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Draft nutrition for healthy term infants - Recommendations from birth to six months: Talking to families about infant nutrition

In practice: Talking with families about nutrition for infants

Infant-led (cue-based) feeding

Breastfeeding is a system of demand and supply. Infant-led, or cue-based, feeding supports good milk production and flow (PHAC, 2019). Mothers and parents should avoid timed feedings and restricting or delaying feedings (Kent et al., 2006). The goal in infant-led feeding is for mothers and parents to recognize and respond to the infant's appetite, hunger, and fullness cues. Hunger cues include restlessness, rooting, or sucking on a hand.

Infants who are fed when they are hungry and suckling effectively will get what they need for satisfactory growth. Infant-led breastfeeding encourages infants to regulate their intake and may protect against the tendency to over-feed in late infancy (Li et al., 2010).

Dietary advice for breastfeeding mothers and parents

Diet quality is important for mothers' and parents' health and energy. However, the day-to-day quality of the diet does not affect milk production, and it has little effect on milk composition for most nutrients. This is because milk composition relies mainly on the breastfeeding mother's or parent's nutrient stores (Wambach & Spencer, 2021). While breastfeeding, they should consume more food to conserve their nutrient stores. They should drink enough fluids to satisfy their thirst. Breastfeeding mothers and parents can meet their nutritional needs with a balanced diet. Refer them to the information on healthy eating when breastfeeding in Canada's food guide.

Breastfeeding mothers and parents should not go on severe diets for weight loss while breastfeeding. Rapid weight loss can reduce their milk supply (Wambach & Spencer, 2021).

There is no evidence that breastfeeding mothers and parents can prevent food allergies in infants by restricting, or including, particular foods from their own diet (Benninga et al., 2016; CPS, 2021; Greer et al., 2019; Halken et al., 2021). Nor can this practice help treat conditions like colic (Benninga et al., 2016).

Breastfeeding support: Indigenous mothers and parents and traditional practices

Indigenous communities have a long history of supporting breastfeeding mothers and parents as well as their families. Before commercial infant formula became widely available, Indigenous mothers and parents traditionally breastfed their infants. Today, Indigenous mothers have the lowest initiation and duration rates (PHAC, 2022).

There are a number of historical and social factors that may make it challenging for Indigenous mothers and parents to breastfeed, including discrimination and racism in health care, the residential school experience which interfered with sharing traditional breastfeeding knowledge, and colonization.

Health professionals should support Indigenous mothers and parents who want to incorporate traditional practices when breastfeeding. It is important to recognize that not all Indigenous groups or individuals have the same beliefs and traditions. Find out if there are any specific breastfeeding traditions and if their families and friends can provide teachings about these traditions.

Ask if they would like to be linked to breastfeeding supports in their community, if available. For example, they may wish to speak to a Knowledge Keeper or Elder with lived experience who can offer comfort, support, and teachings. Other options include connecting them with breastfeeding peers, inviting them to attend breastfeeding classes, and offering one-on-one support.

Many Indigenous communities have breastfeeding sharing circles, where Elders and mentors can teach breastfeeding mothers and parents. Many Indigenous communities have created their own resources to support them and their families, based on the wisdom and experience of community Elders.

Breastfeeding support: milk supply

A common reason that mothers and parents give for stopping breastfeeding early is a perceived lack of milk. In a national survey, 42.5% of those who stopped before six months reported "not enough breastmilk" as the reason (PHAC, 2022). Biological studies, however, suggest that less than five percent of breastfeeding mothers and parents are unable to produce enough milk to meet the nutritional needs of their infant (Ricci et al., 2023).

Supporting mothers and parents in establishing their milk supply is critical for success with breastfeeding. Immediate skin-to-skin contact, and early initiation of breastfeeding, should take place in tandem for optimal benefit. Immediate and uninterrupted skin-to-skin contact facilitates the newborn's natural rooting reflex that helps to imprint the behaviour of looking for the breast and suckling at the breast, which will trigger the milk production (WHO & UNICEF, 2018).

If parents and caregivers intend to 'mix feed' (combine breastfeeding and feeding with human milk substitutes), counsel them on the importance of exclusive breastfeeding in the first few weeks after birth. This establishes the milk supply and ensures that the infant is able to suckle and get milk from the breast (WHO & UNICEF, 2018). Giving newborns any foods or fluids other than human milk in the first few days after birth interferes with human milk production. A newborn's small stomach is easily filled when fed other fluids. They will suckle less vigorously at the breast and thus inefficiently stimulate milk production. This cycle of insufficient milk and increasing supplementation can lead to breastfeeding challenges (WHO & UNICEF, 2018).

Help parents and caregivers understand normal infant behaviours, such as changes in the frequency of feedings. A young infant can show hunger cues eight or more times in 24 hours. Ensure they can access reliable community health services and supports when common challenges or questions arise.

Breastfeeding support: points of contact with expectant and new parents

Health professionals have a responsibility to provide parents with accurate, evidence-based information on infant feeding. Ask to build on what they already know. Tailor the discussion to their individual needs. Clarify any myths or misunderstandings. Identify sources of anxiety or information gaps to help them make informed infant feeding decisions (Haiek et al., 2021).

The critical times for education and support related to decisions about infant feeding include:

With prospective parents, explore their attitudes, values, and beliefs about infant feeding. Explain what is known about the protection conferred by breastfeeding and the risks of not breastfeeding. The health professional's approach when talking with families is critical to outcomes.

At the first and subsequent prenatal visits, ask expectant parents about their infant feeding plans using open-ended questions, such as "What do you know about breastfeeding?". Provide written information, such as 10 great reasons to breastfeed your baby, which explains its importance to both the mother or parent and the infant. For those who say they do not intend to breastfeed, explore their attitudes and beliefs and talk about the importance of breastfeeding even for a short period (WHO & UNICEF, 2018). Support them in making and implementing their decision.

At the time of birth, facilitate immediate (within five minutes) and uninterrupted skin-to-skin contact for one hour or longer. Support mothers and parents to respond to the infant's cues to initiate breastfeeding within the first hour after birth. Promote and support mother-infant togetherness and support exclusive breastfeeding, unless human milk substitutes are medically indicated.

Before discharge, support parents to maintain breastfeeding and manage common difficulties. Continue to support parent-infant togetherness. Encourage responsive, cue-based feeding for infants. Discuss the use and effects of feeding bottles, artificial nipples, and pacifiers with parents.

At discharge and in community health services, provide a seamless transition between the services provided in hospital and those available in community health and peer-support programs. Provide information on resources and supports for breastfeeding in the community. Contact by a health care provider should be made with the family within 48 hours of discharge.

Support exclusive breastfeeding for six months, unless supplements are medically indicated. Advise parents and caregivers to introduce appropriate complementary foods when the infant shows signs of readiness at about six months of age. After solids are initiated, encourage sustained breastfeeding to two years and beyond.

Breastfeeding support: resources for breastfeeding mothers and parents

Facilities providing maternity and newborn services should be able to refer families to professionals, peers, and virtual resources with the core competencies to protect, promote, and support breastfeeding. This helps parents and infants as they transition from the hospital to community health services (WHO & UNICEF, 2018).

Community resources for continued and consistent breastfeeding support include primary health care centres, community and public health programs, breastfeeding clinics, nurses and midwives, lactation consultants, dietitians, home visitors, peer counselors, support groups, and phone lines. These resources can offer support that is culturally and socially sensitive to the needs of families (WHO & UNICEF, 2018).

Peer support groups and community networks, such as La Leche League Canada, give families the opportunity to share breastfeeding practices and experiences. Such groups and networks can enhance their knowledge and confidence about breastfeeding (Rodríguez-Gallego et al., 2021).

International Board-Certified Lactation Consultants and public health nurses provide support in the community to parents with well-baby visits, home and virtual visits, counselling, breastfeeding clinics, telephone counselling, and resource referrals.

Community health programs, such as the Canada Prenatal Nutrition Program, provide breastfeeding education and support, and have also been shown to improve initiation and maintenance of breastfeeding among their participants (Health Canada & PHAC, 2021).

The community at large has a role in supporting breastfeeding 'anytime and anywhere'. Breastfeeding mothers and parents and their infants are protected from discrimination and harassment. Restrictions on breastfeeding may be grounds for complaints of discrimination on the basis of gender or sex under the Canadian Charter of Rights and Freedoms, as well as provincial and territorial human rights legislation.

Breastfeeding support: practice assessment

Health professionals working in maternity, newborn, and infant services should assess their practices in the light of the Baby-Friendly Initiative's Ten Steps to Successful Breastfeeding. You can assess your organization's practices using the Breastfeeding Committee for Canada's BFI Self Assessment tools. These quality improvement tools include patient and client surveys, staff surveys and chart audits, which relate to each of the BFI standards for hospitals and community health services.

The BCC has developed a tool specifically for health professionals working in the community setting as an addendum (PDF format) to the verification toolkit (BCC, 2020). The BCC also offers resources such as staff surveys (BCC, 2020; WHO & UNICEF, 2020).

Engaging with parents and caregivers is the key to determining the effectiveness of your practices. Regularly solicit feedback. Client surveys enable you to hear directly from parents and caregivers about the care they receive. Sample client surveys (Microsoft Word format) regarding both hospital experiences as well as experiences with breastfeeding in the community are available (BCC, 2023).

Breastfeeding support: unethical marketing of human milk substitutes

The International Code of Marketing of Breast-Milk Substitutes was adopted by the World Health Assembly (WHA) in 1981. The Code seeks to set minimum requirements for regulating the marketing of human milk substitutes and any foods or liquids marketed to replace breastfeeding. The Code also addresses feeding bottles and artificial nipples (WHO, 1981).

Marketing techniques have evolved since 1981, necessitating a series of WHA resolutions to keep the Code up to date. These resolutions provide updated information and it is important for health professionals to stay informed. UNICEF's "What I should know about the code (PDF format)" is a resource for Code implementation, compliance, and identifying violations (UNICEF, 2023a).

The following are examples of what you can do to better understand industry practices and protect families (UNICEF, 2023b):

Inclusive language

Inclusive language is crucial to fostering compassionate, family-centred care and a respectful relationship with parents and caregivers. Using inclusive language means being attentive to family preferences and respecting diverse identities. Ask families how they prefer to be identified and be open to changing the words you use. Using inclusive language can make a new parent's journey more affirming and judgement-free. Some family members may prefer she/her/hers or he/him/his. Others may prefer they/them instead. Ask them.

Gender-inclusive language includes those who identify as men, women, intersex, non-binary, or gender-fluid. Until their preference is known, consider using the words 'parent' or 'birthing parent' along with 'woman' and 'mother'.

Ask the partner or support person how they prefer to be identified. Consider using 'spouse', 'partner', and 'significant other'. Keep in mind that many families do not have a co-parent. Also, be mindful that a non-birthing parent may be chestfeeding.

Gender-inclusive terms and breastfeeding

Gender-inclusive language can help ensure that breastfeeding is inclusive of all gender identities (Bartick et al., 2021; BCC, 2021). Breastfeeding is generally considered a gender-inclusive term (Bartick et al., 2021). Other gender-inclusive terms that may be preferred by parents and caregivers include lactating, human milk feeding or chestfeeding (Bartick et al., 2021). It is important to adapt language based on individual preference.

Vitamin D supplementation and high-risk Indigenous infants

Some organizations in Canada recommend supplemental vitamin D in amounts higher than 10 µg (400 IU) per day. The Canadian Paediatric Society's First Nations, Inuit and Métis Health Committee's recommendations for preventing symptomatic vitamin D deficiency and rickets among Indigenous infants and children in Canada advise a higher amount of supplemental vitamin D for high risk Indigenous infants. These infants should be assessed by a health care provider to determine if they are at high risk of vitamin D deficiency (Irvine et al., 2022).

Results from a Canadian Paediatric Surveillance Program showed that vitamin D-deficiency rickets was mostly seen in breastfed infants and children with darker skin pigmentation who were not getting the recommended supplement (Irvine et al., 2022). A quarter of reported cases were among First Nations and Inuit infants and children (Irvine et al., 2022). There were no reports of vitamin D-deficiency rickets among children who were breastfed and given a daily vitamin D supplement of 10 µg (400 IU) (Irvine et al., 2022).

Vitamin D supplements for breastfed infants

Vitamin D supplements are sold over the counter in pharmacies and some grocery stores. A single vitamin D supplement in a liquid (drop) format is recommended for infants. Other products containing vitamin D, such as a multivitamin, are not recommended.

Vitamin D comes in two forms: vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol). Vitamins D3 and D2 appear to have similar efficacy (Health Canada, 2023). Both forms are metabolized similarly (Gallo et al., 2013).

Coverage of vitamins and minerals for infants, such as vitamin D, is available for registered First Nations and recognized Inuit through the Non-Insured Health Benefits Program. Some public insurance programs may also cover vitamin D supplements for infants. Check with the provincial or territorial health authority.

Signs of readiness for solid foods

The signs that infants are physiologically and developmentally ready include the ability to (Grenier & Leduc, 2008; NASEM, 2020):

When complementary feeding begins, breastfeeding continues on-cue. Encourage responsive feeding, paying attention to the child's hunger and satiety signals.

Iron supplementation and breastfed infants

Iron supplements are not generally needed for breastfed infants during the first six months (DGAC, 2020). However, there is a potential for the development of iron deficiency in some healthy term infants who are born with lower iron stores and exclusively breastfed (Baker et al., 2010).

Higher-risk infants include those with a birth weight of less than 3000 grams. Also at risk are those born to mothers and birthing parents who are iron-deficient, have diabetes, or who consumed excess alcohol during pregnancy (Berglund et al., 2010; Pacifici, 2016; Rodolaki et al., 2023; WHO, 2023a; Yang et al., 2009).

Case-selecting infants for testing is a way to assess those who may benefit from supplementation with oral iron drops before six months of age.

Infants at high risk for food allergies

Infants at high risk of IgE-mediated food allergy are defined as having either a personal history of atopy or a first-degree relative (a parent or sibling) with an atopic condition. Such conditions include eczema, food allergy, allergic rhinitis, or asthma. For guidance on introducing allergenic foods to high risk infants see CPS Position Paper Dietary exposures and allergy prevention in high-risk infants.

Breastfed infants tracking low or high on the growth chart

Parents and caregivers need reassurance and confidence that their infant is breastfeeding well and growing normally. "Not enough breastmilk" is the most common reason mothers and parents give for stopping breastfeeding (PHAC, 2022). Insufficient milk production, however, is rare. In most cases, the lack of milk is perceived rather than real (Gatti, 2008; Lewallen et al., 2006; Ricci et al., 2023; Thulier & Mercer, 2009).

In the first two weeks, newborns experience normal weight decline and recovery (Macdonald et al., 2003; WHO, 2009). During this initial period, a trained professional, such as a maternal-child or public health nurse, midwife, or International Board-Certified Lactation Consultant, can observe breastfeeding technique and assess latch or other suspected problems.

After the first couple of weeks, once they have regained their birth weight, steady weight gain is a good indicator of the adequacy of an infant's intake.

Parents and caregivers can also be confident that, when a breastfed infant's growth is tracking high, it is normal growth. Infants should be fed to their hunger and satiety cues, and not to any other goals, such as a percentile on a growth chart. It is not possible to overfeed a breastfed infant (PHAC, 2019).

Proper growth monitoring and assessment using the WHO Growth Charts for Canada can help confirm an infant's healthy growth and development. Or, it can help with the early detection of a nutrition or health-related issue (DC & CPS, 2014).

Jaundice and breastfeeding

An infant with jaundice should generally continue to be breastfed. Jaundice presents as a yellow colouration of the infant's sclera and skin. It is caused by increased bilirubin levels in the body. It is common during the first few days after birth.

Very high levels of jaundice can lead to permanent neurological damage, but early interventions can be very effective (Ng et al., 2025). Several factors can cause jaundice including hemolysis, infections, and liver and metabolic diseases.

In the first days after birth, some infants develop jaundice if there is trouble with the initiation of breastfeeding or the supply of human milk is low. All jaundiced infants should be assessed by an experienced health professional to determine the cause and decide if the level of jaundice requires therapy.

Up to 15% of breastfed infants will display jaundice related to human milk feeding in the second and third week. This can persist for several weeks (Fawaz et al., 2017). Any infant with jaundice at two to three weeks of age should be promptly referred for evaluation by an experienced health professional. This is to ensure there is no other cause for the persistent jaundice, such as hemolysis, metabolic problems, and biliary atresia (Fawaz et al., 2017). It is important not to assume without evaluation that the jaundice is related to human milk feeding, as other potential causes include life-threatening conditions, and early diagnosis can significantly improve outcomes.

Support mothers and parents and their infants to continue breastfeeding during the evaluation.

Herbal teas and infants

There is not enough evidence on the efficacy and safety of herbal teas to warrant their use during infancy. Some families may give herbal teas to infants to help with conditions such as colic (Zhang et al., 2011). However, the use of these products is not without risk, as they may contain pharmacologically active substances. The composition of herbal teas can also vary widely among products, and the tea preparations may also contain sugars or other ingredients. They should be used with caution when breastfeeding as they can displace human milk. Refer to Health Canada's pre-cleared information (monographs) available through Natural health products ingredients database for safety and efficacy information on specific herbal substances.

Alcohol consumption and smoking while breastfeeding

Advise breastfeeding mothers and parents that no alcohol use is the safest option for their infant (Graves et al., 2020; Paradis et al., 2023). This is especially important with newborns, because their ability to metabolize alcohol is underdeveloped (Paradis et al., 2023). Consuming alcohol can also decrease milk production and alter the milk let-down reflex (Chien et al., 2009; Giglia & Binns, 2006; Mennella & Garcia-Gomez, 2001; National Institute of Child Health and Human Development, 2023a; Paradis et al., 2023). It can also can lead to early cessation of breastfeeding as well as affect infant sleep patterns (National Institute of Child Health and Human Development, 2023a).

In addition, alcohol can impair the parent or caregiver's judgement and ability to care for their infant (Graves et al., 2020).

Alcohol enters human milk within 30 to 60 minutes of consumption (National Institute of Child Health and Human Development, 2023a; Paradis et al., 2023). The amount of alcohol in the milk is similar to the mother's or parent's blood alcohol level. Therefore, the passage of time is the only way to reduce the amount of alcohol the infant receives in the milk (Graves et al., 2020). It takes about two hours for the alcohol in one standard drink to be eliminated from the body and leave the milk (Paradis et al., 2023).

Should a breastfeeding mother or parent choose to consume alcohol, risks can be minimized if they breastfeed or express milk before having a drink, then wait at least two hours per drink before breastfeeding again (Harris et al, 2023; Meek and Noble, 2022).

Smoking tobacco while breastfeeding is associated with decreased milk production, changes in milk composition, and reduced breastfeeding rates (Macchi et al., 2021; Meek and Noble, 2022). Continuing to smoke while breastfeeding may also negatively impact infant brain development and sleep patterns in the short term (Mennella et al., 2007; Napierala et al., 2016). In addition, infants exposed to second-hand smoke are at an increased risk of sudden infant death syndrome, ear infections, acute respiratory infections, and more severe asthma (CDC, 2024). Advise breastfeeding mothers and parents to stop or reduce smoking and help them find resources to quit smoking, if they are ready to use them.

Breastfeeding remains important for an infant's health, and even mothers and parents who smoke should be encouraged to breastfeed (Harris et al., 2023; PHAC, 2019). Breastfeeding mothers and parents should receive counselling to quit smoking. If they are unable to quit smoking, advise parents and caregivers to: minimize smoking; not to smoke while breastfeeding; smoke immediately after breastfeeding to minimize the concentration of nicotine and other harmful chemicals in their milk; and not to smoke inside the home or car (Meek and Noble, 2022). Individuals in the household who smoke should go outside to smoke, and always ensure the infant is supervised in their absence (Zhang et al., 2022).

Traditional tobacco use during breastfeeding

For thousands of years, tobacco has had spiritual significance for many Indigenous Peoples in Canada. It was considered a sacred gift from the Creator and has been used traditionally in ceremonies, sacred rituals, and prayers for healing and purifying (National Collaborating Centre for Aboriginal Health, 2013).

Today, traditional tobacco still holds spiritual, cultural, and medicinal value for many Indigenous Peoples. Unlike commercial tobacco products like cigarettes, traditional tobacco is grown and dried with no additives (Ontario Health, 2025). There are many traditional uses for tobacco. Indigenous communities and individuals may have their own unique uses for the sacred medicine. It can be burned over a fire, placed on water, left on the ground, offered to the Creator in dry unaltered form, or smoked in a pipe, either by an individual or in a group.

Healthcare providers working with Indigenous communities and individuals must recognize and distinguish between traditional tobacco use and misuse of commercial tobacco (CAN-ADAPTT, 2011).

Cannabis use while breastfeeding

Cannabis legalization in Canada has heightened the need to inform parents and caregivers of the risks of cannabis use while breastfeeding. Cannabis contains a group of substances called cannabinoids, with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most well-known. While evidence is limited and more research is needed, based on available evidence, it is recommended to advise breastfeeding mothers and parents not to use cannabis. It is known that substances in cannabis are transferred from the breastfeeding mother or parent to the child and can cause them harm.

Using cannabis while breastfeeding can result in the accumulation of THC, the primary psychoactive substance in cannabis, in human milk from where it is absorbed and metabolized by the infant (Graves et al., 2022; Renard & Konefal, 2022). THC has been found in human milk several days to several weeks after the last use. The concentration of THC in human milk depends on the type or strength of cannabis used and the frequency of use (Graves et al., 2022). For that reason, it is not known when an infant can be safely breastfed without exposing them to THC (Graves et al., 2022; National Institute of Child Health and Human Development, 2023b). The human milk of the breastfeeding mother or parent who uses cannabis also contains CBD, and like THC, is detected several weeks after cannabis consumption (Bertrand, 2018; Moss et al., 2021).

Advise a breastfeeding mother or parent that the safest option is to avoid cannabis use during breastfeeding (Graves et al., 2022; Renard & Konefal, 2022). Use a non-judgemental approach to help reduce stigma and fear. Support mothers and parents to make informed decisions.

Make families aware of the risks of using cannabis while breastfeeding. Infants exposed to cannabis through human milk may become drowsy and have difficulty latching (Health Canada, 2018). This can impact how much milk they consume. Limited studies in this area show that cannabis use can reduce milk production (Josan et al., 2023) and breastfeeding duration (Crume et al., 2018). It can also negatively affect normal development of cannabis-exposed infants (Graves et al, 2022).

If breastfeeding mothers and parents are unable to stop using cannabis completely, advise them to try using less, and using it less often (Graves et al., 2022).

Regardless of mode of infant feeding, parents and caregivers should be aware of the risks of using cannabis.

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