Originally posted on our BACE Facebook Page on January 2, 2013.
This posts contains BACE's two submissions to Health Canada's call for public consultation on their new Nutrition for Healthy Term Infants 0-6 months guidelines for health professionals. The guidelines were published in October, 2012.
Response to: Second Consultation Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months
Submission to Health Canada
The Breastfeeding Action Committee of Edmonton (BACE) respectfully submits our comments in response to the open consultation on the revised draft statement, “Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months.
We thank Health Canada for providing this opportunity to review and comment on the draft document after changes were made following the first consultation opportunity. We participated in the first opportunity and are encouraged to see many positive changes in this draft.
We have reviewed INFACT Canada’s submission and are supportive of the work they have done to help ensure this document provides the best possible policy statement.
Specific areas of concern:
Alignment with WHO guidelines and recommendations:
All Health Canada breastfeeding policies, guidelines, statements, promotional brochures and utterances, including these recommendations, should be aligned with WHO guidelines and recommendations on infant nutrition. If there is at any point a deviance from WHO guidelines and recommendations Health Canada should specifically indicate that it is a deviation, and should provide the reason for the deviation including references to the evidence base.
There are still parts of in this draft statement that deviate from WHO guidelines and recommendations; notably, the wording of the overarching WHO recommendation to breastfeed exclusively from birth to six months has been changed to “for about six months” – the word “about” needs to be removed and the wording aligned with WHO recommendations, OR Health Canada should indicate that this recommendation is not aligned with WHO recommendations, and provide an explanation as to why, with references to the supporting evidence base.
There are other deviations from WHO guidelines and recommendations, such as the references to human donor milk. WHO says[i] “For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances. If Health Canada wishes to deviate from this WHO recommendation by ignoring the reference to breast milk from a healthy wet-nurse and by inserting a requirement that donor milk be pasteurized, it should explain why.
WHO does not make the specific recommendation that milk be pasteurized. It is not universally accepted that donor milk must be pasteurized in order for it to be safe. We note that in at least one country, Norway, milk banks use screening appropriate for disease prevalent in the local population, and do not pasteurize donor milk. Peer-to-peer milksharing occurs frequently in Canada and there are not enough milk banks to meet the needs of the population. There may never be enough banked, pasteurized donor human milk available to meet the need. Health Canada should provide guidance to health care providers so they can advise parents on how to share milk safely.
We support INFACT Canada’s wording changes to this section and would further recommend that Health Canada replace this wording: “pasteurised human milk from appropriately screened donors and commercial formula are suitable alternatives. These options depend on individual circumstances.” with the following: “human milk from appropriately screened wet-nurses or donors, pasteurized human donor milk, and commercial formula are suitable alternatives. These options depend on individual circumstances.”
The section on introducing complementary foods should not reference iron-enriched cereal.
We suggest that Health Canada consider defering recommendations around the introduction of complementary foods until it has completed the revision of the feeding guidelines for 6-24 months.
Infant formula additives:
The wording on infant formula additives is confusing and inconsistent. We are concerned that phrases like “These substances are found in breastmilk, but evidence of their dietary essentiality is lacking” could be interpreted to mean certain substances in breastmilk are not essential. We would encourage a thorough review of this section to ensure the intent is well communicated in the final draft.
[i] Infant and young child nutrition - Global strategy on infant and young child feeding, WHO, April 2002 - http://apps.who.int/gb/archive/pdf_files/WHA55/ea5515.pdf
Online Consultation on Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months
Submission to Health Canada
The Breastfeeding Action Committee of Edmonton has been active in for a number of years in Edmonton encouraging and promoting breastfeeding. Some of our activities have included
- contacting pediatricians to ask them to remove infant formula promotional information from their offices
- advocating for the re-establishment of our donor human milk bank
- supporting women who have been asked to stop breastfeeding in public
- working with the City of Edmonton and other public swimming pool operators in our region to support the right of a woman and baby to breastfeed anytime, anywhere[i]
- working with the Art Gallery of Alberta to support the right of a woman and baby to breastfeed anytime, anywhere. [ii]
We welcome the opportunity to comment on the draft recommendations for are submitting recommendations for Health Canada’s Nutrition for Healthy Infants: Recommendations from Birth to Six Months DRAFT.
We have reviewed submissions from a number of organizations and wish to state our support for the recommendations sent by INFACT Canada. We are particularly supporitve of the reminders to Health Canada that breastfeeding is normal and that not breastfeeding is associated with increased risk.
Our submission is based on the fact that normal nutrition for healthy infants ages 0 to six months is provided through breastfeeding, and that the accepted options for feeding healthy infants when the infant cannot be fed at the breast are, as stated in Paragraphs 18 and 19 of the WHO’s Global Strategy for Infant and Young Feeding:
The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.(Recommendation continues with infant formula recommendations as the next and less preferable option) [iii]
All Health Canada policies, guidelines, statements, promotional brochures and utterances, including these recommendations, should be aligned with WHO guidelines and recommendations on infant nutrition. If there is at any point a deviance from WHO guidelines and recommendations we want Health Canada to specifically indicate that it is a deviation, and to provide the reason for the deviation including references to the evidence base, in these recommendations.
Health Canada must advocate for adherence to the International Code of Marketing of Breast-milk Substitutes and all the relevant WHA resolutions on Infant and Young Child Nutrition, which Canada has endorsed. We believe all Health Canada policies, guidelines, statements, promotional brochures and literature and utterances, including these recommendations, should be aligned with the CODE and resolutions.
We want Health Canada to explicitly outline the Code and resolutions in these recommendations.
Our specific recommendations are addressed to section 2, Breastfeeding increases with active protection, support and promotion by hospitals, workplaces, and the community. – DRAFT
However, we urge Health Canada to consider a review of the entire draft to ensure the document is aligned with WHO recommendations and the Code, and further, we ask that you consider our specific wording suggestions below and include similar wording where appropriate elsewhere in the recommendations.
Section 2: Breastfeeding increases with active protection, support and promotion by hospitals, workplaces, and the community. – DRAFT
Under Social and Behavioural factors:
Reword the “intention to breastfeed” paragraph 3 to indicate: Research has found an important factor in breastfeeding success is a woman’s own confidence, or self-efficacy in breastfeeding. Women who have more confidence breastfeed longer and more exclusively. [iv] Exposure to infant formula marketing and promotional materials in hospitals, clinics, and doctors office is both a violation of the CODE and a way of reducing a woman’s confidence in her ability to breastfeed.
State: Although nutritional concerns such as fears the baby isn’t getting enough milk are the main reason women cite for not breastfeeding, a significant number of women cited other psychosocial factors in their decision to wean including not wanting to breastfeed in public or not wanting to or able to breastfeed or pump milk at work.[v]
Under Breastfeeding Policy and implementation, include
There should be no promotional material, references or logos from infant formula manufacturing companies in any facility that serves a breastfeeding mother. For example, there should be no bassinet labels with formula company names, no disposable weigh scale covers with the name and logo of popular brands of formula, no charts on the walls showing the comparative nutritional content of various brands of formula. There should not be samples of formula given at hospital, or cans of formula displayed in the waiting rooms of pediatricians offices. [vi]
Women and their babies have the right to breastfeed “anytime, anywhere” and should be told verbally as well as with literature that not breastfeeding on demand and feeding expressed milk comes with an increased risk of impairing the breastfeeding relationship and the woman’s milk supply. Wherever pregnant and lactating women come into contact with the health care system they should see visual signs welcoming them to breastfeed and reinforcing their right to breastfeed anytime, anywhere. Specifically, Health Canada’s “Anytime Anywhere” symbols , signs and literature should be made available to all pregnant and breastfeeding women. (Note: Health Canada should consider amending its literature to include use of the International Breastfeeding Symbol. )
[i] Breastfeeding at Municipal Pools in Canada - A Report, Strange, Barb (August 16, 2002), Breastfeeding Action Committee of Edmonton
[ii] Art Gallery of Alberta apologizes, changes breastfeeding policy, Edmonton Journal, December 23, 2010,http://www.edmontonjournal.com/health/Gallery+Alberta+apologizes+changes+breastfeeding+policy/4015453/story.html
[iii] Global strategy for infant and young child feeding, World Health Organization, UNICEF, ISBN: 92 4 156221 8
[iv] The impact of a self-efficacy intervention on short-term breastfeeding outcomes, Health Educ Behav. 2009 Apr;36(2):250-8. Epub 2007 Sep 24.
[v] Why Mothers Stop Breastfeeding: Mothers' Self-reported Reasons for Stopping During the First Year, Ruowei Li, MD, PhDa, Sara B. Fein, PhDb, Jian Chen, MSca, Laurence M. Grummer-Strawn, PhDa, PEDIATRICS Vol. 122 Supplement October 2008, pp. S69-S76 (doi:10.1542/peds.2008-1315i)
[vi] These are examples of infant formula promotional materials witnessed by BACE members within the last six months in Edmonton hospitals, clinics, and doctor and pediatrician offices.
Further references include:
Factors influencing the duration of breastfeeding in the Sudbury region
G.L. Bourgoin, N.R. Lahaie, B.A. Rheaume, M.G. Berger, C.V. Dovigi, L.M. Picard, V.F. Sahai, Canadian Journal of Public Health, 1997 Jul-Aug;88(4):238-41
Breastfeeding among Low Income, African-American Women: Power, Beliefs and Decision Making, J. Nutr. 2003 133: 1 305S-
Predictors of the duration of exclusive breastfeeding among first-time mothers, Research in Nursing & Health, Volume 31, Issue 5, pages 428–441, October 2008
Improving breastfeeding outcomes: A pilot randomized controlled trial of a self-efficacy intervention with primiparous mothers., McQueen, K., Dennis, C-L., Stremler, R., & Norman, C. Journal of Obstetric, Gynecologic, and Neonatal Nursing.