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3.6 Introducing solids

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?

Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.

You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?

Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.

Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?

Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.

Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.

Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.

Is there any concern about a slowing of growth around this time?

Topic 3.5: Slowing of growth
Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.

Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?

Topic 3.6: Introducing solids
Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.

Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?

A systematic review commissioned by WHO and released in 2001 found that in most circumstances growth and nutrition of infants exclusively breastfed until six months was no different from those who had complementary foods added to their diet at four months1. In addition, there appeared to be an increase in gastrointestinal illness in infants exclusively breastfed for three instead of six months2. A recent United States study also suggests that the incidence of otitis media and respiratory infection is higher when infants are introduced to complementary foods at four months rather than six months3. The WHO, the NHMRC in Australia, the AAP and bodies throughout the world recommend, at a population level, that infants be exclusively breastfed for the first six months of life(4,5,6). Infants who are at risk of becoming deficient in micronutrients such as iron (e.g. premature infants who have limited iron stores) benefit from medicinal supplements rather than the early introduction of solids7.

After six months, breast milk alone may not provide enough energy (especially protein) for adequate growth, and deficiencies in some micronutrients such as iron and zinc may occur. Therefore, nutrient-rich foods with adequate iron content are the most appropriate solid foods at this age. In developed countries, infants aged six to eight months require approximately 130kcal/day from two or three meals of complementary food. This increases to three or four meals plus one or two nutritious snacks to provide 310 kcal/day at nine to 11 months and 580 kcal/day at 12 to 23 months. Although foods at six months tend to be pureed, mashed or semi-solid, by eight months most infants can manage finger food and by 12 months should be eating the same foods as the rest of the family7. If possible, meats should be introduced early as good sources of protein and micronutrients8. Low-fat products are not appropriate for infants or toddlers.

Notes

  1. # Kramer M et al. (2002) The optimal duration of exclusive breastfeeding. A systematic review.
  2. # Kramer M et al. (2003) Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding
  3. # Chantry CJ et al. (2006) Full breastfeeding duration and associated decrease in respiratory tract infection in US children
  4. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
  5. # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk
  6. # World Health Organization (2003) Global Strategy for Infant and Young Child Feeding
  7. # Dewey KG (2002) Guiding Principles for Complementary Feeding of the Breastfed Child
  8. # Krebs NF et al. (2007) Complementary feeding: clinically relevant factors affecting timing and composition