This submission has been prepared by the Victorian Association of Maternal and Child Health Nurses
The National Health and Medical Research Council Infant Feeding Guidelines are valued and used by Maternal and Child Health Nurse as well as other health professionals working in different settings. The guidelines provide validity to recommendations given to parents and health workers appreciate the ability to access evidenced based information to guide practice.
It is opportune to thank the NHMRC for their commitment to this work and acknowledge that review of these guidelines is a complex and lengthy task and we welcome the ability to provide feedback and comment on the draft. This review provided the opportunity to update the guidelines using new and current evidence and best practice and to improve the usability of the document.
The feedback provided has been offered in two sections, general comments on the overall structure and then more specific suggestions and points of clarification.
Breastfeeding:
The recommendation on exclusive BF seems softer than previous guidelines and the targets have been removed. To inform consistent national policy, review and evaluation, it is recommended that specific national breastfeeding targets for infants are included. In the 2003 edition of the
Infant Feeding Guidelines for Health Workers, aspirational breastfeeding targets were included. The current recommendation does not match the current World Health Organisation (WHO) recommendation of exclusive breastfeeding to six months and continued breastfeeding to 2 years and beyond.
Structure:
To move the contents/index, recommendation table and definitions to the front of the document, followed by the Summary and recommendations section.
Chapter 3 Breastfeeding in the early days includes information about older babies this would be better labelled Breastfeeding with sub heading and include low birth weight (6.6) information in this section. Also include a sub heading on mothers which could include Young mothers, Women and
Paid Work (currently in a chapter which includes infectious diseases and drug use) and Postnatal depression and Mood Disorders.

Suggest including the level of evidence with each recommendation.
If there are lengthy description of conditions and treatment they could be included in an appendix.
Definitions:
Recommend the use of consistent definitions in line with other documents such as the National Breastfeeding Strategy and well accepted terminology, the addition of part time/ partially breastfeeding, non exclusive and spoon feeding is confusing and not all are included in the definitions table.
Definition of ‘supplementary feeding’ in definitions is only for 7 days and throughout the document it is used with older infants as well just need to be consistent
Consistent with other organisations such as WHO making up of formula and SUDI in relation to co-sleeping, the use of the word bassinet (not recommended).
Clear and concise recommendations
Recommendations of the NHMRC are used by health workers from different disciplines to guide parents with breastfeeding, use of formula and introduction of suitable diet. Some of the sections tend to give information and not lead to recommendation; a recommendation is preferable such as boiled water, growth charts, and use of dummy.
Other:
Recommend the use of rice milk to be included in foods not suitable for infants or that should be used with care.
Recommend that cleft lip and palate management in the guidelines, even though infants receive paediatric care other health professionals provide advice to parents caring for an infant with cleft lip and palate.
Recommend that Aboriginal and Torres Strait Islander issues should be given special consideration in the guidelines, particularly given a range of economic, social and cultural issues that may either support or limit breastfeeding rates among urban, rural and remote Aboriginal communities.
There can be particularly serious health risks of not breastfeeding, particularly in remote communities where there can be poor environmental conditions, housing, and hygiene and cost issues associated with using infant formula. Health Workers need to be aware of these issues.

Recommend that there is an expanded section included focussing on ‘Nutrition in the second year of life’. Early life is a critical period in developing children’s food preferences and eating behaviour which can shape healthy weight status outcomes in context of the current obesogenic environment. The second year of life can be particularly challenging for parents and care givers, requiring guidance on managing ‘normal’ toddler developmental issues such as ‘fussy eating’, ‘food fads’, fluctuating appetites and food refusal.
Specific comments:
Page/s no.
Pg. 4
5
5
3-12
18
7
7
Topic Comment
Breastfeeding Pg.4 list benefits in order of evidence strength (ie move “It is probable that infants that are exclusively breastfed experience less
morbidity from GI infection (Grade B)” up higher in the paragraph to be grouped with other Grade B statements. Alternatively may improve readability to use a table for this information.
Pg 4 Add an evidence grading to the statement “Breastfeeding infants have improved cognitive development (Kramer Aboud et al
.2008) to ensure consistency
Inconsistency of top line recommendations (pages 3-12) as to whether or not levels of evidence upon which they are based on is listed eg. fruit juices, colic, constipation etc
First Recommendation Suggest replacing 'encourage' with 'Advocate' as encourage is not a strong word last recommendation Include ‘discourage use of formula when not clinically indicated'
Summary and
Recommendations
If this section is to be regarded as a quick reference it is suggested this be stated in the opening paragraph and reference to more detail information (later in the document) be included.
Recommendation
Tables
When infant is not receiving breastmilk, recommendations dot point one
When infant is not receiving breastmilk, recommendations dot point 5
The formatting of this table is not sequential. It would be preferable if this summary of recommendations was placed at the beginning of the relevant chapter.
Inform parents of benefits of breastfeeding
Recommendation: to include in that sentence health and wellbeing benefits of breastfeeding and risks of artificially feeding.
Recommendation replace with wording such as educate parents on the importance of correctly preparing infant formula and following the instructions carefully including using the correct scoop and not overfilling the scoop.

7-8
7
8
8
8
Other fluids in infant feeding
Juice
Boiled water
Other fluids in infant feeding, recommendations last
2 dot points
Transition to solid foods at around the age of 6 months/22-26 weeks.
After 12 months
Toddler formula milks
Role of breastfeeding
The transition to solids foods
Infant developmental
The Victorian Government recommends as part of it’s range of healthy eating consumer tip sheets (‘Why no sweet drinks for children’ www.betterhealth.vic.gov.au) that sweet drinks, including all fruit juices, soft drinks, energy drinks, cordials, flavoured mineral waters and sports drinks either bought or home-made are not necessary and may cause health problems if drunk in large amounts. http://www.eduweb.vic.gov.au/edulibrary/public/earlychildhood/mch/why_no_sweet_drinks.pdf
It is disappointing therefore that in the current draft of the guidelines the advice in respect to the use of fruit juice is only to ‘limit’ over the age of 6 months. It is well recognised that babies and children prefer sweet tasting fluids. By early introduction of fruit juice a child learns the ‘habit’ of drinking sweet drinks. The guidelines should emphasise that children should be encouraged to drink water, milk and eat fresh fruit and vegetables instead of juice.
Dot point 1) Suggest you also put cooled boiled water
Provide evidence of why boiled water is needed after 6 months given solids introduced and many infants moving around and inserting unsterilized object in their mouth. A requirement for ‘boiled’ water may actually discourage caregivers providing water if not a convenient and easy option. Include information on fluoride.
Pasteurized milk: when weaning onto full strength milk is there any evidence to wean slowly or dilution of cow’s milk which seems to be the practise in some states. Parents often ask how to do this?
22-26 weeks is 5-6 months which is not around 6 months, inclusion of this time frame will lead to introduction of solids at an earlier age, and this is also not consistent with a recommendation of breast feeding to around 6 months.
Dot point 2: recommends some vegetables, which?
Include recommendation here that ‘Toddler formula milks and infant formula are not necessary” (to be consistent with information on page 115)
Add a statement of the role of breastfeeding after 12 months
A statement is needed about developmental signs of readiness for solids.
Suggest adding a statement around ‘parents provide food and child decides how much’, in reference to an infant’s innate ability

8
9
9,
21,134
10
11, 23
39 readiness
Spoon foods to control how much they eat. It is important for parents to understand infant satiety cues.
The use of ‘spoon foods’ throughout the document is not preferable. The term ‘spoon foods’ negates the value of fingers foods, as well as tasting and sharing family foods that are important developmentally and socially when introducing new foods into a baby’s diet. The term ‘spoon foods’ also shifts the locus of control to the caregiver who is manipulating the spoon. Considering the developmental readiness of an infant around 6 months of age , there is value in encouraging an infant to have some control over their own food intake through maximising opportunities to use their fingers, in addition to being fed from a spoon.
Question whether it is appropriate to ensure that foods are of an ‘.acceptable texture and taste’. given that the introduction of solids is all about learning new tastes, rather than expecting that an infant will like everything they taste initially. Also a parental
‘taste’ is not necessarily the same as an infant ‘taste’.
Summary & recommendations section
Concept of taste
Food allergies
Caring for infants food
Recommendation
Recommend clarification around rate and a level of guidance for parents in order to prevent delay and possible deficiencies.
'Ensure parents are given written information and provided with education regarding proper preparation and storage of infant food'
Include hand washing
Honey for ‘infants’ less than 12 months or 2 years? If honey is not recommended under 2 years it needs to be stated at each point where use of honey is discussed.
Caring for Infants’ food, recommendations dot point two
Constipation
Diarrhoeal disease, dot point two
Allergy, asthma and breastfeeding
Not enough information, this is a concern of parents what’s normal what’s not. Maternal and Child Health often answer questions related to constipation.
Recommendation: to define constipation (has been done later in the document)
Colic baby also appears in this section and page 68 under ‘infant behaviour’ and page 87 the ‘crying infant’. This unsettled behaviour by infants causes parents distress and often leads to loss of confidence in breastfeeding. Maternal and Child Health
Nurses report much of parents concern in the early weeks is about breastfeeding issues and crying/unsettled and/or distressed infant.
Add health professional such as Maternal and Child Health Nurse
Early re-feeding is confusing which type of feeding, what does that mean, is restricted feeding recommended and if so breast or formula? Needs more information if restricted feeding is recommended.
Need to include diligent hand washing and frequent nappy changing as a dot point
‘for infants with strong history of atopy, standard infant formulas are recommended, on medical advice’, what does these sentence mean, to seek medical advice? Should include health professionals?

41
44-50
47
50
2
60
62 and
63 64
63, 73
65
66
66
Obesity
Protection, promotional and support of breastfeeding
BFHI 10 steps
Reference the WA study
Hidden in the document. Should be a clearly identified separate chapter
Supporting groups
Following discharge from hospital, support particularly from community midwives and LC’s may be beneficial.
Attaching and positioning at the breast the key to successful breastfeeding
First BF and sleepy infant
The natural patterns of breastfeeding, second paragraph last sentence
Unrealistic expectations
The effects of bottle and pacifier use, second paragraph, last sentence
The effects of giving
These should be highlighted separately and not buried in the document ie. appendix
Step 4 has been replaced with: ‘Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognise when their babies are ready to breastfeed, offering help if needed.’ If this is not yet passed by WHO then reference to the proposed change be made.
Include BFHI 7 community steps (accreditation being trialled in Australia)
Also comment on the paediatric BFHI steps where Australia is up to with these.
Consider cultural information here CALD family
Note, in Victoria, Maternal and Child Health nurses are also qualified midwives, include Maternal Child and Family Health Nurses
This information is the same as the previous guidelines and does not reflect contemporary language and practice. Some of the information is too prescriptive such as sit in upright. There are other references that could be used such as Australian
Breastfeeding Association. Baby led attachment and the importance of skin to skin should be included.
Is the baby ready for the feed - how can you tell , also perhaps give evidence of the long sleep that can occur after birth , strategy for sleepy baby to include jaundice
‘Any breastfeeding problems, either observed during the assessment or anticipated, should be attended before discharge’ What is the potential implication for liability of health services and what does ‘attended to before discharge’ mean?
Include frequent feeding is normal for infants is this a recommendation?
Refer SIDS and kids for current evidence and recommendations.
The recommendation in obtaining permission appears later page 113, add link?

68
69
69
70
70
70
72
73, 63
79
81 supplementary feeds, second last paragraph
Co sleeping
Feeding patterns
Urine output
Percentile growth reference charts
Refer SIDS and kids for current evidence and recommendations.
Recommendation: to add a sentence about the importance of frequency breastfeeding in the early weeks establishes supply and the importance of night time feeds
Include peak time to feed due to higher level of prolactin at 2am. ( give evidence)
Distinguish between cloth and disposable nappies (most parents would not change a disposable nappy 6 times a day for urine alone)
Urine outputs – include, urates can be seen in the early
Would like to see a clear recommendation; the CDC web site recommend use of the WHO codes for the first 2 years and then the
CDC from age of 2 years. Victoria has introduced the WHO growth charts to 2 yrs and CDC thereafter in the new My Health and
Development Record
This section focuses on weight only. Recognition of other important growth parameters including height/length and head circumference need to be included.
Needs to be definite, should be assessed using a 4 week average maybe comment on not taking weighs in isolation to longer time period.
Percentile Growth
Charts
‘In general, weight gain should be assessed on a 4 week average’...
Breastfeeding:
Common Problems and their management
Nipple pain and trauma
This section contains little detail in some problems and detailed treatment is other areas. Specific information on the impact on breastfeeding should be included first and then more detailed information contained in the appendix.
‘before leaving the hospital the breastfeeding mother should be able to position the baby correctly at the breast with no pain during the feeding.’
What implications does this have for health services?
Using tea bags is this a recommendation?
What is clear identification? ‘Clear identification of cutaneous Candidiasis warrants tropical treatment’
4.9 Too little milk’.
The infant is fully breastfed - that is, receiving no other fluids or solids - and producing six to eight very wet nappies
Very- difficult to define
This is a lot of urine and difficult to ensure.

83
87
94
97
109
115
81
82
111
117
Too little milk, last paragraph
‘Test weighing’ was not included in the last guidelines and has in the past been thought to be problematic given the individual nature of the mother infant feeding dyad, is this now a recommendation?
Supply lines – mothers and infants requiring this intervention should be monitored by a professional trained to use the equipment include would be prescribed. The use of galactogogues.
These drugs have been approved as galactogogues in
Australia and any use would be ‘off the label’.
Post natal depression and mood disorders
Regurgitation and
This should be specific information PND related to breastfeeding first, further information screening (is screening appropriate to a feeding guideline) and treatment could contained in an appendix. gastro-oesophageal reflux
This information should also be specific to GOR and breastfeeding with further information and treatment options contained in an appendix. Refer to SIDS and Kids for current evidence relating to this.
Expressing breastmilk There is an increasing trend for women to leave maternity services expressing breastmilk. Initial research in the La Trobe
University MILC study shows this number is significant http://www.latrobe.edu.au/mchr/html/perinatal.html#06
Electric pumps, dot point 7 & 9
Information on indicators and expressing in the early days needs comment/recommendation.
‘Required amount’ what does that mean and how is that determined?
Caffeinated beverages Include a warning about coke cola and energy drinks such as red bull as they contain significant amounts of caffeine similar to coffee.
Infant formula Concern around the following sentence ‘Interchange between formulas within the same generic group is optional and can be
decided on the basis of cost’. At a practical level there can be problems in interchanging between formulas as different brands of
Toddler formula formula have different sized scoops and directions for preparation.
While there is one sentence at the end of paragraph 2 on page 115 stating “Toddler formula milks are not necessary”, this issue is deserving of greater attention and should be considered as a ‘recommendation’ in the guidelines. Toddler formula products are not nutritionally necessary over regular cow’s milk in a healthy toddler’s diet, and are expensive and being heavily marketed to
Breastfeeding and work, dot points
Preparation of infant formula parents.
Include the option that mother breastfeeding and returning to work that older infants can continue to receive only breastfeeds without the need for expressing or formula and receive water and solids while mother at work
The WHO recommendation on preparing formula requires a statement. Is there a recommendation not to follow the WHO guidelines and if so why? This is a contentious issue and requires further explanation.

124
130-2
134
135
136
Fluoride in infant feeding
‘all water used to prepare…..be’ suggesting moving this sentence to the end of that paragraph.
Introduction of Solids This is a significant change since the 2003 guidelines and requires more explanation to guide health professionals
Recommend clarification around the rate and boundaries to guide parents and prevent delay and possible deficiencies
Recommend detailing what is meant by ‘iron containing foods’. There should be more mention of non-meat sources of iron that are appropriate to introduce to infants, particularly ‘legumes’, which are missing from any mention throughout the whole document.
Food not suitable for infants
Fruit juice
Goats milk
Table iX- Developmental stages and examples of foods- aspects of this table do not correspond with new recommendations eg. 8-
12 months egg yolk suggested. What about egg white? Should there be a distinction given new evidence on allergies?
Addition of a statement or recommendation at the beginning of each topic, such nuts are not recommended until age 3 then a short discussion of why not.
Include use of rice milk in this section Add recommendations
Recommendation first such as; fruit juice is not recommended as it offers no nutritional benefit, this section is too long.
Start with a statement about goats milk formula followed by a statement fresh goats milk is not recommended followed by the reason. This section is too long ‘as above’
On behalf of the Victorian Association of Maternal & Child Health Nurses, thank you for the opportunity to provide feedback and we hope that you will consider our comments.
Joanne Fittock
President
Victorian Association of Maternal & Child Health Nurses