Breastfeeding

Breastfeeding is promoted by Health Canada as the optimal method of infant feeding as it provides nutritional, immunological, and emotional benefits to the growing infant.⁽¹⁾  Breastfeeding is also considered to improve the health of the mother^(2,3) and results in economic benefits for the family,⁽⁴⁾ the health care system, and the workplace.⁽⁵⁾ 

Health Canada's Nutrition for Healthy Term Infants (NHTI) recommends that infants be exclusively breastfed during the first six months of life.^(1,6)  Exclusive breastfeeding during this critical period of development promotes optimal nutrition, immunologic protection and growth of the developing infant.⁽¹⁾  With exclusive breastfeeding, the infant is fed only breast milk and is given no other food or liquid (not even water).  They may still receive vitamin and mineral supplement or medicine, in the form of drops or syrups.

The WHO recommends early skin-to-skin contact between mother and infant shortly after birth to help initiate early breastfeeding.  It is recommended that mothers initiate breastfeeding within one hour of birth.  The first milk, or colostrums is very rich in protective factors for the infant.  Any attempt, even once, made by the mother to initiate breastfeeding is considered breastfeeding initiation. 

Mothers who are older, married, and with higher education and income levels have a higher breastfeeding initiation rate than mothers who are younger, single with lower education and income levels.^(7-10)  According to an infant feeding survey in KFL&A area, mothers who initiated breastfeeding were less likely to smoke during pregnancy, and more likely to attend a prenatal or breastfeeding class.⁽¹¹⁾

In 2012/13, 89.4% of mothers in KFL&A initiated breastfeeding.⁽¹²⁾

Figure 1. Newborn feeding at hospital discharge in KFL&A, 2012-2013⁽¹²⁾

Figure 2. Newborn feeding at hospital discharge by maternal age group in KFL&A, 2012-2013⁽¹²⁾

Figure 3. Newborn feeding at hospital discharge by parity in KFL&A, 2012-2013⁽¹²⁾

Interpretation for Figures 1, 2 and 3.

Figure 1 displays what mothers were feeding their newborns at time of discharge from hospital (or 3 days postpartum for home births).  Just over 70% of mothers were feeding their infants breast milk only at hospital discharge.  Figure 2 shows newborn feeding at discharge by maternal age.  Mothers under 20 years of age were more likely than all other age groups to feed their baby formula.  Mothers aged 30-34 were most likely to be feeding only breast milk to their infants.  Newborn feeding at discharge by mother's parity is shown in Figure 3.  Mothers who had at least three children were less likely to be feeding breast milk only compared to mothers with one or two children.

Exclusive breastfeeding is recommended for the first six months of life.⁽¹⁾  As with breastfeeding initiation, mothers who are older, married, and with higher education and income levels breastfeed longer and more exclusively than mothers who are younger, single, and with lower education and income levels.^(13-16) 

The most common breastfeeding concerns or difficulties reported by mothers in KFL&A were sleepy baby in hospital, inability to obtain a latch onto the breast, the perception of insufficient milk supply, sore nipple and mastitis.

Figure 4. Breastfeeding rates for the first six months of life, KFL&A, 2008⁽¹¹⁾

Interpretation for Figure 4.

Figure 4 outlines exclusive and any breastfeeding by mothers in KFL&A from the KFL&A infant feeding survey, 2008.  If mothers make the decision to supplement breastfeeding with formula, it is still desirable that she also continue feeding breast milk to her baby.  Mothers who are breastfeeding and supplementing with formula, with our without feeding other solids or liquids, are considered to be 'any breastfeeding' in Figure 1.  For exclusive breastfeeding, there is a steep decline between one month and two months (51.5% to 28.3%).  After that, the decline slows until five months, where again, there is a steep decline in the exclusive breastfeeding rate.  Approximately half of mothers remained in the 'any breastfeeding group' at six months, (49.7%), and one in four was still breastfeeding at 12 months (24.9%) (data not shown).

Health Canada's Nutrition for Healthy Term Infants provides recommendations for mothers on the best time to introduce complementary foods, as well as the order in which food groups should be introduced.  It is recommended that all mothers exclusively breastfeed for the first six months of like and that complementary foods, i.e. solid foods and liquids other than breast milk or formula, be avoided during the first 6 months of an infant's life.^(1,6)  Also, foods high in iron such as fortified cereals and meats and alternatives should be introduced first or alongside other food groups.⁽¹⁾  Iron is critical nutrient in brain development and is essential to infant growth and cognitive and behavioural development.⁽¹⁾  Introducing complementary foods before 6 months may increase the risk of adverse health outcomes including diabetes, unhealthy weight status and eczema. ^(7-10) 

Figure 5. Distribution of infants age at which liquids only, solids only and either liquids or solids were first introduced, KFL&A, 2008⁽¹¹⁾

Figure 6. First introduction to complementary foods by breastfeeding, KFL&A, 2008^(11,17)

Interpretation for Figures 5 and 6.

Despite potential health risks, four out of five mothers (80.4%) in KFL&A in 2008, fed their infants complementary foods prior to six months (data not shown).⁽¹¹⁾  Figure 5 outlines the distribution of infants age at which liquids only, solids only and either liquids or solids were first introduced.  The 'first' introduction refers to the time at which infants were first introduced more than once to foods in each food group.  It is notable that a number of mothers introduce complementary foods to their infants prior to five months of life.

Figure 6 gives us a look at the introduction of complementary foods by food group as well as the breastfeeding status of the mother.  The 'BF' group refers to mothers who are feeding breast milk to any extent ('any breastfeeding'), and Non-BF refers who were only feeding their infant formula, and no breast milk at six months.  Mothers who were not breastfeeding at six months introduced infant cereals, vegetables and fruit, water, and foods not recommended by Canada's Food Guide significantly earlier than mothers who were 'any breastfeeding'.  'Foods not recommended' were foods not recommended by Canada's Food Guide such as soft drinks, sugary beverages, artificial fruit drinks, hot dogs, and salty or sweet foods like potato chips, candy or chocolate.  There is no age at which these foods in this final category are recommended given that these foods have little or no nutritional value and may be high in sugar or salt.  But, in particular, infants have high energy needs and small stomachs, and their hunger should not be satisfied by foods that do not promote optimal growth and development.⁽¹⁾

In summary, more support is needed for mothers prior to two months in order to promote exclusive breastfeeding and from two to four months in order to promote the delayed introduction of complementary foods.

Researchers look at the "confidence levels" of percentages being compared to decide if there is a statistically significant difference between percentages. A statistically significant difference means that:

• the difference between two percentages is unlikely to have occurred by chance alone, and
• there is a true difference or change in the percentages.

In this report, 95% confidence intervals will accompany each percentage in all figures and tables.  This interval represents the range in which we are 95% confident the true percentage will fall within.  In tables, the 95% confidence intervals will be written with the percentage, followed by the 95% confidence interval range in brackets (e.g., 25% (12.3, 32.4)).  In figures, the 95% confidence interval is represented by vertical bars in each bar line.

1. Health Canada, Canadian Paediatric Society, Dietitians of Canada. Nutrition for Healthy Term Infants: Recommendations from birth to six months. Health Canada [ 2012  Available from: URL:http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php
2. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep ) 2007;(153):1-186.
3. Leung AK, Sauve RS. Breast is best for babies. J Natl Med Assoc 2005; 97(7):1010-1019.
4. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010; 125(5):e1048-e1056.
5. Department of Health and Human Service Office on Women's Health. Benefits of Breastfeeding. Nutr Clin Care 2003; 6(3):125-131.
6. World Health Organization, UNICEF. (2003). Global Strategy for Infant and Young Child Feeding.  2003. World Health Organization, Geneva, WHO Library Cataloguing-in-Publication Data.
7. Moss BG, Yeaton WH. Early childhood healthy and obese weight status: potentially protective benefits of breastfeeding and delaying solid foods. Matern Child Health J 2014; 18(5):1224-1232.
8. Tarini BA, Carroll AE, Sox CM, Christakis DA. Systematic review of the relationship between early introduction of solid foods to infants and the development of allergic disease. Arch Pediatr Adolesc Med 2006; 160(5):502-507.
9. Gaffney KF, Kitsantas P, Cheema J. Clinical practice guidelines for feeding behaviors and weight-for-age at 12 months: a secondary analysis of the Infant Feeding Practices Study II. Worldviews Evid Based Nurs 2012; 9(4):234-242.
10. Rosenbauer J, Herzig P, Kaiser P, Giani G. Early nutrition and risk of Type 1 diabetes mellitus--a nationwide case-control study in preschool children. Exp Clin Endocrinol Diabetes 2007; 115(8):502-508.
11. KFL&A Public Health. (2011). Feeding practices of infants in the Kingston, Frontenac, Lennox & Addington area during the first year of life.  2011.  KFL&A Public Health.
12. BORN Information System, Fiscal years: 2012-2013. (2014).  2014.
13. Dennis CL. Breastfeeding initiation and duration: a 1990-2000 literature review. J Obstet Gynecol Neonatal Nurs 2002; 31(1):12-32.
14. Whalen B, Cramton R. Overcoming barriers to breastfeeding continuation and exclusivity. Curr Opin Pediatr 2010; 22(5):655-663.
15. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics 2008; 122 Suppl 2:S43-S49.
16. Meedya S, Fahy K, Kable A. Factors that positively influence breastfeeding duration to 6 months: a literature review. Women Birth 2010; 23(4):135-145.
17. Fegan S, Bassett E, Peng Y, Steel OK. Adherence to complementary feeding recommendations for infants and implications for public health. Public Health Nutr 2015;1-12.