Common offending food antigens are protein-rich foods such as cow's milk, fish, eggs, soy and peanuts. If maternal diet modification is deemed necessary, counselling from a dietitian or nutritionist may be beneficial.

(iv) Enhanced cognitive development. Although the mechanism is unknown, there is documentation from cohort studies that the mean value for cognitive development in populations of children who are breastfed is slightly higher compared to bottle-fed infants from similar environments (Rogan and Gladen, 1993; Lucas et al., 1992; Morrow-Tlucak et al., 1988; Taylor and Wadsworth, 1984). Interpretation of these results is complicated by the concurrent association between breastfeeding and socio­environmental factors.

Maintenance of acceptable growth

Recent North American cohort studies have demonstrated that the growth rate of infants from similar socioeconomic and ethnic backgrounds who have been breastfed for more than 3 months is slower than that of formula-fed infants (or infants breastfed for less than 3 months) (Dewey et al., 1992, 1993). Behavioural development, activity level and morbidity were not different between breastfed and formula-fed groups, suggesting that there was no health-related significance of the slower growth rate (Dewey et al., 1993). When this slower growth pattern of otherwise healthy and thriving breastfed infants is misinterpreted as "growth faltering," it can lead to unnecessary concern about the adequacy of breastfeeding, and interfere with the promo­tion of breastfeeding for the first 4 to 6 months of life (Grummer-Strawn, 1993; Sheard, 1993a). There is no evidence that breastfed infants are at increased risk because of slower growth. Comparing the growth of breastfed infants to reference data can lead to unnecessary monitoring and investigation, as well as parental concern.

Development of reference growth charts for exclusively breastfed infants has recently started, but further reference data are needed (WHO, 1994). Meanwhile, regardless of which growth charts are used, growth is considered normal when weight and length track along similar percentiles or growth channels. Only when length and weight percentiles are dispropor­tional, or when length and/or weight cross percentiles downwards by a significant amount, is intervention appropriate.

Factors influencing initiation and duration of breastfeeding

Duration of breastfeeding has decreased since 1960. Recent Canadian statistics show that while almost 75% of mothers begin breastfeeding in hospital, only 60% and 30% are still exclusively breastfeeding at 3 and 6 months, respectively (Health Canada, 1996). By 9 months, only 18% of mothers still breastfed in a Vancouver cohort (Williams et al., 1996). Breastfeeding trends vary across the provinces; rates are higher in the west and drop off from Quebec to the east (Health Canada, 1996). Breastfeeding initiation and maintenance rates increase with increasing education and income levels. This suggests that there are many social factors that influence the method of infant feeding (Health Canada, 1996).

Since 1978, the World Health Organization (WHO) and Health Canada have made the promotion of breastfeeding a primary goal. The WHO currently recommends that breastfeeding exclusively to the age of about 6 months, then continuing breastfeeding and complementary foods for up to 2 years of age or beyond, is the optimal method for feeding infants and young children (WHA, 1994; WHO/UNICEF, 1990).

All health care professionals have a vital role and responsibility to promote and support breastfeeding, both antenatally and postnatally. The following measures are paramount to improving both the initiation and duration of breastfeeding: (a) supportive practices and written breastfeeding policies at health care institutions (ideally, these written policies should be based on the WHO/UNICEF 10 Steps) (WHO/UNICEF, 1989) and the WHO International Code of Marketing of Breast-milk Substitutes (WHO, 1981); (b) education and support for parents by health professionals and educators; and (c) more community-based programs as the length of hospital stays decreases. As well, supportive environments for breastfeeding in the community and workplace are important measures aimed at improving the duration of breastfeeding (Levitt et al., 1996; Zlotkin, 1995; Wang, 1994). In Canada, less than 5% of hospitals have a policy for breastfeeding which complies with the WHO and UNICEF "10 Steps to Successful Breastfeeding" (Levitt et al., 1996).

There are social, environmental and health factors that influence the practice of breast-feeding. A successful breastfeeding experience after discharge is related to support geared to the mother's unique needs, complete combined mother-infant care, frequent feeds in the early postpartum period, banning of formula samples in the peripartum period, and avoidance of artificial teats and pacifiers (Yamauchi et al., 1992; Elander et al., 1984; Salariya et al., 1978; Illingsworth et al., 1952). The benefits of initial postpartum feeds of water have not been documented.

(i) Maternal lifestyle. In today's society, many women are pursuing their education or are in the work force. It is not uncommon for a new mother to return to school or employment soon after birth or a maternity leave of 3 to 6 months. Some mothers discontinue or never attempt nursing their babies under these circumstances, believing that they will be unable to maintain a milk supply, or that breastfeeding will take too much of their time or cause discomfort when they are away from the baby. After lactation is well established, an occasional bottle of breast milk substitute should not necessarily have a detrimental effect on the continuation of nursing (Riordan and Auerbach, 1993). Many mothers have successfully maintained breastfeeding after returning to work or school with support in the workplace and appropriate child care arrange­ments (CICH, 1996). Factors which may increase the duration of breastfeeding include the use of breast pumps to express milk, flexible work schedules and part-time nursing (Hills-Bonczyk et al., 1993).

(ii) Shortened postpartum length of stay. Shorter postpartum hospital stays (12-48 hours) need not negatively impact on breastfeeding success. When health care professionals in the community and hospital provide consistent, clear, breastfeeding information and support for mothers throughout pregnancy, childbirth, and the postpartum and the breastfeeding period, the breastfeeding experience can be positive and successful for both mother and baby.

The effect of distributing discharge packs on the duration of breastfeeding is uncertain. While no study has demonstrated a positive effect of discharge packs on the initiation or duration of breastfeeding, in high-risk populations the provision of formula-containing discharge packs may (Dungy et al., 1992; Frank et al., 1987), or may not (Neifert et al., 1988; Bergevin et al., 1983), decrease the duration of breastfeeding.

Criteria for discharge from hospital should include at least two successful nursings managed independently by mother and baby (CPS, 1996; AAP, 1995). It is recommended that parents demonstrate a clear understanding of how they will feed their baby, and should receive written information on the signs of successful breastfeeding, their infant's birth and discharge weights, and a list of breastfeeding resources in the community. In addition, it is recommended that mother and baby be evaluated by a health care professional within 48 hours of discharge to assess the infant's feeding and hydration, and to evaluate for jaundice and other abnormalities (CPS, SOGC, 1996).

(iii) "Top-up" feeds. Glucose water and infant formula are often provided between feeds or to "top up" breastfeeds in the first days of life. The rationale, while unproved, is that such practices minimize weight loss and/or the development of early hyperbilirubinemia (Inch and Garforth, 1989; Gray-Donald et al., 1985; Nicoll et al., 1982). This practice may adversely affect both the demand for and supply of milk. The decline in the infant's hunger may also undermine the mother's confidence in being able to provide adequate milk for her infant and, thus, indirectly diminish the chance of breastfeeding success (CICH, 1996; CPS, 1994a; Howard et al., 1994; Inch and Garforth, 1989). Since the benefits associated with this practice are unproved, women who are trying to establish their milk supply are advised to avoid feeding supplementary or complementary bottles of breast milk substitutes or water, or using pacifiers, for the initial 2 to 4 weeks of an infant's life (Riordan and Auerbach, 1993).

(iv) Smoking. Mothers who smoke have lower breastfeeding initiation and duration rates than non-smokers. Nicotine metabolites have been found in the urine of breastfeeding infants whose mothers smoke, and in both breastfed and bottle-fed infants, where passive smoking occurs. Heavy smoking (more than 10 cigarettes per day) has been associated with decreased milk production, decreased milk ejection, infant irritability and poor weight gain (Lawrence, 1994).

Breastfeeding mothers should be encouraged to stop or reduce smoking. However, even if smoking continues, breastfeeding is still the best choice. The harmful effects of smoking on the baby can be reduced by smoking after breast-feeding rather than before. Mothers who smoke (whether bottle- or breastfeeding) and other smokers in the household should be encouraged to smoke outside or, at least, in a different room than the baby, to reduce the effects of environ­mental tobacco smoke (CICH, 1996).

Potential contraindications to breastfeeding

(i) Drugs. Most prescription and over-the-counter drugs are minimally excreted through breast milk and are pharmacokinetically benign to the infant. Illegal drugs of abuse are contra­indicated during breastfeeding (CICH, 1996). Breastfeeding is not advised for infants of mothers who are receiving long-term chemo­therapy. Breastfeeding should be temporarily stopped (anywhere from 1 day to 2 weeks depending on the type of isotope used) when radioactive compounds for diagnostic or therapeutic reasons are required (Fulton and Moore, 1990). Some of the drugs that may be contraindicated during breastfeeding include bromocriptine, cyclophosphamide, cyclosporine, doxorubicin, ergotamine, lithium, methotrexate and phencyclidine (AAP Committee on Drugs, 1994). Local drug information lines are useful in keeping up to date with information on drug usage and breastfeeding (CICH, 1996).

Herbal remedies may contain pharmacologically active substances. It is recommended that they be used with caution by breastfeeding mothers (Newall et al., 1996).

(ii) Alcohol. Mennella and Beauchamp (1991) demonstrated that significantly less breast milk was consumed by infants of mothers drinking alcohol during a 3-hour period compared to when non-alcoholic beverages were consumed. The habitual ingestion of more than a moderate amount of alcohol (> 0.5 g/kg/day, equivalent to about 2 drinks) is contraindicated during breast-feeding. The Mother Risk Program (The Hospital for Sick Children, Toronto) suggests that if several alcoholic drinks have been ingested, nursing should be postponed at least 2 hours for each drink (personal communication). It takes an adult woman (55 kg) about 1.25 hours to metabolize 10 g of alcohol. Since the average drink contains 10 g of alcohol, a recommenda­tion to wait 1 hour after a drink is reasonable.

(iii) Environmental contaminants. There is no current justification to warrant restriction in breastfeeding due to environmental contaminants (Rogan, 1996). Reports have continued to document accumulation of polychlorinated dibenzo-p-dioxins (PCDDs) and dibenzofurans (PCDFs) in breast milk (Abraham et al., 1996). Accumulation of lipid soluble environmental contaminants in breastfed infants due to relatively high daily exposure via breast milk (about 50 times higher per kg body weight than in adults) has caused concern about possible adverse health effects (Beck et al., 1994). Although there is documentation of adverse neurodevelopmental outcomes and impaired intrauterine growth associated with prenatal exposure to polychlorinated biphenyls (PCBs), at present, exposure to PCBs, PCCDs or PCDFs in breast milk has not been associated with adverse outcomes (James et al., 1993; Tilson et al., 1990; Koopman-Esseboom et al., 1996).

(iv) Maternal infections. The role of breast-feeding in the horizontal transmission of HIV has been uncertain because of the difficulty in differentiating congenital from early postnatal infection. Transmission of HIV through breast milk was initially recognized in situations where the mother acquired the infection shortly after birth (Goldfarb, 1993). The chances of the virus being spread to the infant depended on the mother's degree of infection. A woman who is viraemic during the acute phase of the primary infection is more likely to shed viruses into her milk than if she were HIV antibody positive with an established infection (Dunn et al., 1992). The estimated risk of transmission through breast milk by a woman of high viral burden is 29% (95% C.I.: 16%-42%); by a woman who is already HIV antibody positive during the pregnancy, 14% (95% C.I.: 7%-22%) (Newell and Peckham, 1994).

When the mother is known to be HIV antibody positive, alternatives to breastfeeding are indicated. This recommendation is consistent with that of the Canadian Institute of Child Health (CICH, 1996), as well as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (AAP and ACOG, 1992). If the infant is HIV antibody positive at birth, breastfeeding would be indicated; however, currently, there are no diagnostic tools to determine HIV infection status of the newborn with an acceptable level of confidence (Goldfarb, 1993).

Tuberculosis is rarely transmitted by breast milk, but can be transmitted by exposure to sputum from an infected mother or other caretaker. Mothers with active tuberculosis should breastfeed their infants only after they are receiving adequate therapy and are considered to be non-infectious (AAP and ACOG, 1992).

Cytomegalovirus and rubella have been found in milk of infected mothers. The presence of these viruses in human milk is not considered a contraindication to breastfeeding since in the term infant they cause asymptomatic infections (Goldfarb, 1993). If present in the mother, hepatitis B is most likely to be transmitted during delivery, although it has been isolated from breast milk. For the nursing mother who acquires hepatitis while nursing, an important preventative measure for the infant is prompt immunization with the hepatitis B vaccine. Breastfeeding can then be encouraged. Although herpes simplex virus is unlikely to be shed into breast milk, breastfeeding would be contra­indicated in women who have active herpetic lesions on or near the nipple (Sullivan-Bolyai et al., 1988).

Vitamin/Mineral supplementation of breastfed infants

The quality of the breastfeeding mother's diet is important for her health and energy, but has a variable effect on milk production and on milk composition (Riordan and Auerbach, 1993). Minerals and fat-soluble vitamin (A,D,E,K) levels in breast milk are minimally influenced by recent maternal diet as these can be drawn from storage in the body. Water-soluble vitamins (eg. ascorbic acid, nicotinic acid, thiamin, riboflavin, pyridoxine, B 12 ) are readily influenced by the maternal diet (Riordan and Auerbach, 1993; Atkinson, 1992). However, if the mother is well nourished, there is no need for supplementation. Only if a mother eats a very restricted diet (e.g. vegan) should supplemental nutrients be recommended to ensure adequate nutrient intake for her and adequate delivery of vitamins to the breastfed infant. With the exception of vitamin D, vitamin and mineral supplementation of breastfed term infants in the first 6 months is not recommended.

(i) Vitamin D. It is recommended that all breastfed, full-term infants in Canada receive a daily vitamin D supplement of 10 µg (400 IU). After 1 year, all children should have a daily intake of 5 µg (200 IU) of vitamin D. Supplementation should begin at birth and continue until the infant's diet includes at least 10 µg (400 IU) per day of vitamin D from other dietary sources, or until the breastfed infant reaches 1 year of age.

For more details concerning this recommendation, consult the following document: "Vitamin D supplementation for breastfed infants, 2004 Health Canada Recommendation".

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