Nutrition for Healthy Term Infants
The Good, the Bad, and the Compromise?
The newly released Nutrition for Healthy Term Infants (Joint
Statement) by the Canadian Paediatric Society, Dietitians of
Canada and Health Canada has been long in making its appearance.
The document aims to provide information that is basic, communicating
a consistent message about infant nutrition to parents and care-givers
in Canada. Also it claims to be based on available scientific
evidence, and in the absence of solid science the recommendations
are based on accepted practice. INFACT Canada has
asked a number of people to review the statement. We have compiled
the results as well as comparisons to the infant feeding positions
of La Leche League (LLL) and the American Academy of Pediatrics
Joint Statement: Breastfeeding is the optimal method
of feeding infants. Breastfeeding may continue for up to two
years of age, and beyond.
INFACT Reviewers: The Joint Statement is generally
good and a positive improvement over previous statements. Inclusion
of the word may implies the giving of permission
and is redundant. This should be replaced by the word can or
AAP: Human milk is the preferred feeding for all infants,
including premature and sick newborns, with rare exceptions.
When direct breastfeeding is not possible, expressed human milk,
fortified when necessary for the premature infant, should be
Joint Statement: Encourage exclusive breastfeeding for
at least the first 4 months of life.
INFACT Reviewers: Age if introduction of complementary
foods remains stuck at four months. Is this based on the scientific
evidence the Joint Statement claims for its recommendations?
Many health care workers and breastfeeding support groups are
following the recommendations of the World Health Assembly Resolutions
WHA 47.5 and WHA 49.15.
WHA 47.5: ...fostering appropriate complementary feeding
practices from the age of about six months, emphasizing continued
breastfeeding, and frequent feeding with safe and adequate amounts
of local foods.
WHA 49.15: ...to ensure that complementary foods are
not marketed for or used in ways that undermine exclusive breastfeeding.
LLL: Most babies show sign of readiness (for
solid foods) at about the middle of the first year. How
to tell that a baby is ready?
- The ability to sit up.
- A fading tongue-thrusting reflex so that the baby does not
automatically push solids out of his mouth with his tongue.
- Readiness to chew.
- The ability to pick up food and put in his mouth.
- An increased demand to nurse that is unrelated to illness,
teething pain, and or a change in routine.
This readiness can be observed at about six months of age.
If a baby is much younger than six months, a mother should be
cautious to assume that the baby is ready for solids as increased
need to feed may be related to other factors such as a growth
spurt, an illness or a change in routine.
AAP: Exclusive breastfeeding is ideal nutrition and
sufficient to support optimal growth and development for approximately
the first 6 months after birth. Gradual introduction of iron
enriched solid foods in the second half of the first year should
accompany the breast milk diet.
Joint Statement: Provide antenatal and postnatal counselling
about the principles and practice of breastfeeding.
Encourage frequent feeds during the early post natal
AAP: (Includes recommendations as set out by the Ten
Steps to Successful Breastfeeding)
Breastfeeding should begin as soon as possible after birth,
usually within the first hour of life. No supplements should
be given to breastfeeding newborns unless medically indicated.
Breastfeeding mothers and their newborns should be seen by a
health care practitioner within 2 to 4 days after hospital discharge.
Joint Statement: Provide a vitamin D supplement to all
breastfed infants starting at birth and until the diet provides
a source of vitamin D.
LLL: In some rare cases, some breastfed babies benefit
from vitamin supplements. If the mother is undernourished and
if she and the baby are dark-skinned and they both stay out of
the sun for months at a time and the mother does not consume
enough vitamin D enriched foods such as milk, only then is there
a possibility of an increased risk of rickets.
AAP: Vitamin D (and iron) may be given before the age
of six months in selected groups of infants. Vitamin D for infants
whose mothers are vitamin-D deficient or for those infants not
exposed to adequate sunlight.
Joint Statement: Potential contraindications to breastfeeding
INFACT Reviewers: This section lists no real contraindications
but only warnings about drugs, alcohol, environmental contaminants
and maternal infections. In comparison the section on artificial
feeding (entitled Alternative milks) has no contraindications.
The statement does not include the risks of artificial feeding.
In this regard the Reviewers question if the Joint Statement
complies with the International Code.
Article 4.1 Governments should have the responsibility to ensure
that objective and consistent information is provided on infant
and young child feeding for use by families and those involved
in the field of infant and young child nutrition.
Article 4.2 Informational and educational materials
should include clear information on all the following points:
- a) the benefits and superiority of breastfeeding;
- b) maternal nutrition and the preparation for and maintenance
- c) the negative effect on breastfeeding of introduction of
partial bottle feeding;
- d) the difficulty of reversing the decision to not breastfeed;
- e) the proper use of infant formula
including the social and financial implications;
the health hazards of inappropriate foods or feeding methods;
the health hazards of unnecessary or in appropriate use of infant
such materials may not idealize the use of breastmilk substitutes.
AAP: Advises that practitioners thoughtfully weigh
the benefits of breastfeeding against the risks of not receiving
human milk. Discusses where breastfeeding is not in the interest
of the infant - infants with galactosemia, whose mothers uses
illegal drugs, whose mother has untreated active tuberculosis,
and in the US whose mother has been infected with HIV. The AAP
statement comments that in some countries the risks of not breastfeeding
outweigh these risks.
The AAP also mentions the social and economic costs of not
breastfeeding: Breastfeeding provides significant social
and economic benefits to the nation, including reduced health
care costs and reduced employee absenteeism for care attributed
to child illness. The direct economic benefits to the family
have been estimated to be $US 855 for formula for the first year
of the childs life.
LLL: The LLL Answer Book refers to drugs that are contraindicated
during breastfeeding rather than breastfeeding being contraindicated
when drugs are needed.
Joint Statement: Other fluids in infant feeding
INFACT Reviewers: The Joint Statement makes no reference
that no other fluids are necessary for the breastfed infant during
the first six months. Instead there is a discussion of types
of water to use and how it should be boiled and stored to ensure
it is pathogen free.
AAP: In the first six months, water, juice and other
foods are generally not needed for breastfed infants.
LLL: Recommends exclusive breastfeeding for about the
first six months
Joint Statement: Transition to solid foods
INFACT Reviewers: The Joint Statement contradicts the
WHO Resolution 47.5 ...fostering appropriate complementary
feeding practices from the age of about six months, emphasizing
continued breastfeeding, and frequent feeding with safe and adequate
amounts of local foods. Instead the Joint Statement reverts
to ...introduce complementary foods at 4 to 6 months,...
stating that infants are then physiologically ready for new
foods, textures and modes of feeding....Iron fortified cereals
are recommended as the first foods.
AAP: Recommends gradual introduction of iron enriched
foods in the second half of the first year should complement
the breastmilk diet.
Joint Statement: Infant feeding during the second year
INFACT Reviewers: Although the Joint Statement initially
recommends breastfeeding may continue for up to two
years and beyond, there is no mention made of breastfeeding in
the discussions on infant feeding in the second year.
Joint Statement: Changes in infant feeding practices
are not recommended at this time for the purpose of preventing
INFACT Reviewers: Although epidemiological data has
shown that breastfeeding reduces the risk of both juvenile and
non-insulin dependent diabetes melitis, this statement is a seemingly
out-of-place comment that does a disservice to native communities
where diabetes rates are 10-fold the mainstream rates and where
breastfeeding rates are still very low. This community has more
to gain than any other community in Canada by increasing breastfeeding
Differences between the recommendations of the Joint Statement
and the scientific evidence for optimal infant feeding
practices continue to exist. Are these compromise positions the
result of conflict of interest? Who stands to gain? Who stands
to lose? We note that the infant food products industry representatives
are active participants on the Canadian Paediatric Society Nutrition
INFACT Canada and its Reviewers recommend that the Joint Statement
be reviewed and revised in two years time and that the review
include a more broad-based participation of infant feeding experts.