EAT FOR HEALTH

Infant Feeding
Guidelines
SUMMARY

www.nhmrc.gov.au
www.eatforhealth.gov.au
GPO Box 1421, Canberra ACT 2601
16 Marcus Clarke Street, Canberra City ACT
T. 13 000 NHMRC (13 000 64672) or +61 2 6217 9000 F. 61 2 6217 9100 E. [email protected]

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EAT FOR HEALTH

Infant Feeding Guidelines

Information for health workers
SUMMARY

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 Commonwealth of Australia 2013

Paper-based publication
This work is copyright. You may reproduce the whole or part of this work in unaltered form for your
own personal use or, if you are part of an organisation, for internal use within your organisation,
but only if you or your organisation do not use the reproduction for any commercial purpose and
retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from
rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other
rights are reserved and you are not allowed to reproduce the whole or any part of this work in any
way (electronic or otherwise) without first being given the specific written permission from the
Commonwealth to do so. Requests and enquiries concerning reproduction and rights are to be
sent to Strategic Communications, National Health and Medical Research Council, GPO Box 1421,
Canberra ACT 2600 or via email to [email protected].
ISBN Print: 1864965819
Commonwealth of Australia 2013
Electronic document
This work is copyright. You may download, display, print and reproduce the whole or part of this work
in unaltered form for your own personal use or, if you are part of an organisation, for internal use
within your organisation, but only if you or your organisation do not use the reproduction for any
commercial purpose and retain this copyright notice and all disclaimer notices as part of that
reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this
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part of this work in any way (electronic or otherwise) without first being given the specific written
permission from the Commonwealth to do so. Requests and enquiries concerning reproduction and
rights are to be sent to Strategic Communications, National Health and Medical Research Council,
GPO Box 1421, Canberra ACT 2600 or via email to [email protected].
ISBN Online: 1864965827
NHMRC (National Health and Medical Research Council) (2013). Infant Feeding Guidelines: Summary.
Canberra: National Health and Medical Research Council.
To obtain information regarding NHMRC publications contact:
Email: [email protected]
Phone:
Toll free 13 000 NHMRC (13 000 64672) or call (02) 6217 9000
Internet: http://www.nhmrc.gov.au
NHMRC Publication reference: N56b
Published: February 2013

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contents

How to use this resource

Disclaimer 1
Overview 2
Breastfeeding 3
Promotion of supportive social and physical environments
for breastfeeding

Special considerations

When an infant is not receiving breastmilk

Other fluids in infant feeding

The transition to solid foods

10

After 12 months

12

Caring for infants food

13

Nutrition in the second year of life

14

Other aspects of infant nutrition

15

Food allergies

15

Colic 15
Constipation 16
Dietary fat

16

Dental caries

17

Diarrhoeal disease

18

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How to use this resource

This document provides a summary of the Infant Feeding Guidelines from the
NHMRCs Eat for Health Program published in 2012.
The Infant Feeding Guidelines are aimed at health workers to assist them in
providing consistent advice to the general public about breastfeeding and infant
feeding. They support optimum infant nutrition by providing a review of the
evidence, and clear evidence-based recommendations on infant feeding for
health workers.
The main recommendations for infant feeding, including the introduction of
solid food, are briefly described in this summary.
The full text of the Infant Feeding Guidelines can be downloaded from
www.eatforhealth.gov.au.

Disclaimer
The Infant Feeding Guidelines and the information in this summary are
relevant to healthy, term infants of normal birth weight (>2500g). Although
many of the principles of infant feeding described here can be applied to low
birth weight infants, specific medical advice is recommended for pre-term
and underweight infants.
This document is a general guide to appropriate practice, to be followed
subject to the clinicians judgement in each individual case.
The Infant Feeding Guidelines are designed to provide information to assist
decision-making and are based on the best information available to the date
of compilation.

Infant Feeding Guidelines: Summary

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Overview
Australia is a nation in which breastfeeding is protected, promoted, supported
and valued by the whole of society.
Breastfeeding provides major public health benefits. The nutrition and growth
of infants has an important effect on early morbidity and mortality and there
is increasing evidence of the medium and long-term effects on health. Infant
growth is now recognised as one of the influences on health and longevity
later in life and breastfeeding is the backbone of early nutrition.
All health workers should promote breastfeeding in the community and ensure
that best practice in breastfeeding is followed. When mothers choose to use
infant formula it is also best practice to provide them with all of the information
and support that they need.
The Marketing in Australia of Infant Formulas: Manufacturers and Importers
Agreement (MAIF) is based on the WHO International Code of Marketing of
Breast-milk Substitutes (the WHO Code) and provides the basis for control
of the marketing of infant formula in Australia.
Australias breastfeeding initiation
rate is good at 96%. However, only a
small proportion of women achieve
the goal of exclusively breastfeeding
to around 6 months. The role of
health workers in supporting
breastfeeding is important to further
increase Australias breastfeeding
initiation and duration rates.
This summary provides background
information and recommendations
that will help health professionals
support parents and promote the
above objectives.

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Breastfeeding
Breastfeeding is the healthiest start for infants. Breastfeeding confers protection
against infection, some chronic diseases including type 1 and type 2 diabetes,
coeliac disease and inflammatory bowel disease, is associated with lower
cardiovascular disease risk factors including high blood pressure and elevated
total and LDL cholesterol and obesity. Breastfeeding also contributes to improved
cognitive development.
There are also maternal benefits, with evidence for a reduced risk of ovarian
and breast cancer, as well as a reduced risk of developing type 2 diabetes
among women with a history of gestational diabetes.
In Australia, it is recommended that infants be exclusively breastfed until
around 6 months of age when solid foods are introduced. It is further
recommended that breastfeeding be continued until 12 months of age
and beyond, for as long as the mother and child desire.
While many mothers encounter some difficulties with breastfeeding, usually
these can be overcome with support and encouragement from health
professionals, family and community organisations. Many mothers can also
continue breastfeeding if they choose to return to work. While exclusive
breastfeeding is ideal, any amount of breastmilk is beneficial to the infant
and mother. If mothers express and store breastmilk, it is important to
follow correct procedures to ensure food safety and hygiene.

Recommendations
XX Encourage, support and promote exclusive breastfeeding
to around 6 months of age.
XX Continue breastfeeding while introducing appropriate solid
foods until 12 months of age and beyond, for as long as the
mother and child desire.
XX While breastfeeding is recommended for the first 6 to
12 months and beyond, any breastfeeding is beneficial
to the infant and mother.

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Promotion of supportive social and physical

environments for breastfeeding
The active promotion and support of breastfeeding by community health, lay
and peer organisations, primary health care services, hospitals, and workplaces
will increase the proportion of women breastfeeding (both exclusive and
non-exclusive) up to age 6 months. The implementation of the Baby Friendly
Hospital Initiative may also improve breastfeeding outcomes.
Appropriate and effective positioning at the breast and correct attachment and
milking action are vital for the efficient removal of milk from the breast without
nipple pain or trauma. Antenatal education on positioning and attachment
technique is recommended to prevent or reduce any nipple pain associated
with breastfeeding.
The use of a pacifier before 4 weeks of age may also be associated with a
reduced duration of breastfeeding (any, predominant and exclusive).

Recommendations for individuals

XX Provide antenatal information and counselling about the
benefits and practical aspects of breastfeeding (and the risks
of not breastfeeding) to all potential mothers, fathers and
primary carers.
XX Pay particular attention to positioning and attachment when
advising on breastfeeding.
XX Take steps to identify breastfeeding difficulties by asking
appropriate questions during any health-related visits with
the mother. Manage those difficulties if appropriately
qualified, or refer to a health professional for management
(e.g. lactation consultant).
XX Provide postnatal breastfeeding support information.
XX A pacifier (dummy) may be offered, while placing infant in
back-to-sleep-position, no earlier than 4 weeks of age and
after breastfeeding has been established.

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Recommendations for creating a supportive

environment
XX Promote the principles of the Baby Friendly Hospital Initiative.
XX Encourage caregivers to access community-based services
supporting breastfeeding families: such services are of
increasing importance as the length of hospital stays decrease.
XX Encourage support in the community and workplace for flexible
work schedules, suitable environments for breastfeeding,
expressing breastmilk, storage of expressed breastmilk and
child care. Encourage the use of available paid parental leave
schemes and lactation break entitlements.
XX Continue to implement the WHO International Code of
Marketing of Breast-milk Substitutes and the Marketing in
Australia of Infant Formulas: Manufacturers and Importers
Agreement and ensure that all health professionals understand
their obligations.

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Special considerations
There are very few contra-indications for breastfeeding. Maternal and paternal
smoking is negatively associated with breastfeeding duration and predominant
or exclusive breastfeeding, but smoking and environmental contaminants are
not valid reasons to stop breastfeeding. In households where smoking occurs,
infants who are breastfed have lower rates of respiratory infection.
Consumption of moderate amounts of alcohol by breastfeeding women may
be associated with increased risk of adverse infant outcomes, but moderate,
infrequent use of alcohol is not an indicator for stopping breastfeeding.
Most prescription and over-the-counter drugs, and most maternal illnesses are
not indications for discontinuing breastfeeding.

Recommendations
XX Encourage mothers, fathers, primary carers and other
household members who smoke to stop or reduce smoking
and to avoid exposing the infant to tobacco smoke. Even if
parents persist with smoking, breastfeeding remains the
best choice.
XX Advise mothers that not drinking alcohol is the safest option.
For women who choose to drink, provide advice on the
recommended maximum intake level (e.g. two standard
drinks or less in any one day) and the optimal timing of
breastfeeding in relation to intake.
XX Encourage and support mothers to avoid illicit drugs.
XX Most prescription drugs and medicines are compatible with
breastfeeding, but each case should be specifically assessed
by a health professional. Statins should not generally be
used during pregnancy or breastfeeding.
XX At present, breastfeeding is contra-indicated when a mother
is known to be HIV positive (specialist advice is needed for
each individual case).

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When an infant is not receiving breastmilk

If an infant is not breastfed or is partially breastfed, commercial infant formulas
should be used as an alternative to breastmilk until 12 months of age. It is
important to prepare and store feeds correctly.

Recommendations
XX Parents should be informed of the benefits of breastfeeding
and of the risks of not breastfeeding when a change from
breastfeeding is being considered.
XX If supplementary feeding is needed in hospital, it should
only be given for specific medical indications and with the
mothers agreement.
XX Use cows milk-based formulas until 12 months of age
(note: all infant formulas available in Australia are
iron-fortified). Use special formulas only for infants who
cannot take cows milk-based products or because of
specific medical, cultural or religious reasons (note: neither
soy nor goat milk-based formulas are suitable alternatives
for infants with allergies to cows milk-based formulas unless
used under medical supervision).
XX Specialty formulas are indicated only for infants with
confirmed pathology: health care professionals should
advise parents accordingly.
XX Educate parents on the importance of correctly preparing
infant formula and following the instructions carefully,
including using the correct scoop and not over-filling or
under-filling the scoop.
XX Infants are not at risk from C. Sakazakii when formula is
prepared with lukewarm (body temperature), previously
boiled water and fed within one hour. Infants may be at risk
when conditions allow the bacteria to multiply to harmful
levels. The problem is encountered through poor storage
practices of infant formula (not preparation).

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When an infant is not receiving breastmilk (cont)

Recommendations (cont)
XX Cows milk should not be given as the main drink to infants
under 12 months, however small amounts may be used in the
preparation of solid foods.
XX As with breastfeeding, bottle feeding according to need
is appropriate. It is important for parents to be aware that
information on formula packages recommending certain
amounts for various ages is a guide only and does not
necessarily suit every infant.

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Other fluids in infant feeding

For infants over the age of 6 months or for those who are not exclusively
breastfed, tap water is preferred (as consistent with the Australian Dietary
Guidelines) but this should be boiled and cooled for infants until 12 months
of age. Consumption of fruit juice may interfere with the intake of nutrientdense foods and fluids and increase the risk of damaging emerging teeth.
Tea, herbal teas, coffee and other beverages are of no known benefit to an
infant and could possibly be harmful.

Recommendations
XX Exclusively breastfed infants do not require additional fluids
up to 6 months of age.
XX Boil and cool any tap water that is to be given to an infant.
Plain bottled water (but not natural or sparkling mineral water
or soda water) can be used if unopened to prepare formula,
but it is not necessary.
XX A cup can be introduced at around 6 months, to teach infants
the skill of sipping from a cup.
XX Fruit juice is not necessary or recommended for infants.
Consumption may interfere with their intake of breastmilk
or infant formula.
XX Do not offer tea, herbal teas, coffee, soft drinks, cordials or
other beverages.
XX Any unmodified milk from non-human species, for example
cows, goats and sheeps milk is not suitable for human infants,
and should not be given as a main drink before 12 months.

Infant Feeding Guidelines: Summary

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The transition to solid foods

At around the age of 6 months, infants are physiologically and developmentally
ready for new foods, textures and modes of feeding, and they need more
nutrients than can be provided by breastmilk or formula alone. By 12 months of
age, a variety of nutritious foods from the Five Food Groups, as described in
the Australian Guide to Healthy Eating, is recommended.

Recommendations
XX Introduce solid foods at around 6 months, to meet the infants
increasing nutritional and developmental needs.
XX To prevent iron deficiency, iron-containing nutritious foods
are recommended to be the first foods. Iron containing foods
include iron-fortified cereals, pureed meat and poultry dishes.
Cooked plain tofu and legumes/beans are also sources of
iron. Care needs to be taken particularly with a plant-based
diet to ensure that supplies of iron are adequate. This is an
important issue because of the neuro-cognitive development
implications.
XX Foods can be introduced in any order provided iron-rich
nutritious foods are the first foods and the texture is suitable
for the infants stage of development. Cows milk products
including full-fat yoghurt, cheese and custard may be given,
but not cows milk as a main drink before 12 months.
XX Ensure that solid foods are of appropriate texture. The texture
of foods that are introduced should be suited to an infants
developmental stages, moving from pureed to lumpy to
normal textures during the 6-12 month period.
XX Avoid whole nuts and other hard foods to reduce the risk
of choking.
XX Do not add sugar or honey to infant foods as this increases
the risk of dental caries.

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The transition to solid foods (cont)

Recommendations (cont)
XX Avoid juices and sugar sweetened drinks. Limit intake of all
foods with added sugars.
XX Do not add salt to foods for infants. This is an important safety
issue as infant kidneys are immature and unable to excrete
excess salt.
XX Consumption of nutrient-poor discretionary foods with high
levels of saturated fat, added sugars, and/or added salt
(e.g. cakes, biscuits and potato chips) should be avoided.

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After 12 months
Solid foods should provide an increasing proportion of the energy intake after
12 months of age. Offering a variety of nutritious foods is likely to help meet
the need for most nutrients and provide a basis for healthy eating habits.

Recommendations
XX Pasteurised full cream milk may be introduced to a childs
diet as a drink at around 12 months of age and be continued
throughout the second year of life, and beyond. It is an
excellent source of protein, calcium and other nutrients.
Do not use unpasteurised cows or goats milk.
XX Low-fat and reduced-fat milks (skim milk and milk with
2-2.5% fat) are not recommended in the first two years
of life.
XX Soy (except fortified soy products and soy formula where
specifically indicated), and other nutritionally incomplete
alternate milks or milk substitutes (e.g. goats milk, sheeps
milk, coconut milk, almond milk) are inappropriate alternatives
to breastmilk, formula or pasteurised whole cows milk in the
first two years of life.
XX Rice and oat milk can be used after 12 months, as long as a
full-fat, fortified variety (at least 100mg of calcium per 100ml)
is used and alternative forms of protein and vitamin B12 are
included in the diet. These products are suitable when used
under health professional supervision.
XX Toddler milks and special and/or supplementary foods for
toddlers are not required for healthy children.
XX From 12 months of age and beyond, toddlers should be
consuming family foods consistent with the Australian
Dietary Guidelines.
XX Milk and other drinks should be offered in a cup rather than
a feeding bottle.

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Caring for infants food

All foods given to infants should be nutritious and be fed in a safe way. Foods
provided to an infant must be free of pathogens and of suitable quantity, size
and texture. Infants should be supervised during feeding. Propping the bottle
against the infants mouth and leaving the infant to feed from the bottle without
supervision should be avoided as the infant may fall asleep with the bottles
teat still attached to their mouth, increasing the risk of choking, ear infection
and dental caries.

Recommendations
XX Store foods safely and prepare them hygienically.
XX To prevent botulism, do not feed honey to infants aged
under 12 months.
XX To prevent salmonella poisoning, cook all eggs thoroughly
(i.e. until the white is completely set and yolk begins to thicken)
and do not use uncooked products containing raw eggs such
as home-made ice cream or mayonnaise.
XX Hard, small, round and/or sticky solid foods are not
recommended because they can cause choking and aspiration.
XX Ensure that infants and toddlers are always supervised
during feeding.
XX Avoid feeding an infant using a propped bottle.

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Nutrition in the second year of life

Healthy eating is important in the second year of life and builds on
nutritionally sound practices established in infancy. It provides the energy
and nutrients needed for growth and development; it develops a sense
of taste; an acceptance and enjoyment of different family foods;
and instils attitudes and practices that can form the basis for lifelong
health-promoting eating patterns.

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Other aspects of infant nutrition

Food allergies
Breastfeeding may be associated with a reduced risk of atopic disease in
infants with and without a family history of atopy. Introducing a variety of
solid foods around the age of 6 months is consistent with reducing the risk
of developing allergic syndromes. There is no evidence that delaying the
introduction of solid foods beyond this age reduces the risk of atopic disease.
Delay in the introduction of solid foods until after the age of 6 months is
associated with increased risk of developing allergic syndromes.
Treatment of proven food allergies involves avoiding foods known to
cause symptoms.

Recommendations
XX Encourage exclusive breastfeeding for around 6 months.
There is no particular order that is advised for the introduction
of solid foods or rate that new foods can be introduced, other
than first foods should be nutritious and iron-rich.
XX If food choices have to be restricted for medical reasons, seek
the advice of a dietitian or appropriate health care professional
to ensure that dietary intake continues to meet nutrient and
energy needs.

Colic
Changes in diets and restrictions on individual foods have had limited success
in the treatment of colic. Research into this common area of concern is ongoing,
but at this point no specific dietary recommendations for the treatment of colic
can be made.

Recommendation
XX Ensure that any dietary modification or pharmacological
intervention is safe and does not result in nutritional
deficiencies.

Infant Feeding Guidelines: Summary

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Constipation
True constipation is infrequent in breastfed infants. If parents are concerned,
they should consult an appropriate health professional.

Recommendations
XX To avoid unnecessary intervention, inform parents about the
wide variation in normal bowel function in infants (particularly
those who are breastfed). If parents are concerned, they should
consult an appropriate health professional.
XX Health professionals should check that infant formula is prepared
according to instructions (i.e. to the correct concentration).

Dietary fat
Dietary fat is an important source of energy. Some fats provide essential fatty
acids. Fat is also needed for the absorption of essential fat-soluble vitamins.

Recommendations
XX Restriction of dietary fat is not recommended during the
first two years of life because it may compromise the intake
of energy and essential fatty acids and adversely affect
growth, development, and the myelination of the central
nervous system.
XX Consumption of nutrient-poor discretionary foods with high
levels of saturated fat (e.g. cakes, biscuits and potato chips)
should be avoided.

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Dental caries
The prevalence of dental caries is lower where infants and children have access
to fluoridated water and by avoiding exposure of teeth to sugar-containing
foods and liquids. However excessive fluoride intake can cause dental fluorosis.
Frequent consumption of foods containing added sugars in childhood increases
the risk of dental caries, as does putting an infant to bed with a bottle.

Recommendations
XX Fluoride supplementation is not recommended.
XX For children between the ages of 6 months and 2 years who
are living in areas where the household water supply is not
fluoridated, seek advice from a dentist. Advice will relate to
the region or state in which the infant lives.
XX Put an infant to bed without a bottle or take the bottle away
when the infant has finished feeding or before they fall asleep;
dont let the infant keep sucking on the bottle.
XX Avoid leaving an infant unattended with a bottle containing
liquids (i.e. no bottle propping).
XX Do not dip pacifiers or bottle teats in sugar, jam, honey or any
other sugary substance.
XX Avoid juices and sugar-sweetened drinks and foods and drinks
with added sugars.
XX Dont put anything in an infants mouth if it has been in
someone elses mouth to avoid spreading bacteria that cause
dental caries.

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Diarrhoeal disease
Mild to moderate dehydration associated with gastroenteritis should be managed
with continued breastfeeding and, if required, oral rehydration therapy on the
advice of a health professional. Formula fed infants may require interruption
of formula for rehydration, but this should be resumed as soon as the infant
is rehydrated. Lactose malabsorption in formula fed infants may require use
of a low-lactose formula. Early reintroduction of food, following a bout of
gastroenteritis, is beneficial. Weight loss is the best guide to level of dehydration
and any infant suspected of suffering dehydration should be assessed by a
medical practitioner.

Recommendations
XX For breastfed infants, continue breastfeeding while
supplementing their fluid intake with an oral electrolyte
solution as necessary.
XX Manage mild to moderate dehydration with an age appropriate
oral electrolyte solution and early re-feeding.
XX For formula fed infants, it may be necessary to briefly interrupt
feeding for rehydration.
XX Any infant suspected of suffering dehydration should be
assessed by a medical practitioner.

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EAT FOR HEALTH

Infant Feeding
Guidelines
SUMMARY

www.nhmrc.gov.au
www.eatforhealth.gov.au
GPO Box 1421, Canberra ACT 2601
16 Marcus Clarke Street, Canberra City ACT
T. 13 000 NHMRC (13 000 64672) or +61 2 6217 9000 F. 61 2 6217 9100 E. [email protected]

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