Practice point
Posted: Dec 5, 2014 | Updated: Dec 12, 2019 | Reaffirmed: Feb 24, 2023
Jeffrey N Critch; Canadian Paediatric Society; Nutrition and Gastroenterology Committee, Nutrition and Gastroenterology Committee
Paediatr Child Health 2014;19(10):547-49
Nutrition for Healthy Term Infants is a joint statement by Health Canada, the Canadian Paediatric Society, Dietitians of Canada and the Breastfeeding Committee for Canada. It was republished in September 2012, with recommendations on infant feeding from birth to six months of age. The statement was most recently updated in April 2014, with recommendations for feeding older infants and young children from six to 24 months of age. The present practice point outlines the statement development process and principles of feeding, with specific recommendations for clinicians. Health professionals who counsel families on nutrition in infants and young children are advised to read the statement in its entirety because discussion in the longer document expands on and clarifies advice summarized in the principles and recommendations given here. The complete statement is available on Health Canada’s website: www.canada.ca/en/health-canada/services/canada-food-guide/resources/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months/6-24-months.html
Key Words: Breastfeeding; Iron; NHTI; Responsive feeding; Vitamin D
In 2009, a formal review of Nutrition for Healthy Term Infants (NHTI) was initiated by the collaborating organizations of the Infant Feeding Joint Working Group, consisting of representatives from the Canadian Paediatric Society Nutrition and Gastroenterology Committee, Dietitians of Canada, the Breastfeeding Committee for Canada, the Public Health Agency of Canada and Health Canada. The review was divided into two parts, with focus on feeding from birth to six months of age and from six to 24 months of age. The document covering the period from birth to six months was released in September 2012 and is available online in English and French on Health Canada’s website: www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php. The document covering nutrition from six to 24 months was released in April 2014 and is available at: hwww.canada.ca/en/health-canada/services/canada-food-guide/resources/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months/6-24-months.html
Developing the NHTI involved extensive review of the scientific evidence in the peer-reviewed literature. Guidance on content was provided by the Infant Feeding Expert Advisory Group, with broad stakeholder and public consultations.
The NHTI provides health care professionals with evidence-informed advice for communicating accurate and consistent information to Canadian parents and caregivers. The statement is not intended to be an all-encompassing practical guide to infant feeding. While the recommendations are based on available scientific evidence, it is important to note that many infant nutrition studies are not randomized trials. Such research is neither possible nor ethical in many circumstances.
Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months is organized around seven principles, each of which contains a number of underlying recommendations, rationales and references. These principles and recommendations are summarized below. Clinicians should read the statement in its entirety because discussion in the longer document expands on and clarifies advice summarized in the principles and recommendations.
Breastfeeding – exclusively for the first six months, and continued for up to two years or longer with appropriate complementary feeding – is important for the nutrition, immunologic protection, growth and development of infants and toddlers.
1. Breastfeeding is an important source of nutrition for older infants and young children as complementary foods are introduced.
The rationale notes: Breastfeeding beyond six months has been associated with a number of positive infant and maternal health outcomes. Breastfeeding longer, in addition to a wide range of other determinants, may have a protective effect against overweight and obesity in childhood.[1]-[3] Limited evidence suggests breastfeeding continues to provide immune factors during the first and second years.[4][5] An observational study suggests breastfeeding to 12 months may protect against infectious illnesses, particularly gastrointestinal and respiratory infections.[6] Findings have consistently shown a decreased risk of maternal breast cancer with longer durations of breastfeeding.[7]-[9] Limited evidence also suggests a protective effect for the breastfeeding mother against ovarian cancer.[10]-[12] Mothers who breastfeed their older infants and young children also report experiencing an increased sensitivity and bonding with their child.[13]-[15]
To help improve breastfeeding durations, it is important to promote the implementation of the WHO/UNICEF’s Baby-Friendly Hospital Initiative outlined in the Ten Steps to Successful Breastfeeding.[16] Its Canadian adaptation is the Baby-Friendly Initiative Integrated 10 Steps for Hospitals and Community Health Services.[17] Baby-friendly initiatives are known to increase the initiation, exclusivity and duration of breastfeeding.[18]
2. Supplemental vitamin D is recommended for infants and young children who are breastfed or receiving breastmilk.
3. Complementary feeding, along with continued breastfeeding, provides the nutrients and energy to meet the needs of the older infant.
4. Responsive feeding promotes the development of healthy eating skills.
5. Iron-rich complementary foods help to prevent iron deficiency.
6. Foods for older infants and young children must be prepared, served and stored safely.
7. From one year of age, young children begin to have a regular schedule of meals and snacks. Generally follow the advice in Canada’s Food Guide: www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
The NHTI statement recognizes that some infants may not be exclusively breastfed for personal, medical or social reasons. A separate section addresses recommendations on the use of breast milk substitutes. Families need support to optimize an infant’s nutritional well-being. The International Code of Marketing of Breast-milk Substitutes[19] advises health professionals to inform parents of:
Families who have made a fully informed choice not to breastfeed should be counselled on the use of breastmilk substitutes. For an older infant or child who is not breastfed or receiving breastmilk:
The NHTI statement concludes with questions and answers to help health professionals communicate with families about early nutrition, with information on topics such as the ‘picky eater’ and when to transition to low-fat milk. Sample menus for different age group are provided.
It is important to emphasize that further research is needed in many areas of infant nutrition. While the current statement is evidence-informed, incomplete data have made some feeding topics controversial. Further data from well-designed and well-conducted studies in both developed and developing countries are necessary to validate and/or refine recommendations in the present statement.
CPS NUTRITION AND GASTROENTEROLOGY COMMITTEE
Members: Dana Boctor MD, Jeffrey N Critch MD (Chair), Manjula Gowrishankar MD, Jonathan B Kronick MD (Board Representative), Jae H Kim MD (past member), Catherine Pound MD, Sharon Unger MD
Liaisons: Genevieve Courant, Breastfeeding Committee for Canada; A George Davidson MD, Human Milk Banking Association; Tanis Fenton, Dietitians of Canada; Jennifer McCrea, Bureau of Nutritional Sciences, Health Canada; Sarah Jane Schwarzenberg MD, American Academy of Pediatrics; Lynne Underhill, Bureau of Nutritional Sciences, Health Canada
Principal author: Jeffrey N Critch MD
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.
Last updated: Feb 7, 2024