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Draft nutrition for healthy term infants - Recommendations from birth to six months: Guidelines and recommendations

Breastfeeding is the unequalled method of feeding. It provides important nutrition and immunologic protection for an infant's growth and development.

  • Recommend exclusive breastfeeding for the first six months.

Rationale

Exclusive breastfeeding for the first six months after birth is the nutrition standard for infants and is promoted as a global public health recommendation (IOM, 2006; UNICEF, 2018a; UNICEF, 2018b; WHO, 2023a).

With exclusive breastfeeding, an infant is fed only human milk (breastmilk) directly at the breast or by other methods (such as a cup or syringe). When not feeding directly at the breast, the first alternative is to feed expressed human milk from the infant's own mother or birthing parent. When breastfeeding is not possible, there are other alternatives.

The exclusively breastfed infant is given no other food or liquid, not even water (UNICEF, 2018b). For healthy, full term infants, there is no evidence of benefit from adding other fluids or foods before six months (Smith & Becker, 2016).

Infants who are exclusively breastfed can still receive vitamin and mineral supplements or medicines in the form of drops or syrups. They can also be given oral rehydration solution, if needed (WHO, 2021a).

There are exceptions to this recommendation in only a very few medical situations (WHO, 2021a).

Human milk provides the correct quantity and composition of nutrients, allowing infants to absorb them easily and efficiently (Wambach & Spencer, 2021). To support optimal growth, the balance of nutrients in human milk changes during feedings and as the infant matures (Brockway et al., 2023a; Casavale et al., 2019; Martin et al., 2016; Wambach & Spencer, 2021).

Beyond nutrients, human milk's unique and complex composition includes bioactive factors, such as anti-infective immunoglobulins, white blood cells and oligosaccharides (Brockway et al., 2023b; Casavale et al., 2019; Martin et al., 2016; Wambach & Spencer, 2021). It also contains factors that stimulate the maturation of the small intestine and help the infant digest and absorb nutrients (Martin et al., 2016; Wambach & Spencer, 2021).

The importance of breastfeeding to infants' short- and long-term health is well recognized (DGAC, 2020; NNR, 2023; Patro-Gołąb et al., 2019). Breastfeeding is associated with beneficial neurocognitive development, and protects against sudden infant death syndrome and some infections (Jullien, 2021; NNR, 2023; PHAC et al., 2021; Yang et al., 2018). Observational research also suggests a protective effect in childhood against asthma and type 1 diabetes, as well as a protective effect later in life against type 2 diabetes and inflammatory bowel disease (DGAC 2020; NNR, 2023).

Exclusive breastfeeding to six months of age is associated with protection for the infant against gastrointestinal infections (NHMRC, 2012). It is also associated with protection against respiratory tract infections (Kramer & Kakuma, 2012).

In practice: Talking with families about nutrition for infants

Breastfeeding initiation and duration rates increase when people and organizations protect, promote, and support breastfeeding

  • Implement the policies and practices of the Baby-Friendly Initiative (BFI) for hospitals and community health services.

Rationale

In Canada, most parents plan to breastfeed and 91% of them start out breastfeeding their infant (PHAC, 2022). However, breastfeeding rates decrease over time. The sharpest decline happens in the first month after birth, when exclusive breastfeeding rates drop to 72.8% (PHAC, 2022). However, these rates are self-reported and may reflect recall bias and social desirability bias (Ricci et al., 2023).

Breastfeeding rates are on the rise in Canada (PHAC, 2022). However, only about 35% of infants in Canada are exclusively breastfed for six months, while about 62% of infants are partially breastfed for at least six months. The rate of exclusive breastfeeding to six months is still below the global target of at least 50% by 2025 and 70% by 2030 (WHO & UNICEF, 2014).

Breastfeeding contributes to food security (Tomori, 2023). Several social determinants of health are associated with increased rates of exclusive breastfeeding to six months (Ricci et al., 2023), as are other factors including higher maternal age, higher education, and living in an urban centre. To create supportive environments for breastfeeding, it is important to address the determinants of health and remove barriers to breastfeeding (Rollins et al., 2016).

Culturally safe care

Indigenous Peoples in Canada are diverse with distinct histories, cultural traditions, languages and healing methods (National Collaborating Centre for Indigenous Health, 2021). Providing culturally safe care involves recognizing and respecting diversity, fostering relationships and trust, and tailoring care to the specific cultural contexts of different Indigenous Nations, communities, and families to meet their needs (Alberta Health Services, 2019; Perinatal Services BC, 2024; Perinatal Services BC, 2021). Healthcare providers are encouraged to collaborate with Indigenous communities, Elders, and Knowledge Keepers to learn from them (PHAC & BCC, 2014), and to co-design and co-deliver support services that honour Indigenous worldviews and practices (Best Start, 2013). Providing culturally safe care requires an understanding of the historical and systemic factors that impact Indigenous health as a foundation for ongoing learning and self-reflection (Best Start, 2019; Truth and Reconciliation Commission of Canada, 2015).

The first few days after birth are a critical window for offering parents the support they need for successful breastfeeding. The United Nations Children's Fund and the World Health Organization launched the Baby-Friendly Hospital Initiative (BFHI) in 1991. Its evidence-based standards protect, promote, and support breastfeeding in facilities that provide maternity and newborn services. The BFHI outlines key responsibilities for scaling up the implementation of its Ten steps to successful breastfeeding (PDF format) (WHO & UNICEF, 2018, pp. 15).

The Breastfeeding Committee for Canada (BCC) has adapted the BFHI as the Baby-Friendly Initiative (BFI) to reflect that there is a continuum of care from hospital to community health services (BCC, 2017). The BCC oversees the initiative's implementation and assessment in most of Canada. Provincial and territorial committees collaborate with the BCC and with hospital and community facilities at the local level. In the province of Quebec, the Ministère de la Santé et des Services sociaux is the authority for breastfeeding and the BFI. It applies its own standards and assessment process within the province.

For designation requirements and assessments, refer to the BFI Implementation Guideline (PDF format). Facilities must fulfill the requirements of the Ten Steps to Successful Breastfeeding in Canada to become BFI-designated (BCC, 2021b). The BCC has quality improvement tools and resources to assess practices and support facilities in implementing and sustaining the BFI standards (BCC, 2023). For the province of Quebec, consult the Ministère de la Santé et des Services sociaux for standards (Ministère de la Santé et des Services sociaux, 2021).

The Ten Steps to Successful Breastfeeding in Canada (BCC, 2021b)

BFI Critical Management Procedures
  1. 1.a. Comply with the International Code of Marketing of Breastmilk Substitutes and relevant World Health Assembly Resolutions.
  2. 1.b. Have a written Infant Feeding Policy that is routinely communicated to all staff, pregnant women/persons and parents.
  3. 1.c. Establish ongoing BFI monitoring and data-management systems.
  4. 2. Ensure that staff have the competencies (knowledge, attitudes and skills) necessary to support mothers/birthing parents to meet their infant feeding goals.
BFI Key Clinical Practices
  1. 3. Discuss the importance and process of breastfeeding with pregnant women/persons and their families.
  2. 4. Facilitate immediate and uninterrupted skin-to-skin contact at birth. Support mothers/birthing parents to respond to the infant's cues to initiate breastfeeding as soon as possible after birth.
  3. 5. Support mothers/parents to initiate and maintain breastfeeding and manage common difficulties.
  4. 6. Support mothers/parents to exclusively breastfeed for the first six months, unless supplements are medically indicated.
  5. 7. Promote and support mother-infant togetherness.
  6. 8. Encourage responsive, cue-based feeding for infants. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
  7. 9. Discuss the use and effects of feeding bottles, artificial nipples and pacifiers with parents.
  8. 10. Provide a seamless transition between the services provided by the hospital, community health services and peer-support programs.

WHO International Code of Marketing of Breastmilk Substitutes

The WHO International Code of Marketing of Breastmilk Substitutes was approved in 1981. The Code, and subsequent resolutions of the World Health Assembly, seek to protect, promote, and support breastfeeding by ensuring the ethical marketing of human milk substitutes (infant formulas), foods marketed to replace breastfeeding, feeding bottles, and artificial nipples, including pacifiers (WHO, 1981).

The Code includes these ten important provisions (BCC, 2024):

In practice: Talking with families about nutrition for infants

Supplemental vitamin D is recommended for all breastfed infants

  • Recommend a daily vitamin D supplement of 10 µg (400 IU) for exclusively and partially breastfed infants.

Rationale

A daily vitamin D supplement of 10 µg (400 IU) is recommended, beginning at birth, for infants receiving any amount of human milk. Infants being fed only with human milk substitutes (commercial infant formula) do not require a vitamin D supplement. That is because commercial infant formula contains added vitamin D.

Without the supplement, a breastfed infant's stores of vitamin D can become depleted (IOM, 2011). Supplemental vitamin D for infants has been shown to be effective in preventing vitamin D deficiency and vitamin D-deficiency rickets (Lerch & Meissner, 2007).

Rickets is characterized by inadequate mineralization of bone tissue. The most common signs are altered growth and deformation, mainly in the long bones. The relationship between vitamin D and bone health is well-established (IOM, 2011). Evidence consistently links low blood levels of vitamin D (serum 25-hydroxyvitamin D [25(OH)D] concentrations) to confirmed cases of vitamin D-deficiency rickets in infants and children (Chung et al., 2009; IOM, 2011; Tan et al., 2020; Winzenburg & Jones, 2012).

In Canada, 87% of breastfed infants are given vitamin D supplements (Weiler et al., 2024). However, this statistic does not include people living in First Nations communities. Cases of rickets caused by vitamin D deficiency still occur in Canada among infants who do not receive a daily vitamin D supplement (CPS & PHAC, 2015; Irvine et al., 2022). Indigenous infants who are breastfed and not given the recommended vitamin D supplement are disproportionately impacted by rickets due to vitamin D deficiency (Irvine et al., 2022). During routine infant care visits, an assessment of risk can help determine if Indigenous infants are at high risk for vitamin D deficiency.

Breastfed infants with darker skin pigmentation, who are not given the recommended supplement, have also been reported to have higher rates of vitamin D-deficiency rickets (Irvine et al., 2022). Reinforcing to parents and caregivers the importance of giving the vitamin D supplement daily, and in the amount of 10 µg (400 IU), can support the appropriate uptake of the recommendation (Francis et al., 2021). This can help prevent vitamin D-deficiency rickets.

The adequate intake level for vitamin D for infants is 10 µg (400 IU) per day (IOM, 2011). A daily supplement exceeding this level does not appear to provide additional benefits to support bone health during infancy (Gallo et al., 2013; Gharibeh et al., 2023).

A 10 µg (400 IU) daily supplement is appropriate for infants living in any part of Canada, no matter the season or latitude (IOM, 2011). Vitamin D intake levels are set assuming only minimal sun exposure (IOM, 2011). Sunlight stimulates the formation of vitamin D in the skin and is a source of vitamin D for humans. However, sun-safe practices advise keeping infants out of direct sunlight due to the risk of skin cancer, skin damage, and dehydration (Health Canada, 2022).

For infants under six months of age, vitamin D intake should not exceed the tolerable upper intake level (UL) of 25 µg (1000 IU) per day. The UL is not a recommended level of intake (IOM, 2011). It is the highest average daily intake level likely to pose no risk of adverse health effects (IOM, 2011).

The practice of supplementing a breastfeeding mother or parent with vitamin D instead of supplementing the breastfed infant is not recommended. Breastfeeding mothers or parents would need to take a vitamin D supplement at levels above the UL for themselves so that infants could achieve serum 25(OH)D concentrations that are similar to what is achieved by directly supplementing the infant with the recommended dosage (Kazemain et al., 2023; Tan et al., 2020). As intake increases above the UL, the potential risk of adverse effects for breastfeeding mothers or parents increases (IOM, 2011).

In practice: Talking with families about nutrition for infants

First complementary foods should be iron-rich

  • Recommend meat, fish, legumes, eggs, and iron-fortified cereal as an infant's first complementary foods.

Rationale

Iron deficiency during infancy and childhood can have serious and irreversible effects on growth and development (Pacifici, 2016). Most healthy term infants are born with sufficient stores of iron to meet their needs until they are about six months old (DGAC, 2020). However, at about that time, iron stores are depleted, and human milk alone can no longer meet all the nutrient requirements of the rapidly growing infant (WHO, 2023a).

At this stage, along with breastfeeding, it is important to provide iron-rich foods. Both animal-based and plant-based iron-rich foods can be offered as first foods. Such foods include meat (such as beef, poultry, lamb, goat, or game), fish, legumes (such as well-cooked beans or lentils, or tofu), eggs, and iron-fortified infant cereals (DGAC, 2020; NNR, 2023; WHO, 2023a). First foods can reflect cultural preferences and food traditions. Foods must be prepared, served, and stored safely to reduce the risk of choking and prevent foodborne illness.

For many First Nations, Inuit, and Métis Peoples, traditional or country food is important for cultural and spiritual well-being (Batal et al., 2018; Caughey et al., 2021). It is important to acknowledge the diverse traditions and practices of different Indigenous communities and to understand and respect the cultural significance of Indigenous traditional or country food. Traditional or country food, including local animals (such as moose, elk, deer, caribou, muskoxen, goose, duck, ptarmigan, seal, or rabbit) or fish (such as salmon, eulachon, or trout), is a source of many nutrients, including iron (Caughey et al., 2021; FNFNES, 2019). Research shows that on days when traditional or country food is consumed, the intake of many nutrients, including iron, is higher (FNFNES, 2019; Kuhnlein et al., 2004). For Inuit, traditional or country food has been associated with a higher intake of protein and micronutrients, including iron (Caughey et al., 2021).

Infants should be introduced to complementary foods at about six months of age. The timing of the introduction of complementary foods is individual and considers an infant's signs of readiness (DGAC, 2020). The timing may be a few weeks before or just after the sixth month. Introducing solid foods too early decreases the duration of exclusive breastfeeding. Delaying the start of complementary feeding beyond six months increases the risk of iron deficiency (WHO, 2023a). It also postpones the timely introduction of potential food allergens (Lutter et al., 2021).

While other foods are introduced, breastfeeding is still the main source of nutrition. Infants should be offered iron-rich foods two or more times each day (WHO, 2023a). The amount of food offered should be guided by the infant's hunger and satiety cues (Elorriaga et al., 2021; WHO, 2023a).

Infants can be offered water from an open cup as complementary foods are introduced.

If iron-fortified infant cereal is being introduced, advise parents and caregivers to offer a variety of grains. This can reduce the infant's exposure to chemical contaminants such as arsenic. The levels of arsenic in foods sold in Canada are generally low. However, offering a variety of nutritious, complementary foods can reduce an infant's exposure.

Certain fish have been identified as being more of a concern when it comes to mercury in fish. There is specific advice for infants to limit their consumption.

In practice: Talking with families about nutrition for infants

Offering potential food allergens during the introduction of complementary foods can help prevent the development of food allergies.

  • Recommend potential food allergens be offered frequently among the first complementary foods.

Rationale

About 6% of children under the age of 18 in Canada have a probable food allergy (Clarke et al., 2020; Health Canada, 2020).

The introduction of eggs and peanuts among the first complementary foods, at about six months, is supported by evidence as an effective approach to prevent immunoglobulin E (IgE)-mediated food allergy for these foods (DGAC, 2020; Kakieu Djossi et al., 2022; Perkin et al., 2016). The evidence particularly supports this recommendation for infants at high risk of developing allergic conditions (Abrams et al., 2020). However, current consensus is that this recommendation is also beneficial for preventing IgE-mediated food allergy for infants with low risk of food allergy (CPS, 2021).

To determine that the infant is developmentally ready for solid food, iron-rich complementary foods should be introduced prior to potential food allergens (Togias et al., 2017).

Potential food allergens can be introduced on successive days. Parents and caregivers can monitor for signs of allergic reactions due to food allergies. Following the successful introduction of a potential food allergen, parents and caregivers should be advised to continue to offer it regularly, at least once a week (Abrams et al., 2023). This is to maintain the child's tolerance. To reduce the risk of choking and aspiration, these foods should also be offered in an appropriate texture and size.

Besides eggs and peanuts, there is currently not enough evidence to promote or discourage the introduction of other potential food allergens among the first complementary foods for allergy prevention. Other foods that commonly cause allergic reactions are cow's milk, wheat, soy, tree nuts, sesame and mustard seeds, fish, crustaceans and molluscs. They should be introduced in accordance with parental preferences and cultural norms. While cow's milk can be introduced as a complementary food at about six months, it should not be used as a substitute for human milk before nine to 12 months of age.

There are other conditions classified as non-IgE-mediated food allergies (Abrams et al., 2021). For more information, refer to non-IgE-mediated food allergy: evaluation and management.

In practice: Talking with families about nutrition for infants

Routine growth monitoring is important for assessing infant health and nutrition.

Rationale

In infancy, routine growth monitoring helps identify nutrition or health problems in their early stages, when corrective action is most effective (Collaborative Statement, 2010). Growth monitoring requires accurate anthropometric measurements, appropriate equipment and techniques, and consistent, accurate plotting on a growth chart appropriate for the infant's age and sex (Collaborative Statement, 2010). Serial measurements of weight, length, and head circumference should be part of scheduled 'well-baby' visits. Measurements at 'unwell' visits should be done for infants who do not attend regular 'well-baby' visits (Collaborative Statement, 2010).

The WHO Child Growth Standards are based on the growth of healthy breastfed infants living in "conditions likely to favour the achievement of their full genetic growth potential" (WHO, 2006). The Standards provide the normative growth model for how infants and young children grow regardless of their ethnic background and regardless of feeding method (Collaborative Statement, 2010).

The WHO Growth Standards have been adopted and adapted for use in Canada by the Dietitians of Canada, the Canadian Paediatric Society, the College of Family Physicians of Canada, Community Health Nurses of Canada and the Canadian Pediatric Endocrine Group. Growth charts, interpretation guides for health professionals and parent and caregiver information are available from Dietitians of Canada and the Canadian Paediatric Society.

Assessing infant growth using the WHO Growth Charts for Canada requires several measurements, taken over time. Interpretation of the growth pattern should include clinical, developmental, and behavioural assessments, as well as an assessment of feeding.

Growth monitoring is a screening tool and is one component of a primary health care assessment for infants and children. Consider all the following factors before suggesting a change to diet or invasive investigation:

Investigation and intervention should focus on identifying and addressing health or nutritional issues. If none are found, the focus should be on reassuring parents and caregivers (CPS, 2023).

In practice: Talking with families about nutrition for infants

Feeding changes are unnecessary for most common health conditions in infancy.

  • Explain that feeding changes do little to manage infantile colic.
  • Educate about the wide variation in normal bowel function, noting that true constipation is rare.
  • Reassure that reflux or regurgitation is common and rarely needs treatment.
  • Manage mild to moderate dehydration from acute gastroenteritis with continued breastfeeding and oral rehydration therapy.

Rationale

During the first six months, infants may show symptoms and behaviours that lead to unnecessary interventions. Such interventions can compromise exclusive breastfeeding. Unfortunately, many practices intended to manage common symptoms are not evidence-based and may be harmful. It is generally not beneficial to alter feeding practices, interrupt breastfeeding, supplement with formula, or restrict the diet of the person who is breastfeeding.

Health professionals should be knowledgeable about the wide variation in infant behaviours, such as crying time and frequency, consistency of bowel movements, and regurgitation. A breastfeeding assessment can help protect, promote, and support continued breastfeeding through such challenges. It can increase confidence, help with the application of cue-based feeding techniques, and recognizing when an infant is feeding well (PHAC, 2019).

Infantile colic

Infantile colic typically peaks at about six weeks of age and resolves by three to six months (Johnson et al., 2015). Infants with colic have periods of irritability, fussiness, or crying that start and stop without obvious cause and with no evidence of failure to thrive. Colic is reported to affect between 10% and 40% of infants, depending on how it is defined (Johnson et al., 2015). A commonly used definition of colic is when the parent or caregiver reports episodes lasting three or more hours a day, during at least three days of the preceding week (Zeevenhooven et al., 2017).

The etiology of infantile colic is unknown. It may have several independent causes, such as:

There is inadequate evidence that eliminating cow's milk protein, either from infant formula or from the diet of a breastfeeding mother or parent, is viable or effective (Benninga et al., 2016).

There is some evidence suggesting that Lactobacillus reuteri supplementation can be considered for reducing colic symptoms (Schneider & Sant'Anna, 2022; Zermiani et al., 2021). However, the limited evidence on the efficacy of these supplements in alleviating colic symptoms should be weighed against their financial cost (Schneider & Sant'Anna, 2022).

While infantile colic is a self-limiting condition, it can be very stressful for parents and caregivers. This often results in a variety of behavioural, nutritional, and pharmacological interventions. Few of these interventions have gone through appropriately designed trials for validation.

Health professionals should first reassure parents and caregivers that colic usually resolves by itself around four months (Johnson et al., 2015). They should provide counselling and encouragement. They should check that parents and caregivers have sufficient supports in place and refer as needed. Skin-to-skin care, cuddling, rocking, stroking, massaging, and positioning adjustments are common ways to soothe an infant with colic.

Constipation

Parents and caregivers frequently express concern over infant bowel habits. The frequency of bowel movements varies widely during infancy. In the first one or two days after birth, newborns pass meconium, which is a dark green, almost black bowel movement. After that, the stools become lighter.

Infants fed human milk have, on average, three yellow, loose bowel movements per day (den Hertog, 2012; Moretti et al., 2019). Some infants may have stooling with each feeding. After the first four to six weeks, some healthy infants fed human milk may have bowel movements as infrequently as once every three to four days or even longer (Tabbers et al., 2014).

While breastfed infants who receive adequate milk may produce infrequent stools, constipation is extremely rare (Benninga et al., 2016; Zeevenhooven et al., 2017). Bowel function is still normal, even if an infant appears to be in extreme discomfort, showing straining and reddening of the face. This wide range of 'normal' in infant stooling frequency and consistency is often misinterpreted, leading to a misdiagnosis of constipation and inappropriate intervention.

Reassure parents and caregivers that bowel function is within normal range if the infant is growing normally and there are no signs of obstruction or enterocolitis (Benninga et al., 2016; Tabbers et al., 2014). Home remedies such as corn syrup or brown sugar water are not recommended for infants younger than six months.

Reflux or regurgitation

Gastroesophageal reflux is the passage of gastric contents into the esophagus, with or without regurgitation. This normal physiologic process can occur up to several times a day in healthy infants (Zeevenhooven et al., 2017). About half of healthy three- to four-month old infants regurgitate at least once daily (Rosen et al., 2018).

Gastroesophageal reflux disease (GERD) only occurs when gastric reflux leads to symptoms or complications (Rosen et al., 2018). Most infants who regurgitate have no symptoms or complications and require no treatment. Educate and reassure parents and caregivers, stressing that breastfeeding should continue. In fact, breastfeeding exclusively is associated with less reflux compared to bottle feeding (Chen et al., 2017).

If there is concern that an infant has GERD, they should be referred to a physician experienced in its diagnosis and management.

Acute gastroenteritis

Acute gastroenteritis is diarrhea. This is defined as a decrease in the consistency (loose or liquid) of stools and/or an increase in the frequency of evacuation from what is the norm for that infant. It can occur with or without fever or vomiting (Guarino et al., 2014). In Canada, acute gastroenteritis is usually secondary to viral infections, with rotavirus being the most common cause of severe gastroenteritis (PHAC, 2023). Breastfeeding reduces the risk of gastrointestinal infections in infants (Guarino et al., 2014; Hartman et al., 2019).

Dehydration is the main concern with acute gastroenteritis. It reflects disease severity. For mild to moderate dehydration, rehydration should start as soon as possible using oral rehydration therapy (Hartman et al., 2019; Leung et al., 2006). Breastfeeding should continue during rehydration therapy, as it has been shown to reduce the severity and the duration of diarrhea from rotavirus (Guarino et al., 2014; Hossain & Mihrshahi, 2022; Leung & Hon, 2021). Infants with severe dehydration must be managed in a hospital setting with intravenous rehydration.

In practice: Talking with families about nutrition for infants

Breastfeeding is rarely contraindicated

  • Recommend breastfeeding, except for conditions that justify permanent avoidance and replacement feeding, such as when mothers and birthing parents are living with human immunodeficiency virus (HIV).
  • Recommend breastfeeding, except for conditions that justify temporary avoidance and interim replacement feeding, such as substance use, herpes lesions on breasts, and chemotherapy or radiation treatment.

Rationale

Type 1 galactosemia is one of only a few rare instances when an infant cannot tolerate human milk (BCC, 2021a; Walker, 2014; WHO & UNICEF, 2009). There are also few situations when mothers and birthing parents should avoid breastfeeding, either temporarily or permanently (BCC, 2021a; WHO & UNICEF, 2009; WHO & UNICEF, 2016; WHO, 2023b).

Conditions that may justify permanent avoidance of breastfeeding

Counselling about the risks of HIV transmission during pregnancy and lactation are an important part of early prenatal care (Khan et al., 2023).

HIV can be transmitted to an infant during breastfeeding (WHO, 2008). In Canada, permanent avoidance of breastfeeding and exclusive replacement feeding remains the preferred recommendation for feeding infants born to people living with HIV. This is because safe replacement feeding is available and it is the only strategy that completely eliminates HIV transmission risk (Khan et al., 2023). This recommendation is consistent with the WHO's recommendation in countries where suitable alternatives to breastfeeding are available (Moore & Allen, 2019; WHO & UNICEF, 2016).

Evidence shows that strict adherence to antiretroviral therapy (ART) can significantly reduce (but not eliminate) the risk of HIV transmission through breastfeeding (Khan et al., 2023; Powell et al., 2023; WHO & UNICEF, 2016; WHO, 2021b). An individualized and multi-disciplinary approach to breastfeeding under certain circumstances, which include strict adherence to ART, is emerging in many high-income countries (Khan et al., 2023). Mothers and parents living with HIV should receive patient-centered, evidence-based information to ensure informed decision-making. Those who elect to breastfeed will require comprehensive clinical care strategies for both mother and infant and ongoing support for the duration of breastfeeding (Khan et al., 2023). Currently, exclusive replacement feeding remains the preferred recommendation for infants born to women and people living with HIV in Canada (Khan et al., 2023).

Mothers and birthing parents with a Human T-cell Lymphotrophic virus type 1 or 2 infection can also pass the virus to their infant through breastfeeding, and exclusive replacement feeding is recommended (Bryan & Tadi, 2024; WHO, 2023b).

Conditions that may justify temporary avoidance of breastfeeding

Most conditions are compatible with breastfeeding, but some may require temporary replacement feeding. For example, herpes can be transmitted from lesions on the breast where they may come into contact with the infant's mouth (WHO & UNICEF, 2009). An infant should not feed from or receive milk from the affected breast until the active lesions have healed. However, an infant can breastfeed from or receive milk from an unaffected breast.

It is safe for mothers and birthing parents infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) to breastfeed. However, both viruses can be transmitted from cracked and bleeding nipples. Breastfeeding or feeding milk from the affected breast should be temporarily suspended until the nipples have healed (Bitnun & CPS, 2021; CDC, 2024; Macdonald & CPS, 2006). Breastfeeding mothers and parents with tuberculosis (TB) that is contagious should avoid close contact with the infant and not breastfeed. However, expressed milk can be fed to the infant provided there is no TB mastitis (Kimberlin et al., 2024).

When a breastfeeding mother or parent needs medications or therapies such as antimetabolites, chemotherapeutic agents, or therapy involving radiation or radioactive isotopes, they may need to temporarily avoid breastfeeding, at least for the duration of treatment (Briggs et al., 2021; Hale & Krutsch, 2023; Johnson et al., 2020; Sachs et al., 2013).

While there are some medications that are contraindicated while breastfeeding, many are safe for use because they are minimally excreted through human milk and have little to no effect on infant wellbeing or on milk production (Grueger, 2013; CDC, 2025). Most antibiotics, diabetes medications, antidepressants, and over-the-counter drugs such as acetaminophen or ibuprofen are considered safe (Briggs et al., 2021; Diabetes Canada Clinical Practice Guidelines Expert Committee et al., 2018; Hale & Krutsch, 2023; National Institute of Child Health and Human Development, 2023; Sriraman et al., 2015). If a medication is contraindicated, an alternative breastfeeding-compatible medication is often available. Healthcare providers should discuss the benefits and risks of using any medication while breastfeeding. Pseudoephedrine should be avoided as a single dose can acutely reduce milk production (National Institute of Child Health and Human Development, 2020).

While a drug may not be contraindicated for use while breastfeeding, its safety may not be fully established based on a lack of information. Healthcare providers should consult the Canadian Product Monograph, through the Drug Product Database, or other resources such as the Drugs and Lactation Database (LactMed®). The decision to discontinue breastfeeding or discontinue any medication should take into consideration the importance of the drug to the health of the breastfeeding mother or parent and the possible risk to the infant.

Parents who use substances should be supported in making informed decisions during pregnancy and breastfeeding. Substance use can have potential effects on breastfed infants and may impact the parent's ability to care for their child (Sachs et al., 2013). Wherever possible, parents should be encouraged to avoid substances while breastfeeding to minimize potential harm to the infant. If reducing or stopping substance use is challenging, healthcare providers can offer guidance on the importance of breastfeeding, and the potential risks of specific substances to the infant and milk production. Strategies to navigate these complexities should be offered in a compassionate and non-judgmental manner. Breastfeeding decisions for parents who use substances or have a substance use disorder are complicated and require a patient-centered approaches that consider the parent's and infant's health, as well as the substance involved (Harris et al., 2023). For information on specific substances during breastfeeding, refer to the Drugs and Lactation Database (LactMed®) and the French language website for the centre IMAGe (available in French only).

Breastfeeding mothers and parents should be supported to maintain lactation during a temporary interruption. Frequent effective milk expression is necessary to help maintain milk production. Milk can be expressed by hand, or using a manual or electric pump. Whatever method they use, it is important that they learn how to hand express. This is because they can do it wherever they are to relieve pressure or express milk when a pump is not available. Families should be encouraged to work with a lactation expert to develop the best care plan to support their infant feeding choice.

In practice: Talking with families about nutrition for infants

References

  1. Abrams, E. M., Hildebrand, K., Blair, B., Chan. E. S., & CPS Allergy Section. (2020). Timing of introduction of allergenic solids for infants at high risk. https://cps.ca/en/documents/position/allergenic-solids
  2. Abrams, E. M., Hildebrand, K. J., Chan, E. S., and CPS Allergy Section. (2021). Non-IgE-mediated food allergy: Evaluation and management. https://cps.ca/documents/position/non-ige-mediated-food-allergy-evaluation-and-management
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2025-08-19