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 (AAP).

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 should.

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 provided.

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 period.

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.

WHA 34.22
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 of breastfeeding;

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 formula;
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 child’s 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 diabetes.

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 rates.

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 Committee.

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.