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Infant Feeding

Postpartum (to six months) considerations

Although over 85% of parents plan to breastfeed exclusively, at birth approximately 70% of babies are exclusively breastfed.1 The decrease between intention and initiation indicate many parents do not meet their exclusive breastfeeding goals within the first days of their babies’ lives. Some labour, birth and early postpartum factors associated with exclusive breastfeeding initiation (e.g. caesarean section, supplementation) continue to be associated with breastfeeding duration at two, four and up to six months.1

Health care organizations and providers have an important role supporting parents with infant feeding from birth to six months and beyond. Evidence indicates breastfeeding parents need further breastfeeding support in addition to standard care.2 Interventions that support exclusive breastfeeding for six months incorporate a combination of education, counselling and support () and a seamless continuum of care between early postpartum and community care.3,4 Another critical practice that supports breastfeeding is reduce conflicting advice as much as possible.5,6

Postpartum infant feeding and breastfeeding duration considerations include: postpartum care, supplementation, introduction to solids, and demographic and socio-economic factors. The Baby-Friendly Initiative 7 outlines best practices in providing community- based support for breastfeeding parents (Steps 1 through 10) and parents who are supplementing, combination feeding or feeding formula only (Steps 5 and 6, and Appendix 2.3).

Feeding Babies in Simcoe Muskoka: Postpartum Considerations (to Six Months) Infographic

In Simcoe Muskoka:

At discharge from hospital (or 72 hours for home births):

  • Over 90% (92.0% [91.2% - 92.8%]) of babies are breastfed, including approximately 70% (68.9% [67.5% - 70.2%]) of babies who are exclusively breastfed*.1
  • Rates of breastfeeding initiation and exclusive breastfeeding initiation from BORN differ somewhat from what parents report.
    • SMDHU IFS8 data show 92% (91.8% [88.5% - 94.2%]) of babies are breastfed, including 64% (63.8% [58.8% - 68.5%]) of babies who are exclusively breastfed.
    • An additional 4% [4.2% [2.6% - 6.8%])1 of babies who receive supplementation (with something other than breastmilk, e.g. infant formula) in hospital were being fed only breastmilk by the time of discharge. These babies are categorized as ‘Returned to only breastmilk’ as they cannot be categorized as exclusively breastfed.
  • Almost 1 in 3 babies are fed infant formula in hospital. 1 Simcoe Muskoka data indicate babies who are fed infant formula in hospital are less likely to be breastfed at two, four and up to six months.8

From hospital discharge (or 72 hours for home births) up to six months

  • The number of parents who breastfeed exclusively drops significantly in the first few weeks after birth.8
  • By two months, 80% (82.6% [78.4% - 86.1%]) of babies continue to be breastfed, while 45% (46.4% [41.4% - 51.4%]) of babies are exclusively breastfed.8
  • Between hospital discharge and two months, more than 20% of babies are introduced to formula (exclusive rate drops from 70% to 45%) and an additional 10% stop breastfeeding completely (‘any’ breastfeeding rate drops from over 90% to 80%).8
    • Consistent with literature9,10, the most common reason parents in Simcoe Muskoka reported they stopped breastfeeding before two months were:
      • Perceived insufficient milk supply
      • Baby unable to latch/not breastfeeding well. 11
  • At four months, 75% (73.1% [68.4% - 77.3%]) of babies continue to be breastfed, while 35% (35.3% [30.7% - 40.3%]) of babies are exclusively breastfed.8
  • Up to six months, two-thirds (66.5% [61.5% - 71.1%]) of babies continue to be breastfed, including 20% (20.3% [16.5% - 24.6%]) who are exclusively breastfed.8
  • Between four and six months, the combination feeding rate increases by more than 10%.8 This may be partly due to the early introduction of solids between four and five and a half months. 8 See “Introduction to Solids” for this information.

Infant Feeding Duration Rates at Initation, at Two Months, Four Months and up to Six Months, Simcoe Muskoka 2019

* There are two data sources for initiation data: SMDHU IFS and BORN. The exclusive initiation rates from SMDHU IFS differ from BORN. Reasons for these differences are explained on the SMDHU IFS data source page on the HealthSTATS website.

Nutrition for Healthy Term Infants (NHTI) 12 states breastfeeding exclusively for the first six months, and sustained breastfeeding 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. Introducing solid food early decreases the duration of exclusive breastfeeding which is recommended for the first six months. Currently, there is no evidence to refute the international recommendation of exclusive breastfeeding to six months and the introduction of complimentary solid foods at six months. 13, 14 For this reason the international15 and Canadian16 recommendation for all healthy, full-term infants is exclusive breastfeeding to six months.

At about six months of age, all healthy full term infants required complimentary foods in addition to breastfeeding to meet their nutritional needs.12 This includes breastfed infants who meet the definition of high-risk for development of food allergies as there is little evidence to compare introduction of common allergenic foods at 4 months of age with introduction at 6 months.17, 18

In Simcoe Muskoka:

  • One in three (33.1%, 95% Confidence Interval: 30.9% - 35.3%) babies are fed solid foods earlier than recommended.8
  • Almost all of those who introduce solids early do so between four and five and a half months.8
  • There is an association between being fed only infant formula at 2 and 4 months and being fed solid foods earlier than the recommended six months.19
    • This association may not be causal; there may be other factors influencing both introduction to solids and breastfeeding duration.
  • The most common reason parents reported for introducing solids earlier than recommended was because a health care professional advised them to do so.20

Age AT First Introduction to Solid Food for Infants SMDHU 2015-2019

Providing early and ongoing skilled breastfeeding support from a combination of professionals and trained peers or laypeople supports a seamless transition between postpartum to community care and improves breastfeeding rates, including exclusive breastfeeding rates.21 Breastfeeding support can mitigate the risks of formula supplementation and breastfeeding cessation, which occurs most frequently in the first weeks after birth.4,22 Breastfeeding support and encouragement provided within a trusting relationship with a health care provider can increase breastfeeding confidence and is supportive of longer breastfeeding duration.5 A decrease in breastfeeding confidence is a major factor associated with perceived insufficient milk supply, unnecessary and continued supplementation and breastfeeding cessation.

Health care provider interactions supportive of continued breastfeeding include:

  • The development of a trusting relationship; and
  • Encouragement that affirms the breastfeeding parent’s ability/confidence.5

Interactions can also result in loss of confidence, feelings of being undermined, confusion and guilt.5 Health care provider interactions considered unsupportive of continued breastfeeding include:

  • Fragmented interactions;
  • Interactions lacking in rapport;
  • Being overzealous about breastfeeding; and
  • Providing conflicting advice.5

Health care providers can also provide support by ensuring all parents know about infant feeding programs and services in the community and how to access them. In Simcoe Muskoka:

  • The majority (90.3% [95% Confidence Interval: 86.8%–93.7%]) of new parents are aware of community programs and services to help with feeding their baby.11
  • About half of parents said that they had used a program or service to help them with feeding their baby, while the majority (77.4% [70.1%–84.7%]) of those who did not use a service felt that feeding was going well, and/or they had enough help from friends and family.11
  • Parents most commonly find out about infant feeding programs and services from:
    • Hospital or health care provider interactions (physician, midwife, obstetrician, nurse practitioner, Health Babies Health Children nurses or family home visitors);
      • Participation in community programs (prenatal class, EarlyON, mommy groups, parent/baby classes);
      • Internet (google search, SMDHU website);
      • Written information/package (discharge package, prenatal package, brochure); and
      • Previous experience.11

It is important for health care providers to provide adequate follow up and supplementation management with clients whose breastfed babies are being supplemented. It is also important for these health care providers to recommend supplementation for breastfeeding babies only when it is medically indicated.

For additional information about supplementation and local supplementation data see supplementation section in Labour, Birth and Early Postpartum section

Regression analysis (to determine independent associations) on local data indicates parents may need extra support to continue exclusively breastfeeding if they:

  • Living with an annual before-tax family income of less than $60,000;
  • Are a first time parent
  • Delivered by c- section;
  • Gave birth preterm;
  • Are under 25 years of age or older than 34 years of age. 23

Other factors (education, immigration status and marital status) were also analyzed to assess association with breastfeeding rates and found to not be independently associated. Other social and economic factors such as housing status and access to support networks were not available for analysis however, literature suggests there are underlying social and economic influences associated with breastfeeding initiation including:

  • Parent demographics (e.g. ethnicity, language, income);
  • Parent health status (e.g. diabetes, hypertensive disorders); and
  • Parent confidence, attitudes, knowledge and beliefs. 24, 25, 26

Populations with lower exclusive breastfeeding duration rates may benefit from additional support to address barriers to continued breastfeeding. Additional support may include addressing challenges with food insecurity, lack of support networks or other social and economic factors.

Health care providers can also provide support by ensuring all parents know about infant feeding programs and services in the community and how to access them. In Simcoe Muskoka:

  • The majority (90.3% [95% Confidence Interval: 86.8%–93.7%]) of new parents are aware of community programs and services to help with feeding their baby.11

Health care providers can:

1. Assess parents for barriers and risk factors that may impact how long they continue to breastfeed

This includes assessing:

  • Birth experience and interventions;
  • Breastfeeding knowledge, attitudes and beliefs;
  • Breastfeeding confidence/self-efficacy (including previous breastfeeding experience);
  • Available supports;
  • Pre-pregnancy body mass index;
  • Perinatal mood disorder;
  • Tobacco, alcohol and other substance use; and
  • Social and economic determinants of health (SDOH).

Clinical Resources:


2. Provide tailored education, counselling and support, e.g.

  • Support parents to make informed decisions by providing accurate and unbiased information about infant feeding, including:
  • National infant feeding recommendations;
  • The importance of breastfeeding;
  • The importance of exclusivity;
  • The risks of non-medically indicated supplementation;
  • The health risks of not breastfeeding for both parent and child;
  • The risks and costs of formula feeding.
  • The potential risks of using soothers.
  • Support parents to feed their babies
  • Educate parents who plan to breastfeed about position and latch, and how to tell if their baby is getting enough;
  • Educate parents who plan to breastfeed and formula-feed how to protect their breastmilk supply; and establish a plan with the parent for the ongoing management and evaluation of the supplementation; and
  • Educate and support parents who plan to provide any infant formula to:
  • choose a formula that is acceptable, feasible, affordable, sustainable, and safe (AFASS); and
  • safely prepare, feed and store formula.

  • Educate parents about:
  • Hand expression;
  • Skin-to-skin contact (including skin-to-skin contact/breastfeeding during painful procedures, e.g. blood draws, immunizations);
  • Cue-based feeding;
  • The rights of breastfeeding parents;
  • Possible breastfeeding problems, their solutions;
  • Available breastfeeding and infant care supports in the community; and
  • Contraception compatible with breastfeeding.

  • Encourage skin-to-skin contact and breastfeeding during painful procedures
  • Keep parents and babies together throughout visits.
  • Promote ongoing skin-to-skin contact and skin-to-skin contact/breastfeeding during painful procedures (e.g. blood draws, immunizations).

  • Promote introduction of solids at about six months
  • Recommend introduction of solids based on national recommendations and individual assessment.

Clinical Resources:

Patient Resources

Programs and Services


3. Refer parents to breastfeeding supports, postnatal classes/programs and community social supports

Health care organizations can:

Create an organizational environment supportive of breastfeeding

 

2. Collaborate with community partners to:
  1. BORN, 2019
  2. Meedya S, Fernandez R, Fahy, K. Effect of educational and support interventions on long-term breastfeeding rates in primiparous women: a systematic review and meta-analysis. JBI Database System Rev Implement Rep. 2017; 15(9) 2307-2332.
  3. Kim SK, Park S, Oh J, Kim J, Ahn S. Interventions promoting exclusive breastfeeding up to six months after birth: A systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud. 2018; 80: 132-137
  4. Registered Nurses’ Association of Ontario (RNAO). Best Practice Guideline: Breastfeeding – Promoting and Supporting the Initiation, Exclusivity, and Continuation of Breastfeeding in Newborns, Infants and Young Children. 3rd ed. [Internet]. Toronto, ON. 2018. Available from: https://rnao.ca/bpg/guidelines/breastfeeding-promoting-and-supporting-initiation-exclusivity-and-continuation-breast
  5. MacVicar S, Kirkpatrick P. The effectiveness and maternal satisfaction of breast-feeding support for women from disadvantaged groups: a comprehensive systematic review. JBI Database of Systematic Reviews & Implementation Reports. 2014; 12(6), 420-476.
  6. Schmied V, Sheehan A, McCourt C, Dykes F, Beake S, Bick D. Women’s perceptions and experiences of breastfeeding support. Birth. 2011; 38(1) 49-60.
  7. Breastfeeding Committee for Canada. The BFI 10 Steps and WHO Code Outcome Indicators for Hospitals and Community Health Services. 2017. Available from: https://breastfeedingcanada.ca/wp-content/uploads/2020/03/Indicators-we2019-En.pdf
  8. SMDHU IFS, 2019
  9. Brown, CRL, Dodds L, Legge A. Bryanton J, Semenic S. Factors influencing the reasons why mothers stop breastfeeding. 2014. Can J Public Health; 105, e179–e185.
  10. Wood NK, Woods NF. Interventions that Enhance Breastfeeding Initiation, Duration, and Exclusivity: A Systematic Review. 2018. MCN, American Journal of Maternal Child Nursing; 43 (6): 341-347.
  11. SMDHU IFS, 2016
  12. Health Canada, Canadian Paediatric Society, Dietitians of Canada, & Breastfeeding Committee for Canada. Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months [Internet]. 2014. Available from: https://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
  13. Smith H. Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database of Systematic Reviews. 2016. https://doi.org/10.1002/14651858.CD006462.pub4
  14. Canadian Pediatric Society. Practice Point: Timing of introduction of allergenic solids for infants at high risk [Internet]. 2019. Available from: https://www.cps.ca/en/documents/position/allergenic-solids
  15. World Health Organization. Statement: Exclusive breastfeeding for six months best for babies everywhere [Internet]. 2011. Available from: https://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/#:~:text=WHO%20recommends%20mothers%20worldwide%20to,of%20two%20years%20or%20beyond .
  16. Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada. Nutrition for healthy term infants: Recommendations from birth to six months [Internet]. (2012). Available from: https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months.html
  17. Canadian Pediatric Society. Practice Point: Timing of introduction of allergenic solids for infants at high risk [Internet]. 2019. Available from: https://www.cps.ca/en/documents/position/allergenic-solids
  18. Simcoe Muskoka District Health Unit. HealthFAX: Complimentary Food Introduction for Infants At-risk of Food Allergy [Internet]. 2019. Available from: https://www.simcoemuskokahealth.org/docs/default-source/jfy-healthfax/190504-complfoodintroinfantatriskfa.pdf?sfvrsn=0
  19. SMDHU IFS, 2015-2019
  20. SMDHU IFS, 2015-2016
  21. Provincial Council for Maternal and Child Health. Standards of Postnatal Care for Mothers and Newborns in Ontario: Birth to one-week postnatal period. [Internet]. 2018. Available from:

    http://www.pcmch.on.ca/wp-content/uploads/2018/05/Standards-of-Postnatal-Care-for-Mothers-and-Newborns-in-Ontario-Final-Report-Part-I-2018May16.pdf

  22. McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL, Veitch, Rennie AM, Crowther SA, Neiman S, MacGillivray S. Support for healthy breastfeeding mother with healthy term babies. Cochrane Database of Systematic Reviews. 2017. https://doi.org/10.1002/14651858.CD001141.pub5
  23. SMDHU IFS, 2017-2019.
  24. Baby-Friendly Initiative Strategy for Ontario. BFI Implementation Toolkit [Internet]. 2018. Available from: https://breastfeedingresourcesontario.ca/sites/default/files/pdf/Res_Strategy_BFI_ImplementationToolkit_EN_2018.pdf
  25. Best Start Resource Centre. Populations with Lower Rates of Breastfeeding: A Summary of Findings [Internet]. Toronto, ON. 2015. Available from: https://resources.beststart.org/wp-content/uploads/2018/12/B09-E.pdf
  26. Best Start Resource Centre. Targeted Support for Ontario Populations with Lower Rates of Breastfeeding: 2013-2016 [Internet]. Toronto, ON. 2017. Available from: https://resources.beststart.org/wp-content/uploads/2018/12/B32_E.pdf

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