School of Medicine
Senior Lecturer, Discipline of
General Practice
Dr Wendy Brodribb AM, MBBS,
IBCLC, FABM, PhD
CRICOS PROVIDER NUMBER 00025B
16 April 2020
Dear Sir/Madam,
Thank you for providing an opportunity to comment on the draft of the Infant Feeding Guidelines for Health
Workers.
I appreciate that a lot of time and effort has gone into this extensive revision.
As the President Elect of the Academy of Breastfeeding Medicine (ABM) it is pleasing to see that ABM breastfeeding protocols have been reviewed and included in the document, However, I am disappointed that it appears that no one with breastfeeding clinical expertise has been involved in writing the document or has reviewed the document prior to its release for public consultation. This omission has led to a number of errors concerning clinical breastfeeding issues, and the clinical situation in Australia.
Sincerely,
Dr Wendy Brodribb AM, MBBS, IBCLC, FABM, PhD
Senior Lecturer, Discipline of General Practice, School of Medicine, The University of Queensland
Discipline of General Practice
Level8, Health Sciences Building
Building 16/910
Royal Brisbane and Women’s Hospital
Herston QLD 4029 Australia T +61 7 33465133
F + 61 7 33465178
E w.brodribb@uq.edu.au
W: www2.som.uq.edu.au/som/OurSchool/Disc iplines/Pages/GeneralPractice.aspx

General comments
First, I recognise and acknowledge the tremendous amount of work that has gone into the revision of these guidelines and accompanying literature review. As Australia will be judged on its commitment to breastfeeding and infant feeding by the recommendations and information contained in this document, it is important that we ‘get it right’.
Goals
I would have liked some specific breastfeeding goals to be included in these guidelines so that there is something to strive towards and measure our progress against. Having a goal of 80% of infants being breastfed at 6 months has been an inspiration for researchers and clinicians to investigate ways to help women continue to breastfeed. I think it is important to restate similar goals, including a goal for breastfeeding rates at 12 months.
Recommendations
I am disappointed that the recommendations regarding breastfeeding are not stronger, especially as going research subsequent to the last edition indicates that infants who are not breastfed, and women who do not breastfeed are at increased risk for a number of conditions.
In the second paragraph of the summary where it says ‘In Australia, it is recommended that as many
infants as possible be exclusively breastfed ....Shouldn’t the recommendation be ‘that infants be
exclusively breastfed...’? Sometimes people can’t or don’t want to follow the recommendation – and that is their prerogative, but to say that ‘as many infants as possible’ waters down the recommendation. I note that the wording of this section differs from the recommendation on page 5. As many people will only read the summary, it is important that it is consistent.
I am also concerned that the recommendation on page 5 is written in such a way that people (both mothers and health professionals) take note of the ‘exclusive breastfeeding for 6 months’, and don’t read any further. They assume that 6 months is the recommended duration for breastfeeding. (I had a similar problem with the last edition as well) In addition, it is hard to know whether infants should be breastfed just until 12 months or whether longer is any better. As WHO recommends breastfeeding for at least 2 years, it would be appropriate to make it clear that breastfeeding for more the 12 months is encouraged. I would like to see more emphasis put on the duration of breastfeeding – perhaps saying:
Encourage, support and promote exclusively breastfeeding to around six months of age and continued breastfeeding for at least 12 months. Appropriate complementary foods should be introduced around 6 months. While breastfeeding is recommended for at least the first 12 months, any breastfeeding is beneficial for the infant and mother. or
Encourage, support and promote breastfeeding for at least 12 months – exclusively for around the first 6 months and then with the addition of appropriate complementary foods. While breastfeeding is recommended for at least the first 12 months, any breastfeeding is beneficial for the infant and mother.
We know that one of the most important determinants of duration of breastfeeding is the mother’s intention. To increase the mother’s duration intention we need to inform her of the recommended length of breastfeeding unambiguously. We can’t concentrate on exclusive breastfeeding to 6 months and then wonder why the rate of any breastfeeding at 12 months is dropping.
Spoon foods

The reason behind the terminology of spoon foods is not evident until section 9.1. As it is not a term usually used by clinicians or parents, it would be helpful to know earlier in the document why this terminology is being used. Perhaps always saying spoon or solid foods would assist.
Timing of the introduction of spoon or solid food
While I am happy with the concept of introducing spoon or solid foods around 6 months, I am not comfortably with the definition of around 6 months to be 22-26 weeks. 22 weeks is really just over 5 months, while 26 weeks is at 6 months. Really this recommendation is to introduce solids within the 5 th month rather than around 6 months. The WHO recommends complementary foods be introduced at 180 days (25.7 weeks) – quite a bit later than what is recommended in this document.
No other counties in the world use the definition of 22-26 weeks for ‘around 6 months’.
In addition, 22-26 weeks will not be an easy concept to relay to mothers. By the time their infants are 6 months old mothers calculate infant age in calendar months – not weeks. Therefore health professionals may well relay this recommendation to mothers to introduce solids between 5 and 6 months. From the data presented later in the document, there does not seem to be a reason to introduce spoon foods (or solids) as early as this.
However, giving a specific time (ie 180 days) does not allow for individual variations between infants and their readiness for other foods – regardless of the nutritional need. If a tighter definition is needed, I would suggest 25-27 weeks or 24 -27 weeks.
Breastfeeding ? benefits
In section 1.1 breastfeeding is noted to be the physiological norm, yet in the discussions around the differences in outcome between breastfeeding and formula feeding, formula feeding is assumed to be the norm. Consequently breastfeeding has ‘benefits’ advantages’ and ‘protects’.
Not only is breastfeeding the physiological norm, it is also the biological norm and the societal norm for at least the first 6 months of life (breastfeeding rates at 6 months are above 50%). Assuming formula feeding is the norm and the terminology subsequently used, has unexpected and often unintended consequences.
If formula feeding is seen as the infant feeding standard, breastfeeding becomes the superior product that offers extra features but is seen to be above and beyond the needs of most infants. This leads to confusion with regard to the differences between breast and formula feeding. As an example, in a study I conducted investigating the breastfeeding skills and knowledge of GP registrars, although 99% of participants thought breastfeeding was the ideal food for babies and 95% thought breastfeeding provided health benefits that could not be provided by formula, 26% thought infant formula was as healthy for an infant as breastmilk,
40% thought formula and breastmilk were nutritionally equivalent.(Brodribb, Fallon, Jackson, & Hegney,
2010) Many thought breastfeeding was better, but formula was almost just as good.
To be able to make the distinction between breastfeeding and formula feeding clearer, the language used needs to be more explicit – especially for health professional. Therefore, I recommend that the benefits of breastfeeding be reframed to the disadvantages of formula feeding throughout the document.
(Important in sections 1.1, 2.1)
Terminology
In some parts of the document the words ‘nurse’ and ‘nursing’ and ‘nursing mothers room’ are used instead of breastfeed or breastfeeding.(eg p49) These words are not synonymous in Australia, while they

are in the US. I therefore wonder if the sections with ‘nurse’ and ‘nursing’ in them are lifted from US material.
Infant is used in most places in the document, but there are some references to ‘baby’.
Use dummy rather than pacifier
There is inconsistency of let-down and milk-ejection reflex
Updated Reference
Lawrence and Lawrence have a new edition Lawrence R, Lawrence R. Breastfeeding: A guide for the medical
profession. 7th ed. Maryland Heights: Elsevier Mosby; 2011.
Summary
In para 3 and 4 of the summary there is discussion about support and encouragement for breastfeeding women. Correct information is also important. In the 3 rd para I would also add health professional to the list of people who support mothers.
Breastfeeding – (p4)
There is no mention of respiratory tract infection or otitis media here, although they are more likely to affect children than some of the other illnesses mentioned. They are listed in section 1.1.1.3
P5 para 4 another reference for dummy use is Howard et al (Howard et al., 2003)
P6 Special considerations.
It is important to include information that breastfed babies whose mothers smoke have less respiratory infection than those whose mothers do not breastfeed.(Ladomenou, Kafatos, & Galanakis, 2009;
Woodward, Douglas, Graham, & Miles, 1990)
Pg 9/10 food allergies
May want to add to add something about being best to introduce solids while the infant is still being breastfed – see page 39 where it talks about breastfeeding during the period of antigen introduction facilitates the development of oral tolerance.
Pg 12 The form of iron in breastmilk (lactoferrin) is readily absorbed. While iron binds to lactoferrin and this may aid its absorption, I have never before heard lactoferrin being referred to as the form of iron in breastmilk. There are also other factors that aid the absorption of iron. I would suggest the sentence read:
Iron in breastmilk is readily absorbed and has a high bioavailability. Maybe also add something about delayed cord clamping and iron sufficiency in mother as determinants of iron sufficiency in infants to 6 months.
1.1.1.2
There is probable evidence that infants from developing and developed countries who are exclusively breastfed for six months do not have deficits in growth compared to those who are not exclusively
breastfed. This is a very clumsy sentence. Maybe There is probable evidence that infants from developing and developed countries who are exclusively breastfed for six months grow as well as infants who are
not exclusively breastfed There is also a new reference (Nielsen et al., 2011) that adds further weight to the premise that exclusively breastfed infant grow well.

1.1.1.3
There is an error in the urinary tract infection reference.(Mårild, Hansson, Jodal, Odén, & Svedberg, 2004)
When discussing Raisler’s article, it would be worthwhile mentioning a dose relationship to the effects of breastfeeding/formula feeding.
1.1.2.2
First, I think there needs to be a distinction between using breastfeeding and lactation amenorrhoea as methods of contraception and using the Lactational Amenorrhoea Method of contraception (LAM). LAM consists of three components – amenorrhoea, fully breastfeeding and less than 6 months postpartum. Its efficacy, as stated in the document is less than 2% failure rate per year. I work as a Senior Medical Officer in
Family Planning Queensland, and LAM is listed as one of the forms of contraception suitable for postpartum women. It may not be used as frequently here as in some developing countries but to say that it is not regarded as a reliable method of contraception is not true. Many people do not know how effective it is if used correctly.
Another reference for economic benefits in Holland.(Buchner, Hoekstra, & van Rossum, 2007)
2.1
Breastfeeding should be regarded as best practice for NEARLY ALL full term infants (rather than most – there are very few infants where it would not be best practice. Most may mean the majority)
Antenatal education should include information about breastfeeding duration as well as initiation. Length of breastfeeding is often determined by mothers’ breastfeeding intention prior to the birth, so to increase the length of breastfeeding mothers’ intention must change. The idea that breastfeeding should continue for at least 12 months needs to be out there all the time.
P 52 General practitioners need to be familiar with breastfeeding. What does this mean? That they can recognise breastfeeding when they see it? GPs need at the very least a basic understanding about breastfeeding and breastfeeding related issues so that they a) can assess a woman and refer her if necessary and b) not give the wrong information. This is my area of research and expertise. Let me know if you require any further information.
2.1.1
Need to add inverted or flat nipples and nipple piercing to the list of breast characteristic to note
2.2.1
Peter Hartmann is now using the terms secretory differentiation and secretory activation rather than lactogenesis I and lactogenesis II. They are more descriptive.(Pang & Hartmann, 2007)
P53 second last sentence The secretion of prolactin ...
2.2.4 p55 para 2
Need to add postpartum haemorrhage with or without development of Sheehan’s syndrome as a cause for the delay in initiation of lactation.(Feinberg, Molitch, Endres, & Peaceman, 2005; Thompson, Heal, Roberts,
& Ellwood, 2010; Willis & Livingstone, 1995)

2.2.5 breastmilk composition
Instead of very pale, whitish-blue use opalescent – more positive connotations – many women don’t think their milk is ‘strong’ enough and these words just play into that fear.
2.2.7
Need to emphasise that even women with poor nutrition produce milk of good quality and amount. The problem is with the mother, not the milk she produces for her infant. Again many mothers say they cannot breastfeed because their diet is not good enough – so need to make it a positive recommendation.
2.2.7 Vitamin D
New studies in the MJA this year should be included in this section although the recommendations remain the same.(Stalgis-Bilinski et al., 2011)
2.2.8
There is a lot of discussion about ‘biological nurturing’ and baby led attachment with the mother reclining a little more and the infant more prone on the mother’s chest. This gives the infant good support and allows him/her to search for the nipple and attach with less interference from the mother or health professional.
Information about baby led attachment should be included in this section as well as the information already provided.(Colson, Meek, & Hawdon, 2008)
P61 2 nd para
If the baby is correctly positioned and attached and is sucking correctly there should be no nipple pain.
Pain will persist if there is another problem eg ankyloglossia etc
Maybe reverse the sentence so that
If pain persists when the infant is correctly positioned and attached, and is sucking correctly, there may be another cause for the pain (eg ankyloglossia) and expert assistance is required.
2.2.9 Signs of let-down reflex (? milk ejection)
Add depression.(Cox, 2010)
3.2 – sleepy newborn
Line 8 – even infants who are born at theoretical term (ie 37 weeks) are often sleepy.
‘If the infant does not want to feed after about five hours, he or she should be roused and put to the
breast’ – when in the postnatal course is this? ie is this the first sleep after birth and the first feed, or is it later? If it is after the first feed it may be safe for the baby to go a little longer (ie 8 hours – see QLD policy) or 5 hrs if more than 24 hrs old – but I would be concerned about leaving a baby go for 5 hours between
EVERY feed. ( www.health.qld.gov.au/qcg/documents/g_bf5-0.pdf
)
3.2.1
Include skin-to-skin contact - especially with mother semi-reclining.
Might be better to put section 3.2.2 – persistent sleepiness – before section 3.2.1 because all the strategies still work.
3.4.2 7 th line

Relatively recent research by Peter Hartmann’s group in Perth, found that lactiferous sinuses as milk filled reservoirs are not present in the breast. Gray’s Anatomy are going to change the diagrams in their book.(Ramsay, Kent, Hartmann, & Hartmann, 2005)
3.4.3
There needs to be some metion about the difference between cloth and disposable nappies. Mothers do not need to change disposable nappies as frequently and it is often difficult to know if they are soaked.
References about voids in the first week.(Nommsen-Rivers, Heinig, Cohen, & Dewey, 2008; Shrago,
Reifsnider, & Insel, 2006)
3.4.3
Bowel actions – need to discuss the fact that most breastfed babies should have at least one and ususally more than one bowel motion/day. A decrease in the number of bowel motions, or scanty stools may be the first sign of lack of breastmilk intake. (Nommsen-Rivers et al., 2008; Shrago et al., 2006)
3.4.5
Are weights given here the average? what is expected? or the level below which one should become concerned?
Also the CDC are now using the WHO growth standards and not their own growth reference charts.
4.2
There needs to be more information in this section about other important causes of nipple pain

Staph infections of the nipple (Livingstone & Stringer, 1999);

Thrush (Brent, 2001) (although there is something about thrush in the breast section it probably fits better here); and
 infant abnormalities such as ankyloglossia (Srinivasan, Dobrich, Mitnick, & Feldman, 2006) high arched palate, or high intra-oral pressures (McClellan et al., 2008)
4.2.2
Continue breastfeeding unless the pain is intolerable or, in spite of every effort, the trauma worsens. This sounds awful and the idea that a woman must continue to breastfed even if it is very very painful, is the reason why some stop breastfeeding altogether. For the vast majority of women pain should improve significantly with optimal positioning and attachment, even if there are signs of trauma. If pain is getting worse, another reason for the pain needs to be investigated. Another alternative way of saying it could be
Continue breastfeeding unless it is too painful or the nipples continue to be damaged.
4.2.3
The tricolour change of Raynaud’s phenomenon is not always apparent on the nipples, so vasospasm may be a better terminology.
The most salient physical sign is blanching of the face of the nipple.
Mothers often present with pain and do not notice the colour change. Therefore, it is important to be able to diagnose vasospasm on history and clinical exam – usually nipples are not tender to touch (unless the mother has other problem as well) and pain usually does not start at the beginning of a feed but may come on towards the end of a feed, or not be associated with the feed.

AS well as poor attachment other nipple problems such as infection can also predispose a mother to vasospasm.
Heat is often a very effective treatment – using heat pads immediately after a feed – and much more appropriate than nifedipine.
4.3
Can’t breastfeed with nipple ring in place as it damages the baby’s mouth
4.4.1
There is discussion about avoiding using nipple creams except to treat thrush, but have not discussed thrush.
To reduce the infant’s exposure , topical corticosteroids should be used only as a last resort – if a mother truely has dermatitis or eczema then often nothing else will work within a short time period. Delaying the introduction of a steroid will be detrimental to the breastfeeding relationship. Therefor adequate strength and dose of steroids should be used – sometimes these are quite powerful – but should be used judiciously and washed off before a feed.
Check this reference Royal Women's Hospital (Melbourne). Nipple eczema dermatitis. [Internet]
Melbourne: Royal Women's Hospital; 2006 Available from: http://www.thewomens.org.au/NippleEczemaDermatitis .
4.5
Engorgement also due to vasodilatation as well as milk filling.
3 rd para – the approaches may not reduce engorgement but may improve a mother’s comfort.
Also need to add mother can express off enough milk for comfort (hand expressing is best) and she may need to express so that the breast is soft enough for the baby to attach.
4.6.1
1 st para 3 rd line. Most definitions of mastitis include fever – so often fever seems a little bit odd.
Infective mastitis is cellulitis of the interlobular connective tissue. Just saying infective mastitis is cellulitis will give a very misleading idea about mastitis (ie on the skin).
Treatment of mastitis – the document should use antibiotics relevant to Australian conditions eg from.
Therapeutic guidelines: Antibiotics. 14 ed.(Antibiotic Expert Group, 2011)
They recommend dicloxacillin or flucolxacillin 500mg 6 th hrly, cephalexin 500mg 6 th hrly or clindamycin
450mg 8 th hly.
Also need to mention the risk of MRSA mastitis and breast abscess that will require different antibiotics.
4.6.3 Candida/Thrush
This section would be much better in the nipple section.
4.8 1st para
This is more common in the early days of breastfeeding because women have the potential to produce
enough milk to feed more than one infant.

Cold packs rather than ice packs (don’t have to be ice).
4.9
End of first para – remove related to maternal illness. There may be a breast abnormality or hormonal abnormality, but not necessarily an illness.
See previous comments about wet nappies and bowel motions.
The most common reason for low supply is that the mother is not feeding the baby often enough – not that there is poor attachment or feed disruptions.
Maternal under-nutrition is a very rare reason for low milk supply in our country. Having this here suggests that women who don’t have a good diet cannot breastfeed.
Need to discuss the pros and cons of test weigh and emphasise that a one off test weigh, especially with inaccurate scales, is unlikely to be indicative of the mothers’ milk supply or the infant’s milk transfer. If a test weight is going to be done, it should probably be over a 24 hour period with accurate scales as suggested. Test weighing is used a lot more in the US (Powers ref) than in Australia with no apparent negative consequences for us here.
Management
The list of signs and symptoms needs to be more defined eg what is scant urine production or infrequent urination, and infrequent stools – need to have a level that would cause concern.
Encourage good maternal nutrition and rest
I don’t think there is any good research that improving a mothers diet will increase her milk supply. Many women produce sufficient milk in very poor nutritional circumstances. There is no evidence that increasing a mother’s fluid intake will increase her milk supply either. She should drink to thirst rather than being told she has to have a drink every time she feeds.(Dusdieker, Stumbo, Booth, & Wilmoth, 1990; Morse, Ewing,
Gamble, & Donahue, 1992)
8 th dot point. Supply line is no longer available ‘supplemental nursing system’ or a breastfeeding supplementer
4.10
The sentence Postnatal depression is most commonly assessed using the Edinburgh Postnatal Depression
Scale should go after the next sentence, and then the following one changed. I don’t think that the EPNDS tests for postpartum psychosis.
2 nd para 3 rd -4 th line. Postnatal depression as beginning within the first 12 weeks of birth – not occurring within the first 12 weeks. It sounds as though it is all over by 12 weeks. May have to change the next sentence because it really does not gel.
4.10.2
P 86 Most women with PND in Australia are treated in general practice and do not need to seek expert psychiatric care.
Hormones are not routinely or commonly used to treat PND and would be deleterious to breastfeeding. I note the studies that have looked at the use of oestrogens – but at this point they are not routine treatments.

http://www.australianprescriber.com/magazine/31/2/36/9 by Anne Buist does not mention hormones and talks about GPs being the mainstay of treatment in Australia
Postpartum depression: an essential overview for the practitioner. [Review] by Breese McCoy SJ. Southern
Medical Journal. 104(2):128-32, 2011 Feb also does not discuss hormones
The use of pharmacotherapy needs to be weighed against potential risks to the breastfeeding infant (need to somehow also add the risk of not breastfeeding too)
Despite these known and potential risks, it is worthwhile encouraging breastfeeding to mothers with postpartum depression. (rather than promoting)
4.13 Gastro-oesophageal reflux
There is a difference between GOR – and GORD (gastro-oesophageal reflux disease) which often presents with crying and feeding refusal. I think it is important to make this distinction - ie most infants with GOR just vomit and that is fine. The problems come when there are complications from the GOR – in particular oesophagitis that is the entity that distresses mothers the most because of ongoing crying.
It would be worthwhile mentioning the relationship between cow’s milk allergy and GOR/D.(Cavataio et al.,
1996; Hill et al., 2000; Iacono et al., 1996)
4.16 Ankyloglossia
There is no mention here of the main problem of ankyloglossia – damaged nipples that do not respond to optimal positioning and attachment. In fact snipping the tongue-tie is becoming a very common procedure and has ‘saved’ many breastfeeding mothers and babies. There is now a randomised trial on tongue tie release,(Buryk, Bloom, & Shope, 2011) and another two reviews (Cho, Kelsberg, & Safranek, 2010;
Edmunds, Miles, & Fulbrook, 2011)
5.1.3
I don’t think there is a need to say –continue until half the milk required has been expressed, and then change to the other side. Women express in a number of different ways, and there is no one right way.
For example, some women will express as much as possible from one side while feeding the baby from the other side so that she can store the milk for a specific reason.
5.3.2
Is milk ‘sterile’? When tested it often has some bacterial growth, but it also contains antibacterial properties so that there is less bacterial contamination in milk that has sat on the bench for an hour or so, than straight after expression.
6 - Breastfeeding in specific situations
There is inconsistency between the information given in the introduction to this section and in section 6.1
For example, phenylketonuria is listed as a condition that infants should only be given special formula, yet in 6.2.1 is under relative contraindications.
There are new WHO guidelines for HIV and infant feeding .(World Health Organization, 2010)
6.1 – most of these conditions are not ABSOLUTE contraindications to breastfeeding and may be better putting most/all under the relative contraindications because for most breastfeeding can continue/start after treatment

6.1.1 UNTREATED OR ACTIVE tuberculosis – it has already been said that breastfeeding can usually continue.
Once treatment has been established and the mother has a negative sputum culture, surely the mother can then breastfeed, not just give her baby expressed breastmilk.
6.1.3 UNTREATED Syphilis (yet this is not listed in the ‘maternal conditions that may justify temporary avoidance of breastfeeding – neither is brucelloisis).
6.1.4 This heading should be chemotherapy rather than breast cancer because breast cancer itself is not the contraindication. Again in the introduction to this section it says ‘cytotoxic chemotherapy requires that the mother stops breastfeeding during therapy’
7 – Informed use of supplementary feeds in hospital
There is a new study showing that 23% of Australian babies are supplemented in hospital – although there is no guarantee that it is given as a prelacteal feed.(Biro, Sutherland, Yelland, Hardy, & Brown, 2011)
8.1 Protein levels in infant formula
In this section it says ‘have a slight increased risk of obesity in later life’ while on page 35 there is Evidence
Grade A that formula feeding leads to obesity in childhood and later life.
Other references suggest the protein content of human milk is more like 9 g/L.(M. Picciano, 2001; M. F.
Picciano, 2001)
8.4.2
The type of teat used may be different if the infant is both breast and bottle fed. One factor impacting on infants preferring the bottle to the breast is the easy flow of milk. Therefore it is often suggested that a slow flow teat is used in these situations so that the baby has to work a bit harder for the milk.
P122
The formula requirements for formula fed infants in the first few days postpartum is signficianly higher than the amount of colostrum breastfed infants receive. Do we know why? Are the figures derived from calcuations of what it is thought the infants need? Or is it worked out on what the normal physiological process is ie breastfeeding?
These figures lead to the erroneous belief that when breastfed infants have prelacteal feeds (for any reason) they are given formula in quantities much larger than the physiological need – it stretches their tummy, and then they feel they need more at each feed which then increases the liklihood of requiring further supplements.
8.5
Do all medically diagnosed conditiions have to be by a paediatrician? I am sure GPs are capable of diagnosing some medical conditions that require some specialised formula.
9 Introducing spoon (solid) food
P 127 introducing solid foods too late can also cause problems
This section sounds as though breastmilk loses all its ‘goodness’ suddenly at 6 months. While the risk of not providing sufficient energy and micronurtients is much higher after 6 months, it is not OK just before 6

months and no good just after. I am unclear why ‘immune protection can be compromised’. Is there data for breastfed children who are receiving the immunoprotecive benefits from breastmilk?
May be it could be written:

Growth can falter because breastmilk alone may be insufficient after 6 months.

Micronutrient deficinecies, especially of iron and zinc, can develop because breastmilk alone is unable to meet requirements in the later half of infancy. If infants do not receive another bioavailable source of iron from complementary foods their iron stores may become depleated.
(ref)
9.3
The Graham study was published prior to the implemenation of the recommendation to introduce solids around 6 months so it is nor relevant to the situation today. Are there any more recent studies looking at the introduction of solids?
Practical points (p 133) milk still the most important nutrient/food until 12 months
Appendix D – if the RACPs statement is here, shouldn’t the RACGPs statement also be included?
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Biro, M. A., Sutherland, G. A., Yelland, J. S., Hardy, P., & Brown, S. J. (2011). In-Hospital Formula
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Brent, N. B. (2001). Thrush in the breastfeeding dyad: results of a survey on diagnosis and treatment.
Clinical Pediatrics, 40(9), 503-506.
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Buchner, F. L., Hoekstra, J., & van Rossum, C. T. M. (2007). Health gain and ecomomic evaluation of
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Buryk, M., Bloom, D., & Shope, T. (2011). Efficacy of neonatal release of ankyloglossia: a randomized trial.
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Cavataio, F., Iacono, G., Montaito, G., Soresi, M., Tumminello, M., & Carroccio, A. (1996). Clinical and pHmetric characteristics of gastro-oesophageal reflux secondary to cow’s milk protein allergy. Arch Dis
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Dusdieker, L. B., Stumbo, P. J., Booth, B. M., & Wilmoth, R. N. (1990). Prolonged maternal fluid supplementation in breast-feeding. Pediatrics, 86(5), 737-740.
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