Infant Feeding and Parental Health - 2017
- Breastfeeding should be promoted as the optimal infant feeding method.
- Parents should be supported to make informed decisions about feeding infants.
- Promotion of breastfeeding, not only to women of childbearing age but to all within the community (including men), may have a positive impact on breastfeeding.
- Populations with low breastfeeding rates should receive targeted support to increase breastfeeding initiation and duration. Parents should receive education regarding infant feeding patterns and cues, as well as behavioural and developmental expectations.
- Parents who are unable or choose not to breastfeed should be provided with appropriate care and assistance to formula feed their child.
- Efforts must be made to increase the affordability and availability of fresh food in rural and remote communities to allow for appropriate weaning to occur.
- Doctors, medical students, and other health professionals who provide advice, should be appropriately trained and educated on the benefits of breastfeeding, including education and appropriate support for those mothers who experience difficulties with breastfeeding.
- Access to Perinatal Depression (PND) services should be improved through increasing the availability of specialised mother and baby units (MBUs). Access to maternal and perinatal services should be improved, particularly the provision of culturally appropriate services for Indigenous and culturally and linguistically diverse (CALD) families, and for rural and remote families.
- Ongoing independent research is important to achieve up-to-date national consensus on best-practice breastfeeding recommendations, and effective breastfeeding promotion strategies. National advisory bodies should provide consistent advice surrounding optimal breastfeeding practices, including duration of breastfeeding, and the introduction of complementary foods.
Infant nutrition and early infant growth patterns lay the foundation for eating patterns and weight gain later in life. Infants need a healthy start to life to reduce the risk of chronic conditions later in life, and doctors and healthcare professionals are uniquely positioned to support parents to achieve this.
New parents should be supported to make informed decisions regarding the feeding of their infant, recognising that this will be influenced by numerous social, physiological and individual lifestyle factors.
Both breast and bottle feeding provide opportunities for parents to bond with their infants, whilst ensuring that the infant’s nutritional needs are being met.
Breastfeeding provides health benefits to infants, including reduced risk of infection, asthma and atopic disease, and sudden infant death syndrome1. Breastfeeding allows for passive transfer of maternal antibodies which protect infants prior to their first routine childhood vaccination. Longer-term benefits of breastfeeding include lower prevalence of overweight and obesity, lower systolic blood pressure and lower levels of type 2 diabetes.2 These benefits peak in childhood and adolescence, with a gradual dilution occurring over time3. Breastfeeding should be encouraged, recognising that it may not be the most appropriate option for all caregivers.
Benefits to mothers of breastfeeding include improved bonding with their infant, accelerated recovery from childbirth, and progress towards a healthy body weight4. Breastfeeding is also associated with reduced risk of some cancers5.
In healthy infants, early skin-to-skin contact can help to support breastfeeding initiation, increase duration and improve infant thermal regulation6. It is important that this practice occurs under appropriate supervision from healthcare professionals.
Data indicates that many mothers initiate breastfeeding but do not persist7, highlighting the need for a greater deal of support to allow mothers to extend the duration of their breastfeeding.
Support for breastfeeding
Parents may experience myriad concerns regarding the health, development and behaviour of their infant. General practitioners, lactation consultants, and community or maternal and child health (MACH) nurses, are uniquely placed to provide appropriate reassurances and, where necessary, support to access specialist care.
Populations who may benefit from targeted support
Targeted support should be available for population groups with relatively low breastfeeding initiation and duration. Women who may benefit from increased breastfeeding encouragement and support can include: multiparous mothers with previous negative breastfeeding experience8, mothers returning to work9, mothers who smoke10, mothers of Indigenous children11 and mothers from CALD backgrounds.
Although different in composition, infant formula is an adequate source of nutrients for infants who are not breastfed12. Parents seeking to bottle feed their infants should receive appropriate support and guidance around formula feeding, including: volume, frequency of feeds, feeding cues and sterilisation and preparation of formula.
Mothers who had intended to breastfeed, but were unable to, may feel a sense of guilt or failure for adopting formula feeds. It is important that treating medical practitioners provide appropriate reassurance about the efficacy of formula feeding and work to remove any stigma associated with infant formula.
The Marketing in Australia of Infant Formula (MAIF) Agreement is a voluntary, self-regulatory code which restricts signatories’ ability to promote and market breastmilk substitutes13. The purpose of the agreement is to protect and encourage the promotion of breastmilk as the optimal source of nutrients for all infants. Efforts should be made to ensure that parents who are unable or choose not to breastfeed can still access appropriate support and information to allow them to effectively feed their infant.
Infant feeding patterns
Parents should receive appropriate education regarding infant feeding patterns, perception of milk supply and infant feeding cues. Parental anxiety around feeding can contribute to feeding difficulties, which may further exacerbate the parental anxieties. Every infant is unique and feeding patterns and behaviour are likely to differ substantially, even between siblings. For parents, learning to predict and accommodate the feeding pattern of their newborn infant can be the cause of anxiety and tension. Medical practitioners can be an appropriate source of reassurance and support through this period.
Perceived insufficient milk supply is commonly cited as a reason for the cessation of breastfeeding14, though the number of women who actually experience this is relatively low. Women who believe they are experiencing insufficient milk supply should consult their general practitioner or lactation consultant, and if necessary have their milk supply assessed.
Transition to solid foods
Infants should be breastfed or formula-fed for the first few months of life, until around six months15. When the infant is ready, but not before four months, it is appropriate for parents to introduce complementary foods16. Doctors and child health nurses can guide parents through this transition by providing feedback on the progress and needs of the infant, recognising that each child is unique and developmental trajectories will reflect this. After the introduction of solid foods, parents may wish to continue complementary breast or formula feeding up to two years or beyond. Through the transition to solid foods, infants should be introduced to a variety of foods from each food group17. Ensuring the availability and affordability of fresh food, particularly in rural and remote communities, is important to allow for appropriate weaning.
Infants who have an increased risk of food allergies, such as those with eczema or a family history of allergies, may need to be introduced to certain solid foods earlier to reduce the risk of developing allergies18. General practitioners or MACH nurses should support parents through this transition by providing guidance based on the latest evidence on appropriate introduction of high-risk allergens, such as nuts or eggs.
There are a range of products marketed to parents that are not always necessary for healthy growth and development, such as “toddler milk”. Medical practitioners play an important role in providing parents with realistic expectations about the utility of these products.
Donor human milk and fortified formula
Hospital-based milk banks provide a valuable source of nutrients for infants with a clinical need for donor human milk, such as those who are premature or underweight. The use of donor human milk for premature infants can be significantly beneficial in reducing the risk of gastrointestinal infection19.
Informal breastmilk sharing arrangements that occur without medical oversight pose significant risks to infant health, including the transmission of harmful bacteria or communicable diseases. Parents should be educated about the potential harms of sourcing unpasteurised and untested milk for their infants, to ensure they are able to make informed decisions.
For infants with a clinical nutrient deficiency, prescribed and fortified formula can provide much needed additional nutrients to support the infant to continue to grow and meet their developmental milestones.
The transition to motherhood is a physically and emotionally demanding period, and many mothers experience myriad mental and physical changes. Whilst parents are likely to be prioritising the care of their newborn infant, they should be encouraged to be mindful of their own health and wellbeing, and seek support from a general practitioner if necessary.
The duration of postpartum hospital stays has decreased significantly in recent decades. Mothers can be discharged as early as six to 48 hours after delivery20, long before their milk has come in. Mothers who are from isolated areas, have limited social support networks, or who are recovering from a complicated birth may benefit from an extended postpartum hospital stay. Women should only be discharged from hospital when they are physically and emotionally ready to return home, recognising that flexibility will be required to accommodate the unique circumstances of each family.
Inflammation of the breast tissue, mastitis, can lead to severe pain and infection. It is important that mothers seek treatment at the first signs of mastitis, which include: redness and soreness of the breast tissue and flu-like symptoms. Physical symptoms of mastitis can be managed with measures to reduce pain such as warm or cool packs, local massage, rest, water and expressing milk. Mothers with mastitis should seek assistance from a doctor to manage the infections.
Postnatal depression (PND) is a severe and potentially life-threatening condition which is estimated to affect approximately one in seven new Australian mothers21. The relationship between breastfeeding and PND is complex. Discordance between the feeding intentions and actual feeding experience of a mother may increase the likelihood that she will experience PND, whilst women who are able to breastfeed in line with their intentions have a reduced risk of experiencing PND22.
There is limited access to specialised mother and baby units (MBUs). Waiting times can be lengthy and women who are waiting to access these services need to be monitored and supported in the interim.
Infant feeding can be further compounded by infant conditions such as colic, tongue tie or feeding and swallowing disorders, which occur in both breast- and formula-fed infants. Parents who believe there may be anatomical barriers to successfully feeding their infant should consult their general practitioner for support and assistance to access the appropriate referral pathways if necessary.
Women from Culturally and Linguistically Diverse (CALD) backgrounds
The antenatal experience of women from CALD backgrounds can be affected by isolation from immediate family and community support, language barriers, conflicting cultural expectations, difficulties in navigating the healthcare system, ineligibility for Medicare or cultural barriers such as male clinicians or interpreters.
It is important that clinicians providing antenatal care to women from CALD backgrounds develop their cultural competency to allow them to provide culturally appropriate care to a diverse range of patients. It is important that women from CALD backgrounds have access to culturally appropriate antenatal care, including language services and antenatal education for new parents23.
Recent demographic shifts have seen a decline in the number of Australians who live in rural and remote areas. The reduction in population has led to a significant decline in the availability of maternity facilities in these areas.
Maternal and perinatal mortality rates are higher among families in rural and remote Australia, indicating a need for targeted support24.
Maternal and perinatal outcomes in rural and remote communities can be improved through increasing accessibility of services, provision of infrastructure for tele support and remote consultations, and increased emotional and practical support for women who have to leave their communities to give birth.
Mothers’/new parents’ groups
Mothers’ groups can provide a valuable, peer-support network for new parents as well as a learning opportunity through exposure to differing parenting styles. Hospitals, birthing centres, general practitioners and MACH nurses have a valuable role to play in encouraging and assisting new parents to join new parents’ groups, and can assist parents to find new support groups if their needs are not being met within their current support network.
Antenatal education is an effective means of improving knowledge regarding pregnancy, birth and parenthood, and plays a valuable role in ensuring that new mothers have realistic expectations for their birth, and also for the physical and psychological ramifications of having a child. Women who receive antenatal education generally report lower levels of anxiety throughout the birthing process25. Additionally, women who undergo antenatal education that includes psychological preparation and the development of coping skills are less likely to experience depressive symptoms in the postnatal period26.
Parents seeking information can be overwhelmed with conflicting and often misleading advice from social media, family and friends, and the internet. An increasingly important aspect of antenatal education involves improving the health literacy of parents to equip them to seek evidence-based information from reliable sources, such as government- or hospital-based websites.
1 NHMRC. (2013). Australian Dietary Guidelines. Available from: https://www.nhmrc.gov.au/guidelines-publications/n55
2 Horta, B.L. & Victoria, C.G. (2013). Long term benefits of breastfeeding: A systematic review. World Health Organization. Accessed from: http://apps.who.int/iris/bitstream/10665/79198/1/9789241505307_eng.pdf
3 Horta, B.L. & Victoria, C.G. (2013). Long term benefits of breastfeeding: A systematic review. World Health Organization. Accessed from: http://apps.who.int/iris/bitstream/10665/79198/1/9789241505307_eng.pdf
4 NHMRC. (2013). Australian Dietary Guidelines. Available from: https://www.nhmrc.gov.au/guidelines-publications/n55
5 NHMRC. (2013). Australian Dietary Guidelines. Available from: https://www.nhmrc.gov.au/guidelines-publications/n55
6 Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2014). Provision of routine intrapartum care in the absence of pregnancy complications. Available from: https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Provision-of-routine-intrapartum-care-in-the-absence-of-pregnancy-complications-(C-Obs-31)-Updated-Mar-2015.pdf?ext=.pdf
7 Australian Institute of Health and Welfare. (2011). 2010 Australian National Infant Feeding Survey. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737420925
8 Gijsbers. B, Mesters. I, Knotterus. JA & van Schayck. CP. (2008) Factors associated with the duration of exclusive breastfeeding in asthmatic families. Health Education Research2008;23 (1):158–69
9 Smith, J. P., McIntyre, E., Craig, L., Javanparast, S., Strazdins, L., & Mortensen, K. (2013). Workplace support, breastfeeding and health. Family Matters, 93, 58-73.
10 Australian Institute of Health and Welfare. (2011). 2010 Australian National Infant Feeding Survey. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737420925
11 Department of the Prime Minister and Cabinet. (2014). Aboriginal and Torres Strait Islander Health Performance Framework 2014 Report. Available from: https://www.dpmc.gov.au/sites/default/files/publications/indigenous/Health-Performance-Framework-2014/tier-2-determinants-health/220-breastfeeding-practices.html
12 National Health and Medical Research Council. (2013). Eat for Health - Infant Feeding Guidelines (Summary). Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/publications/170131_n56_infant_feeding_guidelines_summary.pdf
13 Department of Health. (2003). Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement - The MAIF Agreement. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-publicat-document-brfeed-maif_agreement.htm
14 Australian Institute of Health and Welfare. (2011). 2010 Australian National Infant Feeding Survey. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737420925
15 NHMRC. (2013). Australian Dietary Guidelines. Available from: https://www.nhmrc.gov.au/guidelines-publications/n55
16 Australasian Society of Clinical Immunology and Allergy. (2016). ASCIA Guidelines – infant feeding and allergy prevention. Available from: www.allergy.org.au/health-professionals/papers/infant-feeding-and-allergy-prevention
17 Australasian Society of Clinical Immunology and Allergy. (2017). Information on how to introduce solid foods to infants. Available from: www.allergy.org.au/patients/allergy-prevention/ascia-how-to-introduce-solid-foods-to-babies
18 Australasian Society of Clinical Immunology and Allergy. (2016). ASCIA Guide - introduction of peanut to infants with severe eczema and/or food allergy. Available from: www.allergy.org.au/health-professionals/papers/ascia-guide-peanut-introduction
19 Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD002971. DOI: 10.1002/14651858.CD002971.pub3.
20 Australian Institute of Health and Welfare. (2016). Australia’s mothers and babies 2014. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129557657
21 Deloitte Access Economics. (2012). The cost of perinatal depression in Australia – FINAL REPORT. Available from: https://www.deloitteaccesseconomics.com.au/uploads/File/PANDA%20Exec%20Summ%20pdf.pdf
22 Borra, C., Iacovou, M. & Sevilla, A. Matern Child Health J (2015) 19: 897. doi:10.1007/s10995-014-1591-z
23 Department of Health. (2013). CLINICAL PRACTICE GUIDELINES ANTENATAL CARE - MODULE I - 4.1 Women from culturally and linguistically diverse backgrounds. Available from: http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-a~population-groups~diverse-backgrounds
24 Department of Health. (2011). National Maternity Services Plan – Provision of Maternity Care. Available from: http://www.health.gov.au/internet/publications/publishing.nsf/Content/pacd-maternityservicesplan-toc~pacd-maternityservicesplan-chapter3#Rural%20and%20remote%20services