Health Canada revision of Nutrition for Healthy Term Infants: Recommendations from birth to six months

Health Canada is planning the revision of Canada’s infant and young child feeding policy statement: Nutrition for Healthy Term Infants.

The first draft revision makes recommendations for infants from birth to six months.

It is critical that Canada’s revision reflect the evidence based, optimal feeding practices as recommend by the World Health Organization (WHO), and the WHO/UNICEF Global Strategy on Infant and Young Child Feeding.

INFACT Canada urges all those working with infants and young children to respond to the on-line request for comment. The time line to respond is very short: January 6 to February 3, 2011.

INFACT Canada has prepared general comment on the overall draft revision and also specific comment to the proposed principles and the recommendations.

You may wish to use the INFACT Canada comment or add to it, or prepare your own comment. Any way, we urge you to submit your comment to ensure that optimal infant feeding recommendations are protected. “As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal, growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues up to two years or beyond.” (WHO/UNICEF Global Strategy for Infant and Young Child Feeding, 2003)

Online Petition

A petition has been drafted asking Health Canada to extend the deadline for the online consultation and to implement cross-country consultation meetings as they have done recently for revisions to Canada's Food Guide and Canada's Physical Activity Guideline.

INFACT Canada’s General Comments on the Proposed Draft

January 2011

  1. Conflict of Interest declarations provided by the Expert Advisory Group

    INFACT Canada’s position is that those with conflicts of interest should not be working on infant and young child public nutrition policies and should not be participating in this process.

    James Friel: Serves on the advisory boards of Heinz and Danone (Both Heinz and Danone are manufacturers of complementary food products and infant formulas and are in serious violation of the International Code of Marketing of Breast-milk Substitutes and relevant resolutions of the World Health Assembly).

    Sheila Innis: Researcher in infant feeding and infant formulas. Receives research funding from infant formula manufacturers Mead Johnson, Abbott Laboratories and the from Martek Biosciences the maker of fungi and algae sourced fatty acids, DHA and ARA. (All three industries are in serious violation of the International Code of Marketing of Breast-milk Substitutes and relevant resolutions of the WHA).

    Daniel Roth: Is a researcher in vitamin D and has received a travel grant to attend the International Congress of Nutrition from the Organizing Committee sponsored by Coca Cola.

    The remaining five members of the Advisory Group have no competing interests.

  2. Breastfeeding is the normative way to feed infants

    Industrially manufactured infant formulas differ very significantly in nutritional and chemical content as well as the means of feeding. The lumping these two into one document creates a flawed impression that breastfeeding and formula feeding are similar and interchangeable.

    INFACT Canada recommends that Canada’s Nutrition for Health Term Infants should make recommendations about the biologically normal way to feed infants.

    The feeding of other manufactured “milks” should be dealt with as an intervention and the conditions for the use of these products should be addressed either in an appendix or in a separate document on the use of artificial feeding methods and products. Full information about the risks of the use of these products and the feeding methods needs to be stated. Parents should be fully informed when making infant feeding decisions.

  3. The International Code and WHA

    Canada’s government through its delegations to the World Health Assembly have endorsed the International Code of Marketing of Breast-milk Substitutes and all the relevant WHA resolutions on Infant and Young Child Nutrition. It is vital that Health Canada take responsibility and leadership in realizing the implementation of the WHO provisions they have endorsed.

    The International Code and WHA resolution measures are critical to protect the ability of mothers to fully breastfeed their children as recommended. The undermining interference on optimal breastfeeding practices resulting from the continued violations of the provisions of the International Code and resolutions, are extremely costly in personal loss, in health outcomes and in health costs. We all benefit when our children are breastfed.

INFACT Canada’s Formal Comments on the principles and recommendations of Proposed Draft

January 2011

DRAFT - Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months

  1. Breastfeeding is the normal and unequalled method of feeding infants.

    Benefits of Breastfeeding

    Eliminate the incorrect language referring to the “benefits” of breastfeeding. Change heading to read: The IMPORTANCE of breastfeeding.

    Nutrition and digestion

    Breastfeeding is the normal and species specific way to feed infants and young children. Exclusive breastfeeding is recommended for the first six months of life to ensure optimal growth, development and health, provide immunological protection; ensure full neurological, emotional and cognitive development.

    Delete paragraph 2. This paragraph diminishes the critical importance of exclusive breastfeeding for the first six months of life. The reductionist approach of addressing the needs for single nutrients should be addressed in a separate section or in an appendix as these represent interventions. It is preferable to address micro nutrient needs prenatally. Maternal supplementation, for some micronutrients, when needed benefits fetal development and is a much safer approach to micro nutritional needs than supplementing new born and young infants.

    Iron deficiency anemia is rare in iron sated populations for health, term, exclusively breastfed infants. Currently, the best evidence to avoid iron deficiency is to practice exclusive and sustained breastfeeding.

    The Friel (2003) study that is referenced is based on mixed fed infants and not exclusively breastfed infants; the attrition rate is very high; iron levels in human milk are not “low” they are normal and efficiently absorped and utilized; potential lack of safety and side effects of infant iron supplementation in iron sated populations should be noted (Domellof, 2001).

    Breastfeeding confers so much more than a delivery of nutrients.

    The immune system

    The language in these paragraphs needs to reflect scientific and logical accuracy. Breastfeeding is the biological norm – the standard - and formula feeding is an artificial way of feeding infants, then the logical conclusion is that formula fed infants suffer increased infections such as otitis media.

    Paragraph 1: Change to read:
    The anti-infective properties of breastmilk and colostrum PROTECT infant health against acute infections, such as otitis media. Infections are more common and more severe in formula fed infants. (When a formula fed population consistently shows a higher prevalence of otitis media, it should be concluded that the risk for otitis media is higher for formula fed infants.)

    Paragraph 2: Change to read:
    The shorter the duration of breastfeeding the greater the risk of respiratory and gastrointestinal infections and the greater the risk of hospitalization for lower respiratory disease.

    All other paragraphs in this section need to be modified to reflect the increased risk of infectious diseases, increased obesity, increased type 2 diabetes and other non-communicable diseases, and SIDS associated with formula feeding.

    It is preferable that artificial feeding products and methods be dealt with in an appendix or in a separate document.

    Benefits of breastfeeding for mothers

    Change heading to read: IMPORTANCE of breastfeeding for mothers.

    Language used in the following paragraphs should be corrected to reflect the increased health risks associated with not breastfeeding or reduced breastfeeding.

    Benefits of breastfeeding for the community

    Change heading to read: IMPORTANCE of breastfeeding for the community

    In practice: Talking to families about breastmilk supply.

    Additional points to consider:

    • Breastfeeding should start immediately after birth.
    • Breastfeeding should be exclusive.
    • Mothers and babies need to be together (mother-baby dyad) and separation should be avoided.
    • Parents should be informed prenatally about the impact of birthing drugs on breastfeeding.
  2. Breastfeeding increases with active protection, support and promotion by the hospitals, workplaces, and the community.

    Change heading to read: Breastfeeding increases with active protection, support and promotion by ALL SECTORS OF THE HEALTH CARE SYSTEM, GOVERNMENTS, workplaces, and the community.

    Change related recommendation 2.2 to read: Explain the IMPORTANCE and management of breastfeeding to pregnant women and their families.

    Change related recommendation 2.5 to read: ABOLISH advertising and distribution of free samples of formula, bottles, nipples and pacifiers.

    Change related recommendation 2.7 to read: Support flexible work schedules and environments THAT MEET THE NEEDS OF LACTATING MOTHERS AND FACILITATE the expressing and storing breastmilk for continued breastfeeding.

    Recommendations 2.1-2.7 should be based on the evidence-informed and globally adopted policies and practices: The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI), which is based on the Ten Steps to Successful Breastfeeding, The GLOBAL STRATEGY FOR INFANT AND YOUNG CHILD FEEDING, The International Code of Marketing of Breast-milk Substitutes and SUBSEQUENT RELEVANT WORLS HEALTH ASSEMBLY (WHA)_ RESOLUTIONS.

    References to the International Code of Marketing of Breast-milk Substitutes should include the subsequent World Health Assembly (WHA) resolutions on infant and young child nutrition, i.e. International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions.

    Breastfeeding policy and implementation

    Breastfeeding policy and implementation is not limited to implementation of Baby-Friendly Initiaitive hospital practices hospital practices.

    The Planning Guide for the national implementation of the Global Strategy for Infant and Young Child Feeding, WHO/UNICEF 2007 is an excellent source for policy implementation.

    Policy implementation is the responsibility of:

    • all parts of the health care system,
    • governments,
    • communities,
    • professional associations
    • health care providers,
    • the infant foods industries have a special responsibility to ensure that their marketing practices conform to the requirements of the International Code and subsequent relevant WHA resolutions.

    Governments, especially Health Canada needs to address and provide leadership for the meaningful implementation of Canada’s breastfeeding policies. This includes regulatory mechanisms for the implementation of the International Code of Marketing of Breast-milk Substitutes and relevant subsequent WHA resolutions and the funding of programmes and supports to implement the recommended infant and young child feeding policy.

    As follows:

    • Those working on infant and young child nutrition should have no competing interest. Health Canada should implement policies that there should be no participation in policy development for infant and young child nutrition by those who are employed by the infant food products industries, those who receive research funds or other benefits from these industries.
    • All promotions of infant feeding products that come under the scope of the International Code should be banned. Promotions of infant formulas, bottles and teats directly compete with the implementation of national breastfeeding policies.
    • The labeling of infant feeding products and nutrition and health claims should be regulated to support Health Canada’s breastfeeding policies. The current labeling and the use of nutrition and health claims are deceptive, make misleading comparisons to breastmilk and directly compete with breastfeeding, undermining national and regional breastfeeding policies and initiatives.
    • Health Canada should adequately fund independent research to support the implementation of its infant and young child feeding policies.
    • Health Canada should provide adequate funding to support the implementation of its infant and young child feeding policies. Current funding is totally inadequate.
    • Health Canada should provide funding for a donor milk system across Canada so that mothers/families who do not want to use industrial milks - infant formulas - can access human milk as replacement feeds when needed.

    Additional sub-section needed: Breastfeeding Rights

    Breastfeeding is the normal way of feeding anytime, anywhere. Breastfeeding mothers and babies are protected from discrimination and harassment by:

    • Canada’s Charter of Rights and Freedoms- no discrimination on the basis of sex (gender).
    • Provincial and Territorial Human Rights Codes.
    • The UN Convention on the Rights of the Child, ratified by Canada 1991, which obligates Canada to ensure that children are able to achieve the highest attainable standard of health.

    This information should also be included in the Section: In Practice: talking to families about infant nutrition.

  3. Breastfeeding is rarely contraindicated.

    No comments.

  4. In Canada, all infants need supplemental vitamin D.

    This is not scientifically correct – unless all infants in Canada have been tested and shown to need vitamin D supplements. Change heading to read: Health Canada recommends that infants receive supplemental vitamin D.

    More recent research should be considered that recommends maternal supplementation (Taylor S.) so that a variety of policy options can be proposed to parents in their decision making on infant and young child nutrition needs.

    Safety of the provision of vitamin D to newborn and young infants also needs to be addressed. For example, comparisons between non-supplemented populations and supplemented populations show an increase in the prevalence of allergies in the supplemented populations (Wjst).

  5. Commercial infant formulas are the only acceptable alternative to breastmilk.

    The title is not science based. There are human-milk-based replacement feeds that are more acceptable than commercial infant formulas.

    The use of infant formula products and infant formula feeding should be addressed in a separate document/appendix and not be made to appear as an equal alternative to breastfeeding.

    Change heading to read: Replacement feeding options

    These should include:

    • Expressed milk from an infant’s own mother.
    • Donor milk from a milk bank using the Human Milk Banking Association of North America protocols.
    • Pasteurized donor milk from an informed mother-to-mother milk sharing system. Health Canada should provide guidelines for safe milk sharing and home pasteurization.
    • These options reduce the risks of using infant formula and provide optimal species specific nutrition and immunological protection.
    • The recommendation for the use of infant formula as a replacement feed needs to be done with caution. The International Code requires warnings to parents about the inappropriate use, the social and economic costs and the difficulty of reversing the decision to not breastfeed.
    • Infants receiving infant formulas are immuno-compromised and face increased health risks. Formula fed infants need specialized growth and health monitoring and care.
    • The sections on formula use should be deleted as they glamorize the use of infant formula.
    • The BFHI requires that information on formula use should be (a) based on informed decision making to include information about the risks and costs of formula feeding and (b) this information be provided only to mothers who have decided to use these products.
    • The section covering the various additives with nutrient content claims should be eliminated.
    • Health Canada should decide if these ingredients should be in all formulas to eliminate the false and misleading claims for these additives and the highlighting of these additives on labels in the promotions by the formula industries. These advertising gimmicks directly compete with Health Canada’s breastfeeding policies.
  6. Milk provided to infants must be free of pathogens and fed safely.

    This section on the use of infant formula products and infant formula feeding should be addressed in a separate document/appendix and not be made to appear as an equal option to breastfeeding.

    The section on expressed breastmilk should be removed from item 6 as it belongs in section 2 under 2.3

  7. Routine growth monitoring is important for assessing infant health and nutrition.

    Under Basis for growth standards Change the first para to read:

    The WHO Child Growth Standards are based on healthy breastfed infants as the normative growth model for how infants and young children grow regardless of ethnic background.

    Under Interpreting the growth pattern Change the 4th paragraph to read:

    Formula fed infants grow differently than breastfed infants. Formula fed infants tend to weigh less than breastfed infants during the first three to four months of life. After four to six months formula fed infants are heavier and weigh more than breastfed infants by up to 1 kg. (Dewey 1995).

  8. Avoid unnecessary interventions for common infant health conditions and illnesses.

    This section needs to be revised to reflect only essential interventions for breastfed infants.

    Interventions for infant formula fed infants should be addressed in a separate document/appendix and not be made to appear as to be suitable for breastfed infants.

    • the conditions and illnesses described are more prevalent in formula fed infants and are rare in breastfed infants,
    • the interventions required for formula fed infants are different than those required for breastfed infants,
    • interventions are rarely needed for the breastfed infant,
    • the intervention of “changing feeding regimes” should only be used when infants are formula fed. All references to “changing feeding regimes” related to breastfed infants should be deleted. Interventions for breastfed infants may require increased frequency of feeding rather than changing methods of feeding.
  9. At six months, infants need complementary foods along with continued breastfeeding to meet their nutrient needs.

    Should this section be in the infant feeding recommendations for 6 to 24 months?


    First para: Add the following sentence: Exclusive breastfeeding for the first six months of life ensures adequate iron status.

    In practice: Talking with families about infant nutrition

    Complementary feeding after six months is a learning process about foods – the taste, texture, smell and colour of foods. There is no need to hurry this learning process. Breastmilk continues to provide most of the baby’s nutritional and energy needs.

    If an infant seems hungry before six months, they may be experiencing a growth spurt and may need more frequent breastfeeds.

    Eliminate the suggestions for complementing before six months – this is confusing and should be determined by a health provider based on an infant’s individual needs. Healthy, term, exclusively breastfed infants rarely need additional nutrients/foods before six months. Contact with family foods is a learning stage and expands as the baby shows curiosity and interest in tasting, touching and feeling foods.

    Retain the information about developmental readiness.

For more information contact:

Elisabeth Sterken, MSc, Dt
Director INFACT Canada

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