Infant Feeding Guidelines – Are Changes on the Way?

If you haven’t had a chance to check them out, they can be found HERE.

You may have noticed some discussion on these guidelines taking place in the RD world. There is a lot to unpack. I wanted to highlight two points from these guidelines and share my thoughts.

We were a bit taken aback by this recommendation from WHO when we first read it. Giving a 6 month-old cow’s milk as their main milk source instead of formula? Whoa.

But taking a few steps back, Health Canada has endorsed whole cow’s milk for infants from 9-12 months of age for many years now. In the US, the recommendation had been to hold off until 12 months. We’ve always found this difference in recommendations to be notable and interesting. During the COVID formula shortage, we noticed some US clinicians pointing to the Canadian guidelines as an option to consider if formula was unavailable.

With the new WHO guidelines, remember, these are global recommendations. This includes countries where there may be concerns such as the quality of water available to mix formula. Is the risk associated with contaminated water higher than the risk of feeding cow’s milk in younger infants?

An extensive review of the literature was done by the WHO working group where they found low certainty evidence that cow’s milk “may increase the risk of anaemia and IDA, and result in lower serum ferritin concentrations”. No growth differences between cow’s milk and formula were noted.

Reading deeper into the guidelines, it is acknowledged that there is uncertainty regarding the benefits versus harms of formula versus cow’s milk from 6-11 months and “some agreement that there were probably some benefits for infants 6–11 months of age consuming milk formula rather than animal milk”.

In my practice, I will continue to recommend breast milk or formula as the primary milk source during infancy. That being said, there are considerations such as water safety or affordability to consider in some areas of our own country as well as other parts of the world.

In other words … if the baby is already eating infant cereal, it should be fortified. But, don’t encourage infant cereal. Confusing. The focus of the recommendations are on encouraging nutrient dense foods. There were also some valid points made in the recommendations regarding resources needed for infant cereal production, packaging, transport and distribution.

This recommendation in particular is tough, because we know that iron intake can be problematic in the latter half of the first year of life. We also know that iron deficiency anemia may result in long-term developmental consequences.

In breastfed infants, when complementary foods are introduced, iron-rich foods are emphasized as a focus. If you take some time to look at the iron content of foods, it is difficult to meet those high infant iron requirements without fortified food products, even for the most savvy of parents.

The WHO working group did state:

“Consumption of a fortified cereal grain-based complementary food to children aged 6–23 months compared to no consumption improved indicators of iron status, though not zinc, vitamin A or growth outcomes. Children consuming a fortified cereal-based complementary food had better mental skill development scores and motor development scores, but not fine and gross motor scores when assessed.”

They acknowledged the difference.

They go on to state:

“Young children have large nutrient needs that must be met with a relatively small amount of food. Therefore, children, especially those living in low-resource settings where staple foods provide the large part of energy needs, are at risk of nutrient deficiencies. Nutrient supplements and fortified food products can fill some nutrient gaps during the complementary feeding period.”

It really felt that the working group had come to the conclusion that these fortified food products are beneficial, but hesitated to recommend them as a standard due to the resources needed for distribution.

Reading these guidelines result in a lot of “what!!??” moments for me. But as I thought more deeply from a global perspective, the recommendations began to sit a little easier. The points highlighted here were two in particular that I struggled with.

What are your thoughts about the new WHO Infant Feeding Guidelines? We’d love to hear from you! Hit reply and let us know what you think!

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Charlene and Julie

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