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Infant Feeding Guidelines for Health Workers submission

ID: 
80
B. Please provide contact details
Personal information provided, e.g. contact details, will only be used for the purposes of developing resources relevant to this consultation document and will not be disclosed outside of members of NHMRC staff and NHMRC Committees. Such Information will not be used or disclosed for any other purpose, without prior written consent.
First Name: 
Pamela
Last Name: 
Dodrill
C. Additional Information
Please add further information: 
paediatric speech pathologist
E. Submission
Comments: 

INTRODUCTION OF SOLIDS

As a paediatric health professional working in the area of infant feeding, I believe that further clarification in needed regarding the age at introduction of solids.

The current draft version of the guideline suggests starting solids at 'around 6 months of age'.

There is no clarification for the age at which preterm infants should start solids (around 6 months chronological age or corrected age).  Depending of the degree of prematurity of the child, the difference could be in the order of 16 weeks.  Currently >8% of infants in Australia are born preterm.

The main argument given for the introduction of solids at 6 months (vs earlier at 4 months) is based around encouraging longer duration of breastfeeding.  It is unclear if there is any advantage or disadvantages for formula fed children in waiting to 6 months.

It is suggested that 'Delaying the introduction of solids (spoon foods) until around six months will considerably shorten this period of adjustment (to solids)’, based on the results of one observational study in Europe (Hornell, Hofvander et al. 2001), in which only 4% of children were introduced to solids at or after 6 months (vs. 96% who were introduced to solids before 6 months).  Clinical experience from working in the area of infant feeding suggests that children introduced to solids at or after 6 months of age take just as long to transition on to solids as children started at 4-6 months of age.  This is a concern, as many of these children are then 7-8 months of age before taking substantial volumes of solid foods, which puts them at risk of nutritional deficiencies, out outlined in the guidelines.

 

The current draft version of the guidelines state that infants are ready for solids ‘with the disappearance of the tongue-extrusion reflex’ and ‘with the infant’s increasing ability to sit without support, which allows greater manipulation of food before swallowing, so that thicker foods can be introduced’.  It is well documented that most children have mastered these skills by 4-6 months of age (see published work by Morris & Klein, Carruth & Skinner etc) .  If a child has the pre-requisite physical skills to start solids at 4-6 months, and is showing cues to the parent that they are interested in solids, it is a concern for the parent-child relationship that (in following these guidelines) a parent may ignore their child’s cues and withhold solids, despite signs of readiness.

The current draft version of the guidelines recommend consulting a dietitian if concerns arise regarding nutritional intake, but do not list other health professionals who may be able to assist with infant feeding difficulties.  Paediatric speech pathologists specialise in assessing and managing oral feeding difficulties and can assist these children to develop the skills to bite, chew, drink, and swallow effectively and safely.   Given that children are unlikely to be able to meet their nutritional requirements from their diet alone if they cannot masticate and swallow the food efficiently and effectively, it would be useful to recommend consulting a paediatric speech pathologist if concerns arise in this area.

 

BREASTFEEDING AND BOTTLE FEEDING DIFFICULTIES

The current draft version of the guideline states that ‘The normal development of sucking and swallowing behaviour involves the progressive coordination of breathing, sucking and swallowing so that by 36 weeks gestation these activities are well coordinated.’  This statement should be adjusted to say that ‘by 36 weeks gestation these activities are generally well coordinated’.  There are numerous research papers that document that the feeding patterns of infants born preterm are often still less coordinated and less efficient than those of full-term infants at term age (see Dodrill P. Feeding difficulties in preterm neonates. Infant, Child, & Adolescent Nutrition. 2011. [Epub ahead of print] for an overview of this literature).  Currently >8% of infants in Australia are born preterm.

 

The current draft version of the guidelines state ‘There are no well established therapeutic approaches to these children, but generally patient attempts at establishing breastfeeding will be rewarded as the neurological components of sucking and swallowing mature.’  There are numerous research papers that outline common therapeutic options for infants with feeding difficulties (see published paper listed above, as well as papers by Joan Arvedson, Anna Dusick, Lisa Newman etc). 

 

The current draft version of the guidelines recommends consulting a dietitian if concerns arise regarding nutritional intake, but do not list other health professionals who may be able to assist with infant feeding difficulties.  Paediatric speech pathologists specialise in assessing and managing oral feeding difficulties and can assist with managing breastfeeding and bottle feeding issues. 

 

Children who experience difficulty with breastfeeding (e.g. infants with cleft palate, very preterm infants, infants with cardiac/ respiratory disease) are often still able to receive breast milk from the bottle, if the mother is given appropriate support and education to enable breast milk expression, and the child is provided with an appropriate bottle to suit their needs.  Paediatric speech pathologists specialise in determining suitable infant feeding equipment for infants for are not breastfed. 

Page reviewed: 14 December, 2012