Nutrition for healthy term infants
Executive Summary
The Canadian Paediatric Society Nutrition Committee, Dietitians of Canada
and Health Canada collaborated on the preparation of this statement on nutrition
for healthy term infants from birth to 24 months of age. This statement is intended
for the use of health care professionals. It provides information that is basic
to communicating consistent messages about infant nutrition to parents and caregivers
across Canada. It is not designed, however, to be an all-encompassing practical
guide to infant feeding. The recommendations in this statement are based on
available scientific evidence. However, many studies on infant nutrition are
not based on randomized trials because they are neither possible nor ethical
in many circumstances. In the absence of solid science, accepted practice and
its rationale is presented. Throughout the document, we have attempted to clearly
distinguish those recommendations based on science versus those based on common
practice. A summary of the principles and recommendations found in the document
is presented below.
Summary of Principles and Recommendations
Breastfeeding
Breastfeeding is the optimal method of feeding infants. Breastfeeding may continue
for up to 2 years of age and beyond.
Recommendation:
- Encourage exclusive breastfeeding for at least the first 4 months of life.
Active public health, hospital, community and workplace support of breastfeeding
will increase initiation rates and duration of breastfeeding.
Recommendation:
- Provide antenatal and postnatal counselling about the principles and practice
of breastfeeding.
- Encourage frequent feeds during the early postnatal period.
- Provide more community-based programs supporting breastfeeding families
as the length of hospital stays decreases.
- Encourage 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:
- Encourage women who smoke to stop or reduce smoking; however, even if smoking
is continued, breastfeeding is still the best choice.
- Limit intake of alcohol.
- Whenever drugs are prescribed or infection detected, assess each case on
an individual basis.
- 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:
- Provide a vitamin D supplement to all breastfed infants starting at birth
and until the diet provides a source of vitamin D.
Alternate Milks
Recommendations:
- Use cow's milk-based, iron-fortified formulas until 9 to 12 months
of age.
- Iron-fortified follow-up formulas are a preferred alternative to cow's
milk from 6 months until 9 to 12 months of age.
- Use soy-based formulas only for those infants who cannot take dairy-based
products for health, cultural or religious reasons, such as a vegan lifestyle,
or galactosemia.
- Specialty formulas are indicated only for infants with detected or suspected
pathology.
The use of nutritionally incomplete alternate milks as the sole source of nutrition
for infants is inappropriate. Pasteurized whole cow's milk, however, is
an important component of a mixed infant diet after 9 months of age. For infants
unable to take cow's milk products, continue commercial soy formula until
2 years of age.
Recommendations:
- Pasteurized whole cow's milk may be intro-duced at 9 to 12 months
of age and continued throughout the second year of life.
- Partly skimmed milk (1% and 2%) is not routinely recommended in the first
2 years.
- Skim milk is inappropriate in the first 2 years.
- Soy (except soy formula), rice or other vegetarian beverages, whether or
not they are fortified, are inappropriate alternatives to breast milk, formula
or pasteurized whole cow's milk in the first 2 years.
Other Fluids in Infant Feeding
Tap water, well water meeting established standards of safety and commercially
bottled water, except mineral or carbonated water, are generally suitable for
infants. Limit the use of "fruit juice"
to avoid interfering with the intake of nutrient-containing foods and fluids.
Herbal teas and other beverages are of no known benefit to an infant and may
be harmful.
Recommendations:
- Bring all water for feeding infants under 4 months of age to a rolling boil
for at least 2 minutes to ensure that it is pathogen free.
- Limit fruit juice to avoid interfering with the intake of breast milk or
infant formula.
- 21. Do not use herbal teas or other beverages.
Transition to Solid Foods
Infants between 4 and 6 months of age are physiologically and developmentally
ready for new foods, textures and modes of feeding. By 1 year of age, the ingestion
of a variety of foods from the different food groups of Canada's Food
Guide to Healthy Eating is desirable.
Recommendations:
- Introduce complementary foods at 4 to 6 months to meet the infant's
increasing nutritional requirements and developmental needs.
- To prevent iron deficiency, iron-containing foods such as iron-fortified
cereals are recommended as the first foods.
Safety Issues Around Feeding
Foods provided to infants must be free of pathogens, appropriate in size and
texture, nutritionally sound and fed safely.
Recommendations:
- To prevent infant botulism, do not use honey in the feeding of infants under
1 year of age.
- To prevent salmonella poisoning, cook all eggs well and do not use products
containing raw eggs.
- Hard, small and round, smooth and sticky solid foods are not recommended
because they may cause choking and aspiration.
- Ensure that infants and toddlers are always supervised during feeding.
- Avoid feeding an infant using a "propped" bottle.
Nutrition in the Second Year
Healthy eating is important in the second year to: (a) provide the energy and
nutrients needed to grow and develop; (b) develop a sense of taste and an acceptance
and enjoyment of different foods; and (c) instill attitudes and practices which
may form the basis for lifelong health-promoting eating patterns.
Recommendation:
- Small, frequent, nutritious and energy-dense feedings of a variety of foods
from the different food groups are important to meet the nutrient and energy
needs during the second year.
Other Issues in Infant Nutrition
Food allergies
Whenever possible, allergies to food should be prevented.
Recommendation:
- Encourage exclusive breastfeeding for at least 4 months to decrease the
risk of allergy in infants with a positive family history.
Treatment of proven food allergies involves avoidance of foods known to cause
symptoms.
Recommendation:
- When food choices are restricted, ensure that dietary intake continues to
meet nutrient and energy needs.
Colic
Dietary manipulations have had limited success in the treatment of colic.
Recommendation:
- Ensure that any dietary modification or pharmalogical interventions are
safe.
Constipation
In infancy, true constipation is infrequent.
Recommendation:
- Parents need to be educated about the wide variation in normal bowel function
in infants and toddlers to avoid overtreatment of normal variants.
Dietary fat
Dietary fat is an important source of energy and the only source of essential
fatty acids.
Recommendation:
- Dietary fat restriction during the first 2 years is not recommended because
it may compromise the intake of energy and essential fatty acids and adversely
affect growth and development.
Dental caries
Prevalence of dental caries is lower where infants and children have access
to fluoridated water and where long-term exposure of teeth to nutrient-containing
liquids is avoided. Excessive fluoride intake can cause dental fluorosis.
Recommendations:
- Fluoride supplementation is not recommended for infants less than 6 months
of age.
- For infants between the ages of 6 months to 2 years who are living in areas
where the household water supply contains less than 0.3 ppm (mg/L) fluoride,
daily supplementation with 0.25 mg fluoride is recommended. Where the principal
drinking water source contains 3; 0.3 ppm (mg/L) fluoride, supplementation
is not recommended.
- Avoid excessive intake of fluoride.
- Avoid the use of a bottle during sleep time or as a pacifier. Avoid nocturnal
and long-term use of baby bottles containing liquids other than water.
- Do not dip pacifiers or nipples in sugar or honey.
Gastroenteritis
Manage mild to moderate dehydration associated with gastroenteritis with oral
rehydration therapy (ORT). Prevent malnutrition.
Recommendations:
- Manage mild to moderate dehydration with an oral electrolyte solution and
early refeeding.
- For infants who are breastfed, continue breastfeeding while supplementing
fluid intake with an oral electrolyte solution.
Diabetes
The exact role of early infant nutrition as a possible etiologic factor for
infants genetically at risk for diabetes has not been proven.
Recommendation:
- There is no justification at this time to recommend changes to infant feeding
practices for the purpose of preventing diabetes.
Iron deficiency anemia
Iron deficiency is preventable through appropriate
feeding choices.
Recommendations:
- Continue exclusive breastfeeding for at least 4 months.
- Introduce complementary foods containing iron
at 4 to 6 months of age.
- Choose iron-containing formulas for infants
who are not breastfed or for infants receiving
formula as well as breast milk.
- Delay the introduction of whole cow's milk until
9 to 12 months of age.
- Continue to offer iron-fortified foods beyond
1 year of age to provide sufficient iron.
- Where informed parents choose not to adhere
to these recommendations, screen for anemia
at 6 to 8 months of age and provide medicinal
iron drops if necessary.
Vegetarian diets
Nutritional needs can be met by most well-planned vegetarian diets. For vegetarian
diets that are limited in variety and nutritional quality, professional advice
regarding supplements is appropriate.
Recommendations:
- For vegan infants who are not breastfed,
promote commercial soy-based infant formula
during the first 2 years of life.
- After dietary assessment, recommend nutrient
supplements for vegan diets which are found to
be nutritionally incomplete.
|
