Dr Sam Manger  0:00   

 

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the Traditional Custodians on the lands on which this podcast was recorded, and the Traditional Custodians on the lands and waters on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander Elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s First Nations people. 

 

[INTRO] Brigitte Corcoran 0:20 

 

In Australia, we have a significant issue with overweight obesity. Cow’s milk has twice to three times the protein content of infant formula and breast milk. We know that dietary protein intakes in infancy are related to overweight and obesity later in life. 

 

Dr Sam Manger  0:38 

 

Hi, I’m Dr Sam Manger, a GP, and your host of this series, The Clinician’s Guide to the first 2000 Days, brought to you by the Queensland Government through Health and Wellbeing Queensland.  

 

Prevention across the first 2000 days offers an opportunity for healthcare professionals to support generational health improvements, but preventative health will only be successful if it is done with confidence and empathy and an evidence base.  

 

Over the course of this series, I will be talking to some of Queensland’s leading experts to explore how they discuss preventative health and how to create meaningful change for the next generation. Let’s get started. 

 

Today is our first episode in our First 2000 Days series that is starting to consider the health of the baby and to look at the first 12 months of infant life. We have Dr Mairaed Crawford and Brigitte Corcoran joining me today.  

Mairead is a GP at Neighborhood Medical who has a keen interest in antenatal care, breastfeeding and lactation support, as does Brigitte, who is a Pediatric Dietician at Queensland’s Children’s Hospital with over 25 years of experience working in tertiary and community settings.  Thank you both for joining me so much.  

Brigitte Corcoran  1:47   

Thanks for having us. 

Dr Sam Manger  1:48   

So, a baby coming home from hospital is an incredibly exciting but also going to be a very daunting period for mum and the partner. In a previous episode, we looked at shared care models and how life can impact mum in those first few months. In this episode, we’re going to focus more on the baby’s health and growth.  

One of our first choices of pair and pegs for their newborn baby is how the baby will be fed. If we consider breastfeeding versus infant formula, infant formulas market themselves as being incredibly similar to breast milk. Brigitte, are they? 

Brigitte Corcoran  2:15   

Oh, it’s an interesting point. If we just start talking about human milk to start with. It’s a dynamic living fluid, which is full of not only the nutrients that an infant will actually need to grow, but also a number of bioactive components as well. And so, some of these bioactive components are things like prebiotics, human milk, oligosaccharides, for example, we have over 200 different human milk oligosaccharides that have been identified in breast milk.  

In addition to this, we have hormones and growth factors which can range and function from helping to mature the infant’s intestinal mucosa, along with assisting the production of red blood cells and also, sort of, the suppression of inflammation. In addition to this, we also have a number of microbial communities within breast milk. Up to 800 different microbes have actually been identified in breast milk, and these are really important probiotics that have many functions in the infant gut, ranging from establishing a healthy and varied microbiome, which in turn helps to develop and mature the also the infant’s gastrointestinal tract and their immune systems.  

And lastly, but not least, got a number of micro RNAs, which are thought to control epigenetic programming of the infant’s gut, but also the infant’s immune system as well, and these can have significant impacts on prevention of disease later in life. So, all of these components actually work synergistically to help nourish the infant, but also to ensure that the infant can survive and thrive out in the world.  

Infant formula is certainly manufactured food that’s made suitable for infants through ensuring baseline levels of macro and micronutrients, as stipulated by the Food Standards Australia and New Zealand. As we’ve already touched on, breast milk has many non-nutritive components, and the infant formula companies certainly do try hard to get a number of those bioactive components added in the manufacturing process. However, we do know that a lot of these often don’t actually survive the manufacturing process, therefore actually can’t act as their intended purpose. And in addition to this, we know that a lot of these bioactive components actually work synergistically. So, by just by isolating them, we can’t necessarily emulate the benefits of breastfeeding. So, in a nutshell, infant formula will probably never be able to replicate all the benefits that breast milk does actually provide to the infant. 

 

Dr Sam Manger  4:31   

That does seem the case, doesn’t it, such a complex but incredibly impressive sort of mix of different things. They’re benefiting the body and the baby’s body. So Mairaed, can we talk about some of those detailed benefits of breastfeeding?  

Dr Mairaed Crawford  4:44   

There’s obviously benefits to both mother and baby, and then we can also talk to kind of bigger benefits, such as economic and environmental benefits. 

If we think about benefits to baby, breast milk has such an important role in growth and development of infants and young children. And those benefits actually extend into adult life. So, breast milk has the benefit of being a nutrition source that’s purpose built for the changing demands of a growing infant. It’s quite amazing that composition of fats, immunological factors can all change as the baby grows. We also know that in infants that are breast fed, there’s protective factors against illnesses such as middle ear infections, respiratory tract infections, reduced incidence of gastrointestinal infections.  

We know that breastfeeding is protective against things like SIDS, Sudden Infant Death Syndrome. It’s really important for the development of jaw and teeth in infants as well. If we look at the later life benefits for children as they grow and develop, we know that there’s reduced weights of things like childhood obesity, type 2 diabetes and asthma for people who are breastfed. If we look at benefits for mother, there’s things like assisting in reduction of postpartum bleeding, reduced rates of infection in mothers that are breastfeeding. It can be really important when we look at longer term preventative health factors like reducing the inter pregnancy interval, and then also things like helping mothers to maintain healthy weights postpartum as well.  

I think it’s really important that we also consider the economic benefits for families around breastfeeding. It’s very expensive to be formula feeding. There’s obviously all of the logistical challenges that go with formula feeding. It’s not an on demand, on tap, source of nutrition for an infant. And then I think we have a responsibility as health practitioners to also think about the environmental impacts of what we’re recommending. And there’s a significant environmental impact for the manufacturing, processing of infant formula as well. In the farming that happens, majority of the sources come from dairy farms. But that’s a kind of broader concept to think about as well.  

Dr Sam Manger  6:45   

So, there’s profound benefits there aren’t there across the whole physiological system of the baby, every system, you say, lungs, brain, immune system, the gut health, they all get improved by this. And there’s also social benefits there as well, cultural, environmental benefits as well. Now the data we have shows that breastfeeding rates in Queensland are excellent, over 90% when a mother gets discharged from hospital, but they drop dramatically as time progresses, with less than one in three babies exclusively breastfed up until six months. So Mairead, why do you think this is and what approach can we take to improve these stats?  

Dr Mairaed Crawford  7:20   

I think it can be helpful to think about this in two kind of key time points. The first is, I think that breastfeeding doesn’t get a lot of airtime antenatally, there really is a lack of preparation. Often for mothers who are preparing in pregnancy, we get very focused on mum’s health and baby’s health, and don’t necessarily anticipate what might happen in someone’s breastfeeding journey.  

I think if we look at what happens at the time of hospital discharge, people are being discharged from hospital really early, often before feeding is really well established, and that significantly has an impact on troubleshooting issues with breastfeeding in those first few early days of the breastfeeding journey.  

And then I think there’s often this misconception that breastfeeding is a natural process and comes really easily to breastfeeding dyads, and that’s definitely not the case, and many breastfeeding dyads, mother baby pairs, will need lots and lots of support to get themselves established with the breastfeeding process.  

Dr Sam Manger  8:15   

How does this change for different cultural beliefs and societal norms that influence breastfeeding practices?  

Dr Mairaed Crawford  8:21   

One of the key things that impacts this is a massive shift away from the way that families function in the modern world. Many women are returning to work early. Many families are isolated. They don’t have their village to raise children. Often, partners are taking parental leave, which is an excellent initiative, but it means a transition away from baby at the breast, breastfeeding, where mums are expressing. And so all of these have such a complex impact on the way that breastfeeding is established and continues for infants. If we look at some of the kind of demographic I suppose influences on breastfeeding, we know that breastfeeding rates are really low in mums who have babies under the age of 25 and I think that, from a societal perspective, it’s often not something that is seen a lot, and therefore that contributes to the challenges.  

There’s definitely a big impact on the social determinants of health and their impact on breastfeeding, and that probably talks to what we see in terms of education and support around breastfeeding mothers. We know that women who have a tertiary level education are more likely to breastfeed. So again, it talks to those social determinants of health, who has access to support around breastfeeding challenges, and where people might access that.  

And I think it’s also important to note that in our culturally and linguistically diverse population, even for migrant women who express a desire to breastfeed, and where breastfeeding may be really normalised in their culture, often, lack of access to culturally and linguistically diverse and appropriate education is a barrier to supporting those women within our society for breastfeeding. 

Dr Sam Manger  9:57   

There’s many important points you raised there and having that, as you said, whether it’s a First Nations health worker or a woman health worker from that sort of group, so culturally, linguistically diverse group can be a really important aspect as well to bring into the consult if you need to. 

Dr Mairaed Crawford  10:13   

Absolutely. 

Dr Sam Manger  10:14   

You raise a number of potential issues there. And so, we wonder, what are the other common challenges or complications mothers often face with breastfeeding. 

Dr Mairaed Crawford  10:23   

So, some of the things that I would frequently see in practice, perceived low breast milk supply is probably one of the most common reasons for presentation. This can go hand in hand with poor weight gain for the infant, but not always. Often, there’s a description of an infant that might be fussy at the breast or dialing up at the breast, back arching, and very often, people are concerned for things like reflux and how that might present. So that’s a very common presentation, breast or nipple pain and discomfort in the feeding process. Sometimes the presentation can be wrapped up in things like concerns for cow’s milk protein intolerance or allergies. There may be eczema, there might be things like stool changes, so definitely a whole range of feeding challenges. And I think the other common area of presentation is around infants who may have had medical illnesses or some kind of complication. They’re often premature infants or ones who had intervention for feeding early on. And those challenges can be really long term in terms of working with breastfeeding partnerships for continued breastfeeding support as well. 

Dr Sam Manger  11:30   

As a GP, when you’re advising women around initiating breastfeeding, they’re relatively new to it. How do you approach that? Do you advise on, sort of, breast self care, or of early warning signs, or what resources might you provide to ensure that people are getting that full information?  

Dr Mairaed Crawford  11:48   

It’s very dependent on what they’ve already been offered and where at their feeding journey we meet them in general practice. Sometimes they’ve had quite extensive support before they’ve been discharged or with community midwives or lactation consultants, so it’s quite variable I suppose. I think one of the benefits of technology and access to information now is most women come primed with their concerns, and it’s really about navigating their specific challenges on a case-by-case basis to be able to direct them to the most appropriate resources depending on their presenting complaint. 

Dr Sam Manger  12:21   

Now Brigitte, often infant formulas is a way for partners to take some of that burden from the new mum from the breastfeeding process. So how do we encourage breastfeeding if the mum is actually needing a break, which is totally reasonable? 

Brigitte Corcoran  12:33   

So, we’ve heard from Mairaed about a number of different factors that are involved in the promotion and support of breastfeeding, and one of the things that we really look to is partner and also family or social supports to help mothers. Because obviously, to be able to feed an infant, you need time to be able to do that, and the time spent actually feeding will be taken away from domestic duties or other childcare duties or whatever. So, this is a really interesting point, that often infant formula is used to give mothers a break when there’s potentially an opportunity to give mothers a break through different activities, other than feeding. So, through additional help with domestic duties, or childcare would be the two more obvious ones that we’d look at. But if partners are really wanting to be a part of the feeding journey, then certainly we have a number of exciting things on the market in terms of getting expressed milk these days. And in the past, it used to be you’d sit down and be attached to a pumping machine forever and a day, but now we’ve got wonderful wearable expressed breast milk pumps that we can actually buy or hire so that will actually enable mum to actually get some expressed milk and then potentially have the father or the partner involved in the feeding process as well. But certainly, helping out from a domestic front, would, I think, certainly something that I support mothers to actually try to then give them more time to be able to breastfeed their baby.  

Dr Sam Manger  13:51   

So, helping in every other respect. And then, if the feeding is necessary, then there are options there as well, as you say, around express breastfeeding, expression of breast milk. Mairaed, you mentioned before around the concern for some women that they cannot express enough milk, and that’s a common reason you’d hear women stop breastfeeding. So how do healthcare professionals effectively assess this if a baby is getting enough breast milk? What signs do we look for as a first point?  

Dr Mairaed Crawford  14:16   

This is such a common query, and it’s one that comes with lots of anxiety, which I think is very much driven by that biological need to feed our infants, and the concern regarding that, my approach, and the other thing I think is really important to preface is this is not something that can be done in a 15-minute GP consultation. If 15 minutes is all you have, it’s really important to flag the concern and make appropriate time for, for that mother and their baby, because if you don’t do it justice, they will feel unheard. And this is such an important part and point of intervention for us to be able to act as GPs. So, the first step, like always, is to start with a really thorough history. What’s their concern and why are they thinking that they might not have enough milk? Is it concerns for baby’s growth? Is the infant fussy at the breast or struggling to come onto the breast? Are they having marathon feeds or frequently waking and feeding? Is the mum having low volumes when she’s pumping? And that’s her concern around feeding? Because that will help then direct what other information we need to gather. I think it’s really important to take a thorough history of mum’s past, medical history and the birth history, because there’s often some clues in that as to what might be the driver of the low breast milk supply. If she’s had previous feeding experiences, what were they like? And were there previous challenges, things like breast surgeries that might be indicative of breast injury.  

Birth factors are really important, and what may have happened into the birth because that’s such a prime time for establishing feed(ing) in those first few hours of infant mother contact. So that’s looking at things like medical intervention. Was there induction of labour? Was there an instrumental birth or cesarean? Was the baby premature? Because often there can be challenges with premature infants and turning on their feeding reflexes. Things like intrapartum analgesia and fluids. Sometimes use of fluids intrapartum can conflate early weights for babies, and so that needs to be taken into consideration if it looks like a baby might have faltering growth. Was there early separation and loss of that skin to skin, early on?  

Thinking a bit more broadly around things like pregnancy hypothyroidism or big PPH’s (postpartum hemorrhage), where there may have been onset of Sheehan Syndrome affecting breast milk supply. And then thinking also about postpartum factors, so things like retained products of conception.  

The other little tidbit, which I think can be really useful is, is she taking placenta capsules? Because they, the progesterone in those will often inhibit breast milk supply as well. So, a really thorough history from Mum is helpful to help guide us. The next step is really a good history around what’s happening with current feeding. How often is each breast being offered to the infant in a 24-hour period? How long are feeds taking? Is there any nipple pain with feeding? What’s the infant like when they’re bought to the breast?  

One of the common things I see is a bit of a misnomer around spacing feeds and baby needs to wait till the four-hour mark to have feeds, and that’s really a maximum, but we can be really confident that offering the breast flexibly and frequently will help to establish supply. Asking about any features of mastitis or engorgement, working out whether any supplemental feeding has started, because that really can affect milk supply.  

We need to be draining the breast to be producing adequate amounts, and if Dad has started giving a bottle of formula to help mum get an extra rest, that can start to impact supply. And then, if she is pumping, checking pump fit, how frequently that’s happening at what times that’s happening and what volume she’s getting. The other important part of the assessment is checking for any features of dehydration for the baby, so asking questions about features of jaundice, adequate wet nappies, what the baby’s energy levels are like.  

If I’ve got time in this consult, I’ll try and observe a breast feed, because we can get some really good clues from observation. Sometimes we don’t have time for it. And again, use of technology, it can be really good thing to give dad a task of videoing a breastfeed and bringing that back to the next consult to see what’s going on. And then I also want to spend some time examining the infant and I think it’s really important to examine infants. A, so that we know whether they’re we’re concerned about any dehydration and adequate nutrition, but also, parents expect that of us to make sure that we’ve thoroughly assessed infants in this process. So that looks like plotting weights, aiming to get as many weights as we can. I like to use the WHO (World Health Organisation) age charts for that, doing a thorough assessment for medical signs of dehydration, alertness, tone, jaundice, checking fontanelles, what’s the fat distribution like on the baby? Looking for any other clues that might be a flag for feeding issues. So dysmorphic features, checking for cleft palate. And I think sometimes it feels like these things should have been picked up in the hospital. But it’s also really important to know that infants are often discharged early, and it may have been the intern or their RMO (Resident Medical Officers) on their first week examining that baby on discharge.  

So, it’s really, really important to complete a thorough assessment. So, it’s a lot, it’s a lot to cover. Sometimes it needs to be spaced out, but doing your due diligence will give you the clues to help direct how you might be able to help this mum and baby. 

Dr Sam Manger  19:21   

 Yeah, I can see why you say it’s not a 15-minute consult. There’s a lot there isn’t there, and I won’t do it justice to summarise, but in a sort of systematic way, thinking, as you say, around prenatal health and antenatal health and the birth process, then postnatal health. So, taking a sort of chronological history as to, okay, let’s just get the whole history leading up to this point, then looking, as you say, around the breast health and care, the feeding habits, and then how the infant is responding to that process.  

And then an examination, as you say, growth charts, critically important hydration. And then a system is basically head to toe review and just to recheck everything “as it should be”. And I think your idea around a video of a breastfeed is a fantastic idea, very practical idea. We often do things like food diaries and sleep diaries, but why not do a breastfeeding diary and get some actual evidence of it? Is a really very practical tip. So, thank you.  

The next question is around management of that, which is also an enormous question, because it depends on the cause. But what practical steps can we do to improve milk supply if it was inadequate?  

Dr Mairaed Crawford  20:19   

It’s helpful to come back to first principles when we think about this, and a breast that’s draining well will help milk production. So, the first thing is really looking at fit and hold, sometimes called latch, and what that looks like. Because if an infant is draining the breast well, and there’s good milk transfer, that really should be stimulating good breast milk supply.  

I appreciate that in GP training, we don’t get very much breast medicine training at all, and so this is where I would encourage if you are seeing a mum and a baby, and this is not something that feels like it’s in your scope of practice, then making sure you are referring off to our lactation consultant, IBCLC (International Board Certified Lactation Consultant), GP with lactation interest colleagues, because the assessment of the breast feeding process is such an important part of working with mums and infants to establish appropriate supply.  

We talked about the myth of pushing babies out to four hours, and one of the really practical steps is encouraging mothers to offer the breast frequently and flexibly, because that often will help stimulate supply. There’s a concept of magic number of breast feeds, and that relates to how many breast feeds need to occur in a 24-hour period for a mum to continue her supply.  

It is variable, but a good ballpark for mums, particularly in those first few weeks of feeding, is probably draining each breast 12 times in a 24-hour period. So, it’s a lot, and this is where                                                                                                                                                                                                                                                                     talking to what Brigitte spoke to before, around someone else, supporting mum in that time is critical so that those times at the breast are happening. The other part is, is the opportunity to optimise skin to skin. It’s such a practical suggestion that you can offer. So really making sure that if there are challenges with breast milk supplies, mum getting good time where she can have baby skin to skin. It’s something we often prioritise in hospital, but when we go home, can forget about.  

So another really practical tip, and then also highlighting that it often comes with good intention, but it can often be a recommendation from health professionals to just throw in a supplemental feed, particularly if there’s concerns around baby’s weight trajectory, but that then often starts a massive cascade of top up traps, and can be a real challenge. So, I think being really cautious around the advice of supplemental feeds and being really confident that we’ve gone through and checked off everything else that we need to before that advice comes as well. 

Dr Sam Manger  22:41   

And you just had an acronym there, IBCLC. 

Dr Mairaed Crawford  22:44   

International Board-Certified Lactation Consultants. And I suppose the other thing to that is, if you’re struggling to find people in your community, all of the major maternity hospitals have lactation consultants available. It’s usually within the first month of life that women have access to that and if not, Community Health Nurses also will have access to lactation consultants. So, utilising your network of professionals around you is really important. 

Dr Sam Manger  23:10   

Stay with us. We’ll be right back to continue our conversation. 

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Dr Sam Manger  23:47   

And now back to the conversation.  

You haven’t mentioned medication, which is good, because we don’t want to jump to that prematurely. So, it sounds like there’s a lot of things we need to check off the list before we just assume that there’s that sort of answer to this.  

Dr Mairaed Crawford  24:00   

Yeah, it’s definitely a role for Domperidone in some cases, and it’s often done as an adjunct as we work on some of the other interventions, I suppose. But it’s also a medication that’s not benign. There are cardiac risk factors that go with it, and it’s a proper assessment, and it’s not going to be effective if we haven’t addressed the underlying issues either. 

Dr Sam Manger  24:20   

Excellent. Thank you very much.  

Brigitte Corcoran  24:21   

Just wanted to add to Mairaed’s list of suggestions there, but there’s a couple of just very simple things that any breast-feeding woman can do to actually increase volume of breast milk and milk transfer, but also to increase the fat content of the breast milk earlier into the breast feed. And certainly, just simple tweaks like massaging the breast pre and during a breast feed, actually helps to release the fat that lines the milk ducts, and it actually releases into the breast milk. So, you’re not having to wait to stay on, the infant to stay on the breast for a very long time to actually get those released. That fat released in subsequent let downs. And the other one is actually compression. So compression, which is simply  effectively increasing the flow rate can be done when an infant actually starts to slow down their sucking, or slow down their swallowing, sorry, and that will act, can actually increase milk volume at any given feed up to about 30%.  

So, there’s just a couple of simple tweaks that we can actually do. But again, I can go with Mairaed in terms of, obviously all those other things need to be other factors need to be looked at first, but a couple of simple tweaks, there can be strategies that potentially anyone can actually recommend or refer mum to. There’s many, many videos out there, video resources that Mum can actually have a look at to see how to actually do these two simple techniques that might actually help. 

Dr Sam Manger  25:36   

And the compression. You obviously mean breast compression, not baby compression (laughter). Don’t compress babies! 

Dr Mairaed Crawford  25:44   

And the other point that I didn’t talk to was actually just making sure mum’s drinking enough and eating enough. Breastfeeding Mums need lots of calories and lots of fluid, and it’s often something that’s overlooked, particularly if there’s older kids around in the house, and in between feeds, they’re attending to toddlers, so water bottle next to them at every single feed, as well as lots of handheld snacks. And that’s the role of the village, to bring their meal train and make sure mum got lots of easily accessible food on hand.  

Dr Sam Manger  26:11   

I was thinking the same thing when you were saying it, because to maintain breast supply, emptying a breast 12 times each side in a 24-hour period, that’s a lot of breast milk, and that’s a lot of energy to make that amount of breast milk, especially given the complex nature and content of breast milk.  

So I was just going to raise that the number of extra calories a breastfeeding mum will have to eat of healthy food, obviously whole food, and all those sorts of things, so you can make that, is not small in the sense that, you know, we’ve got to make sure we’re looking after mum from that sense, so she can make the breast milk. The massage around the fat content is very interesting, and just for the listeners, I feel like it might be helpful to delve into that, because some may not be aware of the difference in that fat content. To say that sort of for milk, or hind milk, or those sorts of terms. Could you talk about that a little bit? 

 

Brigitte Corcoran  26:55   

So early into a breast feed, obviously, the first function of breast milk is to hydrate, so you get a lot of hydration, and there’s a big carbohydrate or lactose load along with protein in the early part of a breast feed. And then as feed progresses, then more and more fat will actually get released into the breast milk, with subsequent letdowns that come after that initial first let down. And part of that is just because the fat, when breast milk is being made, like any kind of fat, it will actually form a film on the outside of the mammary duct. So just like it does in the fry pan, or it does in, if anyone’s expressed any, any breast milk, you’ll actually see the fat that actually lines the inside of a bottle or a breastfeeding pouch. So to actually get that fat to emulsify into the food, into the breast milk, sorry, you actually just use a bit of massage that will actually help to release that into the breast milk earlier into the feed, so that the infant doesn’t actually necessarily have to stay at the breast for as long to get the full benefit of that fat. 

Dr Sam Manger  27:49   

That’s fascinating. And so that higher fat content milk is more calorie dense and more filling.  

Brigitte Corcoran  27:54   

Correct, yeah. 

Dr Sam Manger  27:55   

Yeah, very good. And right, you mentioned a few other common symptoms there that may be important here in the infant’s health, but also in the breastfeeding process. But what are some practical tips that you would give mum to help a baby with reflux and this term that you have heard for a long while, colic?  

Dr Mairaed Crawford  28:09   

I think they probably speak to two different things. Colic often relates to an infant who might be unsettled, having long periods of crying. We often talk about the concept of purple crying. If we look at an unsettled infant as a presenting issue, it’s really, really important that we do a thorough assessment. We’re ruling out any organic cause for why that infant might be unsettled, and we really need to be able to reassure parents that there is nothing wrong in that instant. Then a lot of the approach around talking about an unsettled infant is around normalising how much crying and we can expect from infants.  

There’s a very good resource published by the Royal Children’s Hospital in Melbourne around purple crying and approach to kind of working through that. And I often show the parents, there’s a purple crying graph. It is bell curve, essentially, and it’s important to talk to parents around the variable nature of infant crying. But as I said, a thorough assessment to make sure there’s nothing else that’s happening for that infant, that they’re growing well, because that’s a really good indicator of what’s happening with feeds.  

If we talk to the concept of infant reflux. Reflux, gastroesophageal reflux in infants is incredibly common, and that relates to the fact that the oesophageal sphincter is immature and needs a period of time to develop. I think if you look at the statistics, it’s about 40% of infants that will have gastro oesophageal reflux.  

It’s really important that we delineate gastroesophageal reflux from gastroesophageal reflux disease in infants, the difference being that in GORD there are associated complications of the reflux, and that really needs a different management strategy.  

So, for infants with reflux, without complications, again, a lot of it is about normalising that it’s okay for infants to posset and vomit post feeds, providing that weights are adequate, and that baby is otherwise thriving.  If we look at gastroesophageal reflux disease, so some of the complications we might see with that are things like choking, coughing, wheezing during feeds. Sometimes there can be hematemesis. There can be lots of distress during feeds or refusing to feed, and that’s usually accompanied with poor weight gain or weight loss in an infant. It then comes to; how do we manage that? Sometimes we don’t need to do anything, per se, because infants do grow out of it. There’s been a big, I suppose, a bit of an uptake in prescribing PPIs and H2R receptor agonists recently, but these also are not benign medications to give to infants.  

And we really need to have that shared decision-making discussion with parents prior to prescribing any of those medications, because there are actually risks associated with those medications. So again, this is a presenting complaint that needs a thorough history, a thorough examination. If we think about some of the other red flag symptoms that might prompt referral to a specialist, we’re thinking about things like bilious vomiting, any blood in the stools, things like onset of vomiting later, six months, after six months of life.  

Things like lethargy in an infant, jaundice, those kinds of things, all were suggestive that something more sinister might be going on, and we really need to go back to basics in terms of ruling out organic causes. I think it’s also really important to highlight that vomiting in an infant has a long, long list of differentials. So again, going back to history, taking an examination to make sure we can be really confident that there’s not another cause of the vomiting is really important. And some GPs may feel like it’s within their remit to prescribe PPIs, but I actually think we’re probably at the level where we’re referring off to our gastrointestinal colleagues, if we’re at that point. 

Dr Sam Manger  32:01   

Yeah, and there’s an interesting component here, as you said, the if the baby’s thriving, and it sounds like we should expect the baby to thrive and grow and the trajectory to be going well, and if it’s not, then we need to sort of go back to first principles, as you say, all right, something we need to look at here, let’s just start a fresh history examination, go through it, just make sure there’s not something that’s interrupting that a good principle.  

So that point around thriving, though, brings us to what GPs will often do with babies and looking at that six-week check. Now, in a past episode, we’ve talked about the mum examination at that six-week check but now let’s focus on the well baby check. What do you include in that? And what are some really important messages that come from that? 

Dr Mairaed Crawford  32:42   

If the baby is new to me, I want to get a really good summary of what happened in the pregnancy, including any pregnancy risk factors that might need, might indicate that anything needs to be followed up. Included in that is whether there’s any siblings that might have had things like developmental hip dysplasia.  

We want a really good birth history. Things like gestation give us some clues around what might happen for this infant, and again, whether anything needs to be followed up, thinking about things like resuscitation, respiratory support, whether there’s any feeding interventions having to have happened already, obtaining the birth weight so we can plot weight trajectories is really important, making sure some of the logistical things like the neonatal screening test and hearing tests have happened in hospital, also really important.  

Also following up on things like vaccinations given in hospital, and if not arranging for those to happen. I take a brief history around feeding, sleep, settling any parental concerns, and I’m sure this was talked about in the previous episode. But if mum’s not a patient at our clinic, I think it’s really important to understand how mum’s coping. Such an important part too, how that infant is going to thrive and what their health will look like. I often ask about a quick developmental screen. So, the things I’d be looking for at six weeks are, is the baby turning their head towards light? Are they starting to watch faces and follow? Is there some social smiling happening? Do the parents have any concerns for babies hearing? Are they starting to startle to loud noises, and are they looking to lift their head with tummy time?  

Again, we go back to a head to toe thorough examination, including a length, a head circumference and a weight and the types of things we’re looking for around birthmarks, colour, any concerns around cardiovascular compromise, checking again, for dysmorphic features, doing things like examining the eyes for red reflexes, checking the hips for any features of developmental hip dysplasia, checking the external genitalia. So again, that head to toe examination reflexes, and that can be really helpful. Parents appreciate you examining their baby adequately and making sure you’re spending the time to really check.   

Dr Sam Manger  34:51   

Yeah, there’s a real therapy just in the examination process, let alone what you find. Thank you very much for that comprehensive list. You mentioned developmental milestones there, and some you might expect to see around that six, eight-week mark. One of the sources of anxiety, to some degree, is that babies and children can develop at quite different rates, and so are there noticeable physical developmental milestones that you’d be concerned about if a baby hasn’t achieved them by, say, six months or 12 months? 

Dr Mairaed Crawford  35:16   

There’s an excellent resource by Children’s Health Queensland, which talks to red flags and early identification of red flags for developmental milestones. I often will pull it up in my consult room and talk through if parents have presented, talking about a concern for slow development. So, at the six-month mark, again, I think it can be really helpful to have an approach to these consults so thinking about the developmental domains. So social domains at six months, if they’re not smiling or interacting with people. From a communications domain point of view, if they’re not starting to babble, I’d be concerned. If we’re looking at gross motor domain, infants at six months, if they’re not holding their head or shoulders up within a prone position, so tummy time or in a supported seating position, I’d start to be concerned.  

And then if you look at the cognition, fine motor self-care domains not reaching or grasping for objects with their hands, their hands are frequently clenched, they’re not looking to explore objects with their hands or their mouth, and they’re not bringing their hands to the midline. So that probably then talks to the resources that I’d use for the 12 months as well, and that document lays it out really nicely, and can be a helpful thing to reassure parents that these are where we would expect their baby to be and that there’s no concerns.  

Dr Sam Manger  36:02   

It’s great having those reputable resources, because that’s a lot to remember and each sort of stage, and you want to be able to resource those and reference those.  

Now let’s talk about some of the opportunities for preventative health messages as they relate to mum and baby in this sort of six-week period, but also in that first sort of 6-12 months. Do you use these six-week checks and others as an opportunity for that? And if so, what’s your approach?  

Dr Mairaed Crawford  36:32   

Again, there’s so much often to cover in these consults. Parents often will save up their concerns for their baby scheduled immunisation checks. So, it can be really helpful either to utilise longer appointments, or this is where it can be really useful to utilise your practice nurse to do some of this preventative care discussion.  

Some of the things that often come up is around safe sleeping, so making sure that there’s a safe place for the infant to sleep, talking about really simple interventions for social and communication development, so things like making sure you’re reading to your baby, having conversations with your baby, responding to baby’s cues, and what that looks like, to promote that bonding.  

Talking about injury prevention, reducing hazards around the home, are there baby gates? Is there a capsule for the car? Has furniture been drilled to the wall appropriately? Talking about sun protection, and I think this is a great time to start to talk about how parents can protect kids from the longer-term effects of early sun exposure, more broadly, thinking about preventative health strategies for the family as a whole.  

So, what’s the parents well being like, remembering that there’s also significant rates of postnatal depression for dads who are often not at the consult. So, inquiring about that stuff can be really important and directing and linking in families with resources early on if there are signs that they’re struggling. And then other preventative stuff around contraception and pregnancy spacing, because that’s a really important intervention for mum again, educating around normal developmental milestones and so that parents feel like they can come to you if they’ve got concerns and questions. 

Dr Sam Manger  38:29   

Don’t go anywhere. Our conversation continues after these messages. 

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Dr Sam Manger  39:07   

And now back to the conversation.  

You mentioned safe sleep practices. So, what are some of these evidence-based recommendations for safe sleep practices for infants?  

Dr Mairaed Crawford  39:13   

Probably the biggest repository of information around safe sleep practices is the Red Nose Foundation. They talk about six safe sleep practicing recommendations for babies in the first 12 months of life. So always putting a baby down on their back to sleep, ensuring baby’s face and head remain uncovered, so no beanies or anything like that while they’re sleeping. Keeping baby in a smoke-free environment, and that’s for anyone that cares for the baby in the household. Then setting up the sleep environment, so making sure that the cot meets Australian standards, the mattress meets Australian standards, that there’s lightweight bedding and it’s only pulled up to the baby’s waist, and if not a certified sleep suit, making sure that the baby is in their own safe sleep space and separate space to their parent or caregiver the first six months of life, and then breastfeeding a baby where possible.  

I think it is really important to talk about safe co-sleeping in this context as well. And the reality is that in the first six months, about 75% of babies will co-sleep at some point. So although we have this evidence base around safe sleeping and putting baby down in their own sleeping space, if most parents are co-sleeping at some point, it’s really important that we address that and we talk about safe co-sleeping so that incidental falling asleep on the couch and those kind of things don’t happen.  

There’s a really good resource for health professionals written by the Lullaby Trust and UNICEF, is a UK-based resource but can be helpful I think, around talking about that discussion about safe co-sleeping, and I think probably the key points in that discussion are talking about when co-sleeping isn’t safe, and how to avoid those situations. So that’s things like making sure if the parent is overly tired or unwell in any way, they’re not co-sleeping. If they’ve consumed alcohol or other sleep-inducing medication, they’re not co-sleeping. We would only recommend co-sleeping in households where there are no smokers. And then that co-sleeping really isn’t safe for premature infants or babies who are born small for gestational age, and that co-sleeping never occurs on a couch or sofa.  

So again, it’s about working with families and making sure that you’re providing them with good information so that they can make informed choices about infant sleep. 

Dr Sam Manger  41:30   

Yeah, some fantastic information and resources there. Thank you. It’s very common for infants and babies not to sleep through the night, and if they do, then amazingly lucky. What practical recommendations do you feel can improve nighttime sleeping for infants? 

Dr Mairaed Crawford  41:45   

This is such a big topic and such a loaded topic for poor sleep deprived parents who are in the thick of it. I also think it’s really challenging to help parents navigate. There are so many resources, myths, all sorts of things around infant sleep, available on social media. There’s lots of sleep consultants who make a business out of vulnerable parents as well.  

There’s, you know, Johnny’s mum who’s done X, Y, Z at mother’s group to be able to get their baby to sleep 12 hours through the night. And it’s such a challenging thing for parents and families who are experiencing sleep deprivation. I think part of this is setting up realistic expectations for infant sleep and what that looks like in the first 12 months of life.  

Babies don’t get the memo to go to bed at six o’clock and wake up at 6am with only two feeds. It would be great if they did, but that’s not the reality. So I think sometimes a lot of this is around education, dispelling some of the myths around what is now probably outdated information around those first wave behavioural interventions and so basically, what’s starting to emerge from the neuroscience evidence and some of the attachment psychology evidence is that we should go back to kind of cue-based care.  

Babies are biologically hardwired to seek caregivers, and sleep is a learned process. Regulation at sleep time is a learned process, and we cannot expect babies to come out of the womb and regulate their circadian rhythm and sleep off the bat. So, talking about the variable needs of individual babies and what their sleep needs might look like. Also reassuring parents that babies with lower sleep needs don’t actually have poorer developmental outcomes, can be a big relief for parents often, because some parents come in and are so fixated on wake windows and making sure their baby’s getting adequate sleep very often, then what happens is this cascade of interventions to try and make their baby have enough sleep during the day, and then we start to see the downfall of night’s sleep.  

So, I talk about the daytime being for living, that sleep can be variable. Babies don’t have to go down for a set amount of time. We can be really flexible in what that looks like. Place of sleep in during the day can be flexible. They might fall asleep in the pram or in the baby carrier or in the car while you’re out and about, if they’re waking on transfer, the sleep pressure’s probably not high enough, and that’s okay. Cat naps are fine.  

So really normalising the variability of sleep, it can be helpful to recommend to parents to set a regular wake time, because that then sets up that concept of circadian clock. Baby’s been in a dark environment for nine months. There’s no lights on, lights off in the womb and so they need to learn that process, and we need to help teach them that process.  

So, another practical tip is to avoid dark environments and quiet environments for daytime sleep. It’s fine if baby’s having a sleep in the living room, in a safe sleeping space while the toddler’s banging the toy on the floor, that’s absolutely okay. So, normalising some of those things. And I think what that does Sam, is then take the pressure off feeding. We don’t have to be at home at 10am for baby to go to sleep in their cot or their snoo and that just allows mums to be a bit more relaxed. And babies do really feed off that heightened anxiety around sleep as well, so they’re probably some of the quick interventions that I’d recommend.  

I think it’s also important to know that any kind of change that we make to babies sleep pattern takes a couple of weeks to kick in. So, if we are reducing daytime sleeps and naps often, we don’t see that change for a couple of weeks as well. And then a couple of other really practical tips, is to avoid the nighttime sleep disruptors, so babies don’t need to be burped, and it’s one of the things that really disrupts nighttime sleep is shushing a baby and holding them up to burp them after their feed. And the other is nappy changes. So, unless it’s a dirty nappy, it doesn’t need to be changed overnight, because it’s another big disruptor to nighttime sleep. I don’t know if you have anything to add to that Brigitte?  

Brigitte Corcoran  45:26   

Just the third thing I would add is just keeping the night feeds quiet and dark. So not turning, you know, setting the whole house alight to feed the baby at night. So just some practical things there. But no agree with all of what you said.  

Dr Sam Manger  45:56   

Once again, some fantastic summary and tips there, you mentioned there around sleep expectations, and that seems to be such an important thing to raise right at the beginning, isn’t it, around expectations of what is normal sleep, because that alone can dispel a lot of things that people might be expecting the baby sleep a certain amount. They’ve got to be fed at this time, and as you mentioned there, around identifying cues and going with those natural, organic style sleep cues, and being aware of nighttime disruptors that, and then a regular wait time as well. It’s very normal for infants to sleep during the day or nap in that first year. But what recommendations do you give to parents when that period of life changes from the first six months to the six to 12 months? 

Dr Mairaed Crawford  46:32   

This is again, about being flexible and responding to kind of baby cues if there’s lots of disruptive sleep. Again, going back to first principles, setting a regular wake time is really important because we can kind of get a sense of if there’s lots of nighttime sleep disruption. What we try and do is calculate the overall 24-hour sleep requirements and then work on knocking back half an hour or an hour of sleep from that to see whether that settles nighttime waking, so I usually get parents to start with setting the morning wake time.  

It’s really hard in Queensland because the sun is up early and so very often that means that babies are up early. This is where I really encourage families to think about whether they can be creative around how mum might get some extra sleep if she’s attending to most nighttime feeds. So that’s when dad puts baby in the pram and takes them for a walk at 4:30am if that’s when baby’s up often. Again, this falls into the expectation that their baby needs to be in bed at six o’clock, and that’s often too much sleep for many infants. So really working on where can we find space to maybe open up wake times for babies and reduce the total amount of daily sleep.  

And if you’ve got a low sleep needs baby, it’s very, very challenging sometimes for a baby, you know, between that six and 12 month period, they may only be having one short nap, but if it means we can then consolidate nighttime sleep, that often is much more workable for parents. So, it’s talking about how we look after mum, if their baby’s not sleeping very much during the day, and then as a family, how can we support what’s happening for sleep overall? 

Dr Sam Manger  48:05   

You mentioned that resource before, with the sort of bell curves around what sort of normal sleep range is, do those resources also enter into that around how sleep changes over that period of time? 

Dr Mairaed Crawford  48:15   

Absolutely, there’s an excellent meta-analysis article that’s been published by the Journal of Sleep, and it’s got a beautiful pictograph, if you google ‘Journal of Sleep – normal sleep needs’ that steps through the variation. I often show this in practice as well, where low sleep needs babies might sit, and that can be really reassuring for parents. Again, “my baby’s getting enough for their age, but they definitely are on the lower end of the curve”, and sometimes that’s enough to work, then with some of the other interventions, that can be really beneficial. 

Dr Sam Manger  48:44   

Again, as you say, as long as the baby is thriving in every other respect, we can be confident about that. Now, Brigitte back to nutrition, and we’re talking about starting solids. The guidelines are to avoid solids before 17 weeks, but to start by six months, which is about 26 weeks, so that’s a little bit vague. There’s quite the gap there. What are some practical time points and milestones we can discuss with parents around this? 

Brigitte Corcoran  49:08   

So just going back to the to those guidelines. So obviously the lower end, we don’t want to introduce solids before 17 weeks, because there is a much higher risk of two things happening. One is developing food allergy if we introduce foods, particularly allergens, to infants in that early period, and the second is actually overweight and obesity.  

So, we do know that when infants are actually introduced to solids really early, they actually have a much higher chance of developing overweight and obesity. So that’s one of the key reasons why we really don’t want to be offering before the 17 weeks. But somewhere between 17 weeks and 26 weeks, infants will start to show us some signs of readiness to eat solids. 

What do these actually look like? Well, first thing first, is to be able to eat solids, particularly a thicker puree that you need to swallow, as opposed to suck all the liquid. You actually need to have some good head control. So that’s the first important thing that we need to see. If a baby doesn’t have good head control, then potentially they’re not ready to start solids.  

Further on from that, they need to have a reasonable amount of trunk support, but they don’t need to be able to fully sit up independently. They should, hopefully, are showing us some, some signs that they’re interested in, in watching you eat. They might start grasping or reaching, putting their hand out for food that you may actually be eating. They’re certainly putting a lot more toys and things like that in their mouth, so there’s a lot more hand to mouth movement as well. That might be an indication that they’re getting ready.  

And last but not least, they actually, might actually open their mouth when you when you bring a spoon or even some food to their mouth as well. So, there’s some of the things that we’re looking at, and most infants that are typically developing will actually show some of those signs, roughly within that window of 17 weeks to 26 weeks. 

Dr Sam Manger  50:42   

And as soon as you say, they’re around the allergen components. So too early may be a risk, but also too late, may be a risk. Now, before we jump into that, what are some of the early foods that are a good trial with a child who is starting to show those signs, they’re starting to watch the food reach out and those sorts of things. What are some early foods that we can experiment with?  

Brigitte Corcoran  51:03   

Obviously, the main reason for introducing solids, from a nutritional point of view, is that infants’ iron stores are essentially depleted by the age of six months. So, while breast milk is, it’s relatively low in iron, but it’s highly available, those infant iron stores are actually essentially depleted by six months.  

So nutritionally, the main need for food in that window of 17 weeks to 26 weeks is to actually obtain some iron containing foods to re boost those iron stores. So, we do have a number of foods that infants are able to eat, but most commonly, infants may start on an iron-fortified rice cereal. The reason why that’s often recommended is it’s fairly bland, it’s fairly easy to prepare, and it doesn’t really matter so much about wastage, because we know that when infants first start eating solids, they’re really just going to be having a few licks and potentially spits as well. 

So, we don’t need to worry about too much wastage. Further on from that, we’re wanting to expose infants to a range of vegetables, if we can. And the reason why we suggest often having vegetables is because they’re a nice carrier for some of our other iron containing foods which are things like meats, which we ideally want to get into an infant’s diet relatively early into the solid weaning phase. So, things like pureed meats, chicken, fish, but also the things that I love, they’re quick and easy and can be really convenient. Foods like tinned legumes and lentils, which are really high in iron, as well as tofu, which is a wonderful early weaning food because it has basically, it’s relatively bland and it just takes on the flavour of any other food that the infant will is likely to eat with it, but it’s really high in iron and protein, so it’s a really good first weaning food. 

Dr Sam Manger  52:38   

That’s very interesting, and as you said, with some of things like those iron-fortified cereals, you can mix breast milk with those, and those sorts of things as well. So, it’s not exclude one or the other, you can combine these things. And you mentioned potential spills and slips. I mean, it’s definite, it’s guaranteed, a guaranteed mess.  

Brigitte Corcoran  52:55   

Yeah.  

Dr Sam Manger  52:56   

And so, let’s explore some of those potential benefits and risks of different approaches to starting solids, such as baby lead weaning versus the traditional period, or textured, modified sort of spoon feeding.  

Brigitte Corcoran  53:06   

It can be a polarised view in the community about which approach you take as a parent. At the end of the day, we need to basically learn to eat wet food and finger food. So, we actually need to develop the oral motor skills to actually manage both.  

In terms of historically, infants were actually given pre masticated food. So, the parents would actually chew the food and get it into a form that an infant could actually take it and be able to swallow it. Effectively, what pureed food is is pre-masticated food. So, it’s presenting food in a form that an infant can actually obtain some nutrition from within their oral motor skill set that they have at that point in time.  

As an infant gets bigger, obviously they will start to learn to develop some more oral motor skills, and that’s where biting, tongue lateralisation, so we actually get the food over onto our gums to be able to chew it. And early chewing actually occurs, and that’s what actually happens with finger food. So, we actually need to develop both of those skills. So, there is a place for both spoon feeding as well as baby led weaning. So, it’s, in my view, there’s a place for both, and it’s not necessarily one or the other. We actually need to learn how to do both.  

Dr Sam Manger  54:14   

Yeah, it’s very interesting when you put it in the context of the development of the child as well around their skills, because it is another fine motor area, not just the hands and feet and so on. So that does make a lot of sense in diversifying those skills and diversifying the food. The pre mastication is a fascinating point from a cultural point of view, isn’t it that that’s what was the more common place. 

And obviously now we don’t recommend that, because we obviously don’t want to get a transfer of bacteria from the parent to the child. 

Let’s talk about milk, because that’s another very common FAQ that comes up. The WHO guidelines now support the use of cow’s milk as a drink from six months. So, what are your thoughts around this for Australian children?  

Brigitte Corcoran  54:50   

So, this is a really interesting one. So, this came about as a result of the WHO review of the infant feeding guidelines in 2020. I’ll just say first up at the NH&MRC have actually come out and said that there’s actually no change to the, to the current Australian infant feeding guidelines. 

Dr Sam Manger  55:04   

And that’s still cow’s milk about 12 months, isn’t it? 

Brigitte Corcoran  55:07   

Correct. Yes. So, if an infant is unable to be breastfed or not breastfed into that second six months of life, then the milk drink that is the best choice for them would actually be infant formula. So, I’ll just preface this conversation by saying that first, we do know, however, that families have got to continue to ask about this because it was a recommendation from the World Health Organization.  

So, we have, to think about how this particular recommendation applies in the local Australian context. What the WHO found when they actually did their review, they found that, obviously there was plenty of evidence to support breastfeeding in the first six months of life and beyond. They also found that there was plenty of evidence for infant formula feeding if a child was unable to be breastfed in that first six months of life.  

In their review, they found that there was a lot of mixed opinion about what the ideal milk should be in that second six months of life, and there was some question about, particularly given that WHO need to factor in infants across the world, which is, is infant formula in the second six months of life really necessary?  

Given that for some less developed countries, access to clean water and even access to formula may actually not be in that infant’s best interest. So, we’ve got another situation here where we’ve got mixed messages for the parents of infants in Australia. There’s a couple of other things that we need to think about. So obviously, we’re not a developing country, and for most of Australia, and I say most of Australia, we have access to clean water. So, for most infants, there should be access to clean water to be able to prepare an infant formula.  

The cost of infant formula is obviously another thing, which I’ll come and talk about in just a minute. In terms of the other factors that we need to think about in Australia, 75% of our infants do not meet their recommended dietary intake for iron from their weaning diet. So, if we were actually to, for those infants who are not able to be breastfed during that time as well, we’re providing them with cow’s milk that actually doesn’t have any dietary iron in it either. But further to that, cow’s milk, the high protein content of cow’s milk, can actually cause gastrointestinal bleeding.  

So, we have already have a cohort of infants in Australia that are not getting enough iron from their weaning foods. If we then put on top of that, giving them a milk-based feed that’s not actually not containing any iron, and that we increase their, further increase their iron losses through their gut, we’ve got a more of a significant issue in terms of iron deficiency anemia, which is a real concern for our infants and our toddlers.  

The third point on this is that in Australia, we have a significant issue with overweight and obesity. Cow’s milk has twice to three times the protein content of infant formula and breast milk. We know that dietary protein intakes in infancy are related to overweight and obesity later in life, so for an average six month old who might be consuming around about a litre of breast milk or formula, if we actually substitute that with cow’s milk, we’re actually going to be increasing the protein intake of those infants threefold. So that has a significant impact on potential prevalence of overweight and obesity for these particular children. So that’s obviously not an issue for a lot of developing countries, but in Australia, that is a significant issue, and that is one of the main reasons why the NH&MRC have actually come about and said not to actually change our infant feeding guidelines.  

Dr Sam Manger  58:32   

Well, that’s very good to be so clear about it. As you say, there’s sort of national context of this as well, as well as local health considerations, and we touched on allergens very briefly, but let’s get into it in a bit more detail around best practices for introducing common allergens.  

You mentioned before that too early, before four months, we may increase the risk of certain food allergies. Too late, introducing solids we may increase the risk of, so there’s, there’s a sort of good period there. What advice do we have around introducing different food allergens?  

Brigitte Corcoran  59:01   

It’s a really good point. So about 10 years ago, our infant feeding guidelines around food allergies actually changed quite significantly, based on a landmark trial that was done in the UK called The Learning Early About Peanut Allergy, and from that particular study in 2015, where infants were actually randomised to receive a relatively high dose of peanut early in infancy versus no peanut until the age of five, we found that the infants who actually received peanut early and quite a bit of peanut early, actually had an 80% reduction in the development of them developing a peanut allergy, which is quite significant because we know that peanut allergy can actually persist well into adulthood.  

So that was a particularly big study that actually really made us stop and think about, okay, well, when should we be introducing allergens? Because up until that point, we had actually erred on the side of actually introducing allergens later in infancy and even into the second year of life, with the thinking that potentially, if we give the immune system a bit more time that well, it might actually prevent allergies from actually occurring.  

It actually seems to be the converse. So based on that study and the subsequent study that came as a result of that, the Inquiring About Tolerance Study, which looked at introducing most of the other allergen, allergenic foods, for example, dairy, soy, other tree nuts, wheat, egg, basically for the results from those studies showed us, the sooner we can actually get some of these allergenic foods into the infant diet, the better.  

That said, practically, obviously, when we’re introducing solids, we want to get a number of other staple foods into the diet, but for most infants, we can actually introduce a number of allergenic solids relatively quickly. They don’t have to be spaced days and days apart, we can actually introduce them essentially one day after the next, after the next, so they don’t have to necessarily have weeks on end in between introducing allergenic foods. In the LEAP study, the average age of introduction of peanut was around nine months. So, we’re generally just recommending that most infants get exposed to these allergenic solids sort of early into that second six months of life, but definitely by 12 months.  

But the second component of this is to ensure that the infants actually continue to receive and eat these particular allergens on a regular basis, because that seems to be also quite protective in not developing a food allergy down the track. 

Dr Sam Manger 1:01:16   

So, let’s move along in sense of their food journey a little bit. There’s an entire supermarket aisle dedicated to baby foods and a lot of marketing around that. Would you recommend a lot of these foods? If so? Why or why not?  

Brigitte Corcoran  1:01:21 

Again, that’s certainly an interesting space. Essentially, an infant doesn’t need those foods full stop, however, they are marketed as convenience foods. What we do know, though, is that families are using them a lot more regularly than what we would probably recommend as a convenience food.  

A lot of families do feel that they are regulated quite closely by the Food Standards Authority. However, there’s actually a lot of scope and loopholes around some of the marketing and some of the labeling that actually can be put on these particular products. So, there’s a number of issues with that particular aisle.  

One is that a lot of these commercial foods are actually quite high in sugar, and when we’re trying to establish infants on weaning solids, having an early taste preference for sweet will really actually knock out a lot of our more high nutrient dense foods, like vegetables, meats, so on and so forth. So that can actually really set up some potential mealtime battles for families.  

The second issue is that there are a lot of a lot of these foods are high in salt. And again, we know that little kidneys don’t cope very well with excessive amounts of salt. The third thing is, for a lot of the items that have come about, a lot of the dissolvable infant snack type foods, the Australian Guide healthy eating and the infant feeding guidelines actually don’t recommend any discretionary foods for infants. So we’ve got a conundrum in that where we’ve got a whole market of snack foods that potentially getting eaten by infants and displacing better, nutrient dense foods that hopefully we’re trying to expose them to and explore and get more of a taste for in order to live well and to thrive, to grow and to actually prevent chronic disease down the track. So, it’s a bit of a conundrum at the moment, and as health professionals, that’s a bit of a battle that we’re actually up against. 

Dr Sam Manger  1:03:03 

It’s a whole conversation in and of itself, but it is an interesting one. In that aisle, there are often things like crisp breads or different sort of little snack things like that. But also, lots of pouches of different types of food, whether it’s fruit pouches or, you know, like a stew pouch or something like that. And so, when you say that they’re not necessary for children, what would be the recommended thing their child should eat in an ideal world? So that’s the first question. And some of those foods in that aisle may not be high in sugar and salt and aspects like that. So maybe we can make informed decisions about the best choice within an aisle, as it were. 

Brigitte Corcoran  1:03:35 

So, if we just address the pouch foods initially, so absolutely, there’ll be potentially some of those foods that can be used in place of home cooked meal. For example, if you’re out and about and you need something quick and easy. That said, if you actually look closely at some of those foods, the nutrient density of those foods is actually quite low in that when we’re talking about iron, which is one of the main nutrients that we actually want infants to eat a reasonable amount of, most of those pouchfoods will actually have minimal amounts of iron in them.  

Second to that, a lot of those pouch foods will actually have a fruit base. So even though the label on the product will actually say something else, the biggest ingredient in that food is actually fruit. So, we do need to look closely at the ingredient list, and we absolutely need to empower and educate families to look closely at those things. In terms of the snack foods, they’re all the puffs, the things like that, that infants don’t necessarily need. It’s just the marketing has been so strong and so effective for those foods that parents feel that their infant actually does need those to develop their chewing skills, to develop their biting skills, etc. Those skills can actually be achieved just with regular food.  

Dr Sam Manger  1:04:47 

That’s fantastic. Yeah, the density is a fascinating point because, like, I have looked at those packets with my three children and look back and go, that looks okay, but there’s like, one lentil and one pee, and the rest of it is water. And you’re like, well, that is a waste. 

Brigitte Corcoran  1:05:00 

Exactly.  

Dr Sam Manger  1:05:00 

They may be okay in certain replacement situations, but really, you should be focusing on a healthy staple diet in the background from the home, as it were now, right? Another common area that comes up is around screen time, and current guidelines would suggest it’s not recommended for children under the age of two. That’s great, but in the real world, how do we encourage exhausted parents to avoid using screens as the third parent or the babysitter?  

Dr Mairaed Crawford  1:05:25 

Such a challenging discussion to have with parents. A couple of practical strategies, I suppose so. One of the things is actually getting your kids to be involved in the everyday tasks that you need to do. If you’re trying to chop dinner, get them up on their learning tower, give them something to do next to you. It’s often a time where giving your kids some water play can be really helpful. They feel like they’re helping having some very easy, go-to indoor activities.  

It might be where you get the craft box out to put up on the dinner table or the bench while you’re trying to get done what you need to get done, scheduling lots of outdoor time. Kids are great at finding things to do in outdoor environments. It might be time out in the backyard, it might be time out in the front yard. It might be scheduled time at the park, but I do appreciate that it’s an incredibly challenging thing for the modern family, often with two parents working full time, who come home and scoop their kids up from daycare on the way home and are exhausted.  

It’s a really, really challenging space, and I think it’s probably a space that we are only just seeing the tip of the iceberg for the later life, developmental effects on kids, attention, ability to learn at school, behavioral challenges. So, I do think it’s an area where, as health professionals, we actually have a responsibility to talk about on table with families in terms of our preventative health messaging.  

Dr Sam Manger  1:06:44 

It’s definitely an emerging area that, because it’s a relatively new technology for all of us, not just children, but for parents as well, in managing the situation, we’re all trying to figure out the safest ways and the best, most effective ways, and harm minimisation and those sorts of aspects.  

There’s the old saying, you know, it takes a village to raise a child, which you sort of alluded to earlier in our talk, and that’s partly why we’re seeing this screen phenomena occur, because it does take sometimes multiple people, not just two parents, to raise a child. And in a modern society where we have smaller families, there is a gap there that is being filled by that technology. So, it’s going to be a challenge socially that we all need to start talking about openly and addressing. I laugh when you mention water and crafts. I think people with children like no more crafts, paint, please. 

Dr Mairaed Crawford  1:07:30 

The key message is it doesn’t have to be complex. And again, the social media is filled with all of these ideas for sensory stuff, but you can literally get the ice cubes out of the freezer and put them on a plate for your child to play around with. It doesn’t need to be corn starch with color dye or any of those things. It can be really simple. It might be giving your child the vegetable peels to play with, you know, cut with a safety tool, but I do appreciate it’s really challenging, and I think building in time around everyday tasks where it’s not your go to. I sometimes get very horrified walking through the shopping aisles and a child sitting in the trolley and looking at a screen, that’s a beautiful opportunity to talk with your child about the colours of the fruits and vegetables, or talk about their day, so thinking about how we can build in some of that stuff. And I appreciate this so much for parents to juggle in the in the modern world of parenting. And I suppose the other thing around screen and screen time and use is, if you are using it, making sure that you’re using it as a family. So, there’s that discussion point and interaction and being really careful around what we’re modeling for our little people, so having our own limits and boundaries around screen time, so that we can be there and be with them.  

Dr Sam Manger  1:08:43 

So, there’s a fantastic range of, sort of medical and preventative care components we’ve covered here in regard to infant health. Brigitte we’ll go to you first, are there any particular practical tools or resources that you found very useful for healthcare professionals to raise awareness about infant health in these first 12 months of life?  

Brigitte Corcoran  1:09:00 

One of the main utilised resources I use is actually the Raising Children’s Network, so the Australian Government. It’s got some wonderful information on breastfeeding. It’s got some great breastfeeding videos, but it’s got some lovely pictorial photos of finger foods, but also some nice, easy recipes. We know that one of the barriers for parents actually introducing nutritious solids is actually cooking skills. So, there’s just some great, easy recipes. There’s pictorial recipes as well, to show families how to actually cook some basic infant weaning foods. One of the ones that I do actually recommend a lot is the ‘Nip Allergies in the Bub’, and this is to help both health professionals as well as consumers in A. Understanding food allergy and but B. Also understanding some practical strategies for how to actually introduce allergenic solids.  

So, there are these lovely pictorials of how to actually introduce different allergens at different ages and stages, but also then how to actually keep those allergens in the diet. So, there’s some really great information on that particular website, but also for health professionals in terms of eczema management and eczema care. There’s also some great videos for how to actually manage more moderate to severe eczema as well. So that’s the three that I do recommend on a regular basis. 

Dr Sam Manger  1:10:44 

Excellent, Mairaed?  

Dr Mairaed Crawford  1:10:45 

Talking about iron rich foods, there’s an excellent PDF from the Royal Children’s Hospital in Melbourne, which has some really good recommends for iron rich food. The other thing is around, so talking about screen time, the Triple P Parenting, which is free access for parents, I think, can start to create some really good conversations for parents around boundary setting with children. And I would argue the question asked about the first 12 months of life, but it can be really important for parents to start to set up some of those discussions around boundary setting, sleep, how they’re managing household and interaction with their young people. And I think that that’s an excellent resource, freely available. You can sign up talks you through a whole lot of modules, which can be really useful as well.  

Brigitte Corcoran  1:11:25 

The other one I was just going to mention, sorry, which I didn’t mention before, was Queensland Health actually have a nutrition education material online, which is has a number of different dietary information sheets for pediatrics. 

Dr Sam Manger  1:11:35 

Well, thank you both for your time and expertise and experience in today’s podcast. It’s been wonderful having you both on.  

Dr Mairaed Crawford  1:11:41 

Thank you.  

Brigitte Corcoran  1:11:41 

Thanks.  

Dr Sam Manger 1:11:42 

Today we’ve been talking to Dr Mairaed Crawford and Brigitte Corcoran about breastfeeding and health in the first 12 months of life. For more information on today’s topics, visit the Health and Wellbeing Queensland website @www.hw.qld.gov.au.  

If you’ve liked today’s conversation, be sure to subscribe for future episode updates. We’ll see you next time on the Clinician’s Guide to the First 2000 Days.