Pediatric Nutrition Guidelines for Health Professionals, January 2025

This document outlines evidence-based nutrition and feeding guidelines along with red flags for healthy, full-term infants and children up to 6 years of age. Further investigation, including possible referral to a Registered Dietitian (RD) for nutrition assessment and ongoing follow-up, may be warranted for infants and children who do not meet guidelines or present with red flags.

We acknowledge all individuals, regardless of sex and/or gender identity or expression may be in a feeding relationship with their baby/child. The term parent is used throughout this document and refers to a parent or caregiver who is involved in the child’s care. The terms breast milk / breastfed / breastfeeding are widely used and we acknowledge the terms lactating / human milk / chestfed / chestfeeding / expressing / pumping can be used interchangeably.

Ontario Dietitians in Public Health would like to thank the various health care professionals who reviewed the guidelines and provided feedback. Your time, expertise and knowledge are truly appreciated.

Definitions

Milestones – Marker or point in development related to feeding.

Guidelines – Evidence-based recommendations for nutrition and feeding.

Red Flags – Findings that may require additional action, investigation and/or referral.

Additional Information – Topics within the guidelines that include additional detail.

About ODPH

Ontario Dietitians in Public Health (ODPH) is the official voice of registered dietitians working in the Ontario public health system. For more information, please visit at odph.ca or email info@odph.ca.

0 to 6 months

Milestones

By 1 month:

• Sucks well at the nipple (2)

By 2 months:

• Feeds every 2-4 hours during the day and may need to feed during the night (2)

By 4 months:

• Holds head steady when supported in a sitting position (2).

At around 6 months, signs of developmental readiness for complementary foods:

• Has better head control (3)
• Can sit up and lean forward (3)
• Can let parent know when they are full (turns head away) (3)
• Can pick up food and try to put it in their mouth (3) 

Guidelines

Division of responsibility:

• The parent is responsible for what to offer. The infant is responsible for when, where and how much is consumed (4).

Fluids:

• Breastfeed exclusively for the first 6 months (3,5). Offer expressed breastmilk if feeding from the breast is not possible (3). 
• If breastmilk is not available, offer safely prepared infant formula approved by Health Canada (3).
• Follow infant’s feeding cues, referred to as ‘infant-led’, ‘on-cue’ feeding or ‘feeding on demand (3). 
• Give a liquid vitamin D supplement of 400 IU (10 mcg) daily to fully or partially breastfed infants. Infants receiving only infant formula do not require a vitamin D supplement (3). 
• Avoid water unless medically indicated (2). Avoid juice or other beverages (3,6). 

Foods:

• First complementary foods should be iron-rich (i.e., animal-based protein, plant-based protein, iron-fortified infant cereals) (3). 
• Introduce complementary foods at about 6 months of age, following signs of readiness.
• Infants at high risk for developing a food allergy have a personal history of atopy, including eczema, or have a first-degree relative with atopy (i.e., eczema, food allergy, allergic rhinitis, asthma) (7). For high-risk infants, based on developmental readiness, consider introducing common allergenic foods, such as peanuts and eggs, at around 6 months of age, but not before 4 months of age (7). If tolerated, continue to offer common allergenic foods weekly to maintain tolerance (7).
• Avoid honey, including pasteurized or cooked, until 12 months (due to risk for infant botulism) (8).

Red Flags

• Loses > 7% of birth weight by day 3 (9).
• Starting at day 5, does not gain an average of 20 g per day for the first 3–4 months of age.
• Does not regain their birth weight by day 10 (9).
• Does not have ≥ 6 wet diapers a day after day 5 and/or urine is not clear to pale yellow with almost no odour (9).
• Consumes cow’s or goat’s milk (including pasteurized or raw), plant-based beverages (e.g., soy, oat, almond), evaporated milk or homemade formula (3) or infant formula not approved by Health Canada (8).
• Not preparing infant formula safely (e.g., diluting infant formula).
• Consumes water, juice, herbal teas or other beverages (3).
• Introduces complementary foods too early (before signs of developmental readiness), including adding infant cereal to a bottle (3).
• Uses a propped bottle or infant is not supervised during feeding (3).
• Feedings are forced or restricted (3).
• Skips feeds in attempts to facilitate longer sleep times (9).
• Parent has depressive symptoms that may impact parent’s responsiveness to infant cues, including feeding (10).
• Worries about not having enough food or running out of food to feed the household.

6 to 9 months

Milestones

Signs of developmental readiness for complementary foods at about 6 months of age:

• Control their head and neck (11)
• Sit up alone or with minimal support (11)
• Grasp objects and bring them to their mouth (11)

Note: infant may still have early gag reflex until around 7 months (12)

Guidelines

Division of responsibility:

• The parent is responsible for what is offered and is starting to become responsible for when and where the infant is fed. The infant is responsible for how much and whether to eat the foods offered (4).

Fluids:

• Continue to breastfeed (8). Offer expressed breastmilk if feeding from the breast is not possible (8).
• If breastmilk is not available, offer safely prepared infant formula approved by Health Canada (8).
• Give a liquid vitamin D supplement of 400 IU (10 mcg) daily to fully or partially breastfed infants. Infants receiving only infant formula do not require a vitamin D supplement (8).
• Delay fluid cow’s milk as a main milk source until 9-12 months (due to risk of iron deficiency) (8).
• Offer water from an open cup, as desired (8).
• Avoid juice (6). Apple juice is a source of inorganic arsenic (13).

Foods:

• Introduce complementary foods at about 6 months of age, based on signs of readiness. Delaying beyond 6 months increases the risk of iron deficiency (3,8).
• First complementary foods should be iron-rich (animal-based protein, plant-based protein, iron-fortified infant cereals) (3). 
• Offer iron-rich foods (e.g., beef, legumes, eggs, fish) ≥ 2 times a day along with vegetables and fruit (sources of vitamin C) (5,8). 
• Offer complementary foods before, after or between breastmilk or infant formula (8).
• Provide a variety of textures (e.g., lumpy, soft-cooked finger foods, shredded, finely minced, pureed, mashed, ground textures) and encourage self-feeding (8,14).
• There is limited evidence supporting baby-led weaning (BLW) as a feeding method. Provide iron-rich foods at every meal. Monitor infant’s growth and iron intake (14). 
• Introduce and offer a variety of vegetables, fruit and milk-based foods (e.g., cheese, yogurt), along with iron-rich foods (8,14). 
• Do not restrict fat intake. Higher fat milk-based foods include yogurt with > 2% M.F. or cheese with > 20% M.F (8). 
• To lower exposure to arsenic avoid fruit juices and if offering infant cereal, offer a variety of grains (13,15). 
• Introduce allergenic foods one at a time to gauge reaction. Allergenic foods can be introduced on successive days. Continue to offer weekly to maintain tolerance (17). 
• Start by offering small amounts of food (2-3 tbsp per day) and gradually offer more based on responsive feeding principles (8). 
• Provide 2-3 larger feedings (meals) and 1-2 smaller feedings (snacks) per day, based on infant’s feeding cues. Include infant in family meals (8). 
• Avoid honey, including pasteurized or cooked, until 12 months (risk for infant botulism) (8). 

Red Flags

• Does not consume iron-rich foods ≥ 2 times per day (8). 
• Consumes homemade formula, cow’s or goat’s milk or plant-based beverages (e.g., soy, oat, almond) as main milk source or infant formula not approved by Health Canada (8). 
• Not preparing infant formula safely (e.g., diluting infant formula, adding infant cereal to bottle).
• Consumes fruit juice, fruit drinks/punch, sports drinks, pop or beverages containing artificial sweeteners or caffeine (coffee, tea, hot chocolate) (6,8). 
• Consumes raw or unpasteurized milk or milk-based products or unpasteurized juice (8). 
• By 9 months, lumpy textures and finger foods have not been introduced or consumed (8). 
• Unsupervised during feedings (8). 
• Feedings are forced, restricted or infant is pressured or praised to eat (8). 
• Food selection and intake is restricted due to food allergy/intolerance, food dislikes or family’s eating pattern.
• Worries about not having enough food or running out of food to feed the household.

9 to 12 months

Guidelines

Division of responsibility:

• The parent is responsible for what is offered and becoming more responsible for when and where the infant is fed. The infant is responsible for how much and whether to eat the foods offered (4,6). 

Fluids:

• Continue to breastfeed (8). Offer parent’s expressed breastmilk if feeding from the breast is not possible (8).
• Give a liquid vitamin D supplement of 400 IU (10 mcg) daily to children who are fully or partially breastfed or receiving breastmilk (8). 
• If introducing cow’s milk, advise to wait until 9 to 12 months of age and limit to no more than 750 mL per day (8). Consider multiple milk sources (e.g. breastmilk, infant formula, cow’s milk) when providing guidance.
• Offer pasteurized, unsweetened homogenized (3.25% M.F.) cow’s milk (8). Pasteurized, full-fat goat’s milk enriched with folic acid and vitamin D can be an alternative to cow’s milk (8).
• For families who cannot or choose not to provide cow’s milk, continue with breastmilk or a soy-based infant formula until 2 years of age (8).
• Offer water and other fluids such as milk in an open cup (8). 
• Avoid juice (6). Apple juice is a source of inorganic arsenic (13). 

Foods:

• Continue to offer iron-rich foods (e.g., beef, legumes, eggs, fish) 2 or more times a day along with vegetables and fruit (sources of vitamin C) (5,8).
• New foods can be offered every day in any sequence (i.e., vegetables, fruit, protein foods, grains) (8). 
• Continue to introduce allergenic foods one at a time to gauge reaction. Allergenic foods can be introduced on successive days (16). Continue to offer weekly to maintain tolerance (17).
• Give allergenic foods, including peanut butter, cooked egg and wheat products by the first year of life (18, 19, 20).
• Offer a quantity of food based on responsive feeding principles (8).
• Provide up to 3 larger feedings (meals) and 1 to 2 smaller feedings (snacks) per day, depending on the infant’s feeding cues. Include infant in family meals (8).
• By 12 months, a variety of family foods with various textures are consumed (8).
• Avoid honey, including pasteurized or cooked, until 12 months (risk for infant botulism) (8).

12 to 24 months

Milestones

• By 12 months, has acquired full chewing movements (8)
• By 18 months, picks up and eats food with fingers independently (5,21)
• By 18 months, tries to use spoon (5)
• By 18 months, can independently drink from an open cup with minimal spilling (21)
• Growth slows compared with the first year (12,22). 

Guidelines

Division of responsibility:

• The parent is responsible for what, when, and where to eat. The child is responsible for how much and whether to eat the foods offered (4). 

Fluids:

• Continue to breastfeed (8). Offer parent’s expressed breastmilk if feeding from the breast is not possible (8). 
• Give a liquid vitamin D supplement of 400 IU (10 mcg) daily to children who are breastfed or receiving breastmilk (8).
• If breastmilk is not provided, offer 500 mL (16 oz) pasteurized, unsweetened homogenized (3.25% M.F.) cow’s milk each day. Pasteurized, full-fat goat‘s milk, with added folic acid and vitamin D can be an alternative to cow’s milk. Consider multiple milk sources (e.g., breastmilk, infant formula, cow’s milk) when providing guidance (8). 
• Offer water when child is thirsty (8).
• Avoid juice (6). Apple juice is a source of inorganic arsenic (13).
• Offer fluids other than breastmilk in an open cup (8). Transition from bottle-feeding to open cup by 18 months (8).
• For most children, there is no indication for the use of infant formulas beyond 12 months (8).
• If using fortified plant-based beverages as a main milk source, ensure that the beverage meets recommended minimum nutrient requirements.

Foods:

• Offer a variety of food from Canada’s food guide. Modify textures of family foods to reduce choking risk..
• Offer iron-rich foods (e.g., beef, legumes, eggs, fish) 2 or more times a day along with vegetables and fruit (sources of vitamin C).
• Offer an amount of food based on responsive feeding principles.
• Schedule 3 small meals and 2 to 3 nutrient-dense snacks per day, 2-3 hours apart. Include child in family meals.

Red Flags

• Does not eat iron-rich foods each day (8). https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/nutrition-healthy-term-infants/nutrition-healthy-term-infants-recommendations-birth-six-months/6-24-months.html
• Does not eat a variety of textures and family foods from Canada’s food guide (8). 
• Common allergenic foods have not been introduced (e.g., peanuts, eggs).
• Dietary fat intake is restricted (8). 
• Consumes > 750 mL (24 oz) cow’s or goat’s milk a day and/or > 175 mL (6 oz) of juice a day (8). Consuming these beverages in excessive amounts displaces complementary foods (22). 
• Main milk source is skim or partly skimmed (e.g., 2%, 1% M.F.) cow’s or goat’s milk or plant-based beverages (e.g., soy, oat, almond) that is not meeting the minimum nutrient requirements (23). 
• Has not transitioned from bottle to an open cup by 18 months (8).
• Drinks from a bottle filled with fluids other than water at night (8). 
• Consumes fruit drinks/punch, sports drinks, pop or beverages containing artificial sweeteners or caffeine (e.g., coffee, tea, hot chocolate) (6,8).
• Consumes raw or unpasteurized milk or milk products or unpasteurized juice (8). 
• Unsupervised during feedings (8).
• Feeding is forced, restricted or child is pressured to eat (8). 
• Coughs and chokes often when eating at 24 months (2). 
• Eats throughout the day with no set meal or snack times (8).
• Food selection and intake is restricted due to food allergy/intolerance, food dislikes or family’s eating pattern.
• Worries about not having enough food or running out of food to feed the household.

2 to 6 years

Milestones

• By 30 months, lifts and drinks from a cup and replaces it on the table (2). 
• Progressing to adult eating pattern but needs adult role modelling (10-21).

Guidelines

Division of responsibility:

• The parent is responsible for what, when, and where to eat. The child is responsible for how much and whether to eat the foods offered (4). 

Fluids:

• Continue to breastfeed or offer breastmilk as long as child and parent want (8).
• If cow’s milk or a fortified plant-beverage is not offered daily, offer a daily Vitamin D supplement and include calcium-rich foods (24).
• Offer water from an open cup when child is thirsty (6).
• Avoid juice (6).

Foods:

• Schedule 3 meals and 2-3 nutrient-dense snacks per day. 2-3 hours apart (12).
• Follow the advice in Canada’s food guide.
• Offer an amount of food based on responsive feeding principles (22).
• Eat together as a family as often as possible (22). 

Red Flags

• Consumes beverages from a bottle (25).
• Consumes fruit drinks/punch, sports drinks, pop or beverages containing artificial sweeteners or caffeine (e.g., coffee, tea, hot chocolate) (12,26).
• Feeding is coerced, restricted or child is pressured to eat (12,22).
• Rarely or never eats meals with their family (22).
• Consumes unfortified plant-based beverages as main milk source (27).
• Consumes raw or unpasteurized milk or milk-based products (28) or unpasteurized juice (29).
• Consumes more than 750 mL of milk per day (30).
• Depends on vitamin/mineral supplements or specialty oral supplements instead of offering a variety of foods (22).
• Eats throughout the day with no set meal or snack times (22).
• Food selection and intake is restricted due to food allergy/intolerance, food dislikes or family’s eating pattern.
• Worries about not having enough food or running out of food to feed the household.

Additional Information

Promoting Breastfeeding

• Health professionals play an important role in providing unbiased, evidence-based information to help parents make an informed feeding decision. This includes the prenatal period, when infant feeding decisions are often made (31). They also are critical in connecting parents to supports, when needed.
• Breastfeeding supports cognitive development3 and decreases a child’s risk of:
  – Sudden infant death syndrome (SIDS) (3)
  – Diarrhea (3)
  – Ear and lung infections (3)
• Individuals who breastfeed benefit from protective factors that increase over time (32) and are less likely to experience:
  – Breast and ovarian cancer (32)
  – Type 2 Diabetes (32)
  – Heart Disease (32)
• Educate parents on the development of milk supply in the early days to reduce unnecessary infant formula supplementation. Some parents question the adequacy of colostrum feedings and perceive they have an insufficient milk supply. Parents may receive conflicting advice about the need to supplement and may benefit from assistance with breastfeeding technique, education about normal physiology of breastfeeding and infant behaviour.
• The Breastfeeding Protocols for Health Care Providers were developed for health care providers to promote, protect and support effective breastfeeding.
• Connect all breastfeeding parents with local community supports, including contact information for public health, hospital outpatient clinics services or Health811. Public health units often have virtual and in-person appointment options as well as online information or support via e-chat or phone.

Expressed Breastmilk (EBM)

• Hand expression in the first hour after birth and continuing after each feeding helps to establish a good milk supply, even when breastfeeding is going well. Families can provide breastmilk by cup or spoon while infant learns to breastfeed effectively. This important skill can (32):
  – Soften the areola to help infant latch
  – Lessen the discomfort of engorged breasts, whether breastfeeding is continued or not
  – Be used as an alternative to a breast pump
• Offering EBM by hand expression or by pump from the infant’s lactating parent is the first choice for supplemental feeding (33).
• For eligible neonates who are in hospital, donor human milk may be an alternative nutrition source. Donor milk is obtained from a recognized human milk bank. The sharing of unprocessed human milk is not recommended (34,35).
• To help preserve milk supply, hold infant skin-to-skin with frequent opportunities to breastfeed if infant is not latching well or is not able to latch.
• Encourage frequent and effective milk expression to maintain or increase milk production; usually once for each time the infant is supplemented or at least 8 times in 24 hours, with at least 1 expression overnight.
  – Empty breast each time breastmilk is expressed to prevent engorgement, compromised milk supply and other complications.
  – Hand expression may result in larger volumes than a breast pump in the first few days following birth and may increase overall milk supply.
  – Breast massage and/or compression along with expressing with a mechanical pump may also increase available milk.
• Options for offering EBM: supplemental feeding device at the breast (lactation tube), cup, spoon, dropper, finger, syringe or bottle.
  – Cup feeding allows infants to control feeding pace (33). Cup feeding has been shown to be safe and may help preserve breastfeeding duration among those who require multiple supplemental feedings (33).
  – When an infant is not breastfed, skin-to-skin contact should still be encouraged while feeding.
• Once hands have been washed with warm soapy water, clean containers and feeding devices with soap and water and air dry or dry with a paper towel before/after every use. They do not need to be sterilized for a healthy infant.
• Use fresh milk first when both fresh and frozen milk are available; frozen milk may have certain immune factors altered.
• Options to thaw frozen EBM: put container in refrigerator overnight, run container under warm water, set container in bowl of warm water or use waterless warmer.
• Connect all breastfeeding parents with local community supports, including contact information for public health, hospital outpatient clinics services or Health811. Public health units often have virtual and in-person appointment options as well as online information or support via e-chat or phone.

Infant Formula

• Discuss infant feeding options with parents, including during the prenatal period. Refer to health professional document Informed Decision Making: Infant Feeding.
• Refer to breastfeeding supports (e.g., local health unit or local breastfeeding clinics) as needed since it is difficult to reverse the decision to stop breastfeeding (3). 
• For infants who are not exclusively breastfed, select a commercial infant formula based on the infant’s medical and family’s cultural/religious needs (3,8). Refer to this infant formula – summary sheet.
• For non-breastfed infants, skin-to-skin contact should still be encouraged while feeding. Formula fed infants need to be fed based on hunger and satiety cues (3). 
• Follow-up infant formulas (e.g., 6 months plus) are not superior to standard infant formulas (e.g., 0 month plus) (8). 
• Refer to Health Canada’s approved infant formulas to ensure safety and nutritional quality.
• Homemade infant formula, including those made with evaporated milk, are not safe alternatives to commercial infant formula as they can cause severe malnutrition and potential fatal illness (37).
• For most children, there is no indication for the use of infant formulas or toddler milks beyond 12 months (8). 

Preparing Infant Formula

• Liquid infant formulas (i.e., liquid concentrate, ready-to-feed) are sterile. Powdered infant formula is not sterile and can be used if prepared properly. Ready-to-feed is the safest choice for higher-risk infants (3). 
• For infants at greatest risk (e.g., preterm and low-birth weight babies in the first 2 months of life or babies that are immunocompromised) liquid infant formulas are recommended to be used (38). 
• Wash all feeding equipment with soap and warm water. Until infant is 6 months of age, sterilize equipment for 2 minutes at a rolling boil (3). Beyond 6 months, parent can refer to manufacturer’s instructions (8).
• Safe water sources include tap water, commercially bottled water and regularly tested well water. Avoid carbonated and mineral water. If water is naturally high in fluoride (higher than the guideline of 1.5 mg/L), another water source is recommended (3).
• Until 6 months of age, boil all water sources used for infant formula preparation for 2 minutes (3). Beyond 6 months, parent can refer to manufacturer’s instructions (8).
  – Ready-to-feed – No additional water required (38). 
  – Liquid concentrate – Mix with previously boiled water. Follow the manufacturer’s instructions on preparation (38).
  – Powdered – If fed immediately after preparation, it is safe to mix with previously boiled water that has been cooled to room temperature. If preparing bottles in advance, mix with very hot water (boiled and cooled to no less than 70°C) to kill any harmful bacteria (38).
• Store any prepared formula in the refrigerator for up to 24 hours (38).
• Use formula within 2 hours from the start of a feeding and discard any leftovers (38).

Growth Monitoring

• Measure weight, length/height and head circumferences at all well-baby visits, or at “unwell” visits for those who are not brought for the recommended visits (3). Monitor growth using appropriate equipment and techniques, and accurate plotting on a consistent growth chart (3). 
• Plot on WHO Growth Charts for Canada when assessing growth (39). 
• Serial measures are more useful than unique measures and are ideal for assessing and monitoring growth patterns (39). 
• Growth measurements indicating a sharp incline or decline in growth in serial growth measures, or a growth-line that remains flat on the WHO Growth Charts for Canada, may indicate growth issues (39).
• Refer to A Health Professional’s Guide for Using the WHO Growth Charts for Canada for recommended cut-off criteria.
• Refer to CPS document Recognizing and Addressing Atypical Growth for case studies and information on how to talk to parents.

Vitamin D

• Give a liquid vitamin D supplement of 400 IU (10 mcg) daily to children younger than 2 years who are receiving breastmilk until diet includes ≥400 IU per day of vitamin D from dietary sources (3,8). Non-breastfed infants do not require a vitamin D supplement because infant formula and cow’s milk contains vitamin D (3). 
• For children older than 2 years, offer 500mL (16 oz) of cow’s milk or a fortified plant-based beverage to help meet vitamin D needs. If milk or fortified plant-based beverages are not being consumed, consider a vitamin D supplement and offering calcium-rich foods (8). 
• There are priority populations that are at higher risk of vitamin D deficiency and may require additional supplementation. See CPS Statement (39).

Iron

• Offer iron-rich foods two or more times each day to reduce the risk of iron deficiency (3,8). 
• Enhance absorption of iron by eating heme and non-heme sources together and consuming foods rich in vitamin C (vegetables and fruit). Iron from meat sources (heme) is better absorbed than iron from non-meat sources (non-heme) (8).
  – Heme iron – beef, wild game, lamb, chicken, turkey, pork, fish
  – Non-heme iron – beans, lentils, chickpeas, tofu, eggs, iron-fortified grains
• Infants at a high risk of iron deficiency include: birth weight ≤3000 grams (≤6 lbs 10 oz), born to individuals with iron deficiency, diabetes or alcohol consumption while pregnant (3). 
• Signs of iron deficiency include: pallor, poor appetite, irritability, and slowed growth and development (8).

Fish Consumption and Methylmercury

• Fatty fish is a good source of the omega-3 fats EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). The optimal amount of EPA and DHA for infants and young children has not been determined (8). 
• Avoid or limit consumption of the following high mercury containing fish – fresh/frozen tuna, shark, swordfish, escolar, marlin, orange roughy, and canned albacore (white) tuna as follows (40):
  – < 1 year of age – 40 g per month of these fresh/frozen types of fish or 40 g per week of canned albacore tuna
  – 1 to 4 years of age – 75 g per month of these fresh/frozen types of fish or 75 g per week of canned albacore tuna
  – 5 to 11 years of age – 125 g per month of these fresh/frozen types of fish or 150 g per week of canned albacore tuna

Food Allergies

• Infants at high risk for developing a food allergy have a personal history of atopy or have a first-degree relative with atopy (i.e., eczema, food allergy, allergic rhinitis, asthma) (16). For high-risk infants, based on developmental readiness, introduce common allergenic foods, such as peanuts and eggs at an appropriate texture, at around 6 months of age, but not before 4 months of age (16).
• Infants at low risk for food allergy, introduce complementary foods at around 6 months of age (7).
• Introduce allergenic foods one at a time to gauge reaction, without unnecessary delay (7) (e.g., every 2 days) between each food (8). Continue to offer common allergenic foods that are tolerated weekly to maintain tolerance.
• Goat’s milk is not a suitable alternative for infants with cow’s milk protein allergy due to their similar protein structure (8,41).
• Common food allergens in Canada are: eggs, milk, mustard, peanuts, crustaceans and molluscs, fish, sesame seeds, soy, sulphites, tree nuts, wheat and triticale (42). 

Choking Prevention

• Recommend being aware of child’s ability to chew and swallow, supervising eating and knowing how to respond if choking occurs. As long as an infant or child is attentive, sitting upright, fed appropriate textures and is free from distractions, the risk of choking is the same as for an adult (8).
• Gagging is not choking and is a natural reflex that helps older infants to avoid choking (8).
• Avoid hard, small and round, or smooth and sticky, solid foods including: hard candies, cough drops, gum, popcorn, marshmallows, whole nuts, seeds, fish with bones and snacks using toothpicks or skewers for children younger than 4 years (8).
• Reduce the risk of choking by dicing or cutting lengthwise hot dogs or sausages, grating raw carrots or hard fruits such as apples, removing pits from fruits, chopping grapes, thinly spreading nut butters on crackers or toast, and finely chopping foods that are fibrous or stringy in texture such as celery, pineapple or oranges (8). 

Food Textures and Baby-Led Weaning

• A variety of textures (e.g., lumpy, soft-cooked finger foods, shredded, finely minced, pureed, mashed, ground texture) can be offered when solid foods are introduced according to infant’s feeding skill ability and are prepared to minimize choking risk (8). There is no order to follow and it is not a progression from one texture to the next (8).
• Self-feeding is encouraged and guided by infant’s feeding skills and interest (8). Both self-feeding and spoon-feeding can occur at a feeding and should be guided by infant’s cues.
• Provide opportunities and support for self-feeding skill development, understanding that messes are part of the learning process (8). 
• Baby-led weaning (BLW) is a method of introducing solid foods to infants. There is no agreed upon definition for BLW and there is no conclusive high-quality evidence to support BLW over other methods of feeding (43). Common components of BLW include the following:
  – Infants are encouraged to self-feed family finger foods rather than being spoon-fed by someone else, therefore avoiding pureed foods (43).
  – Food is offered in many shapes and sizes that infants can easily handle.
• Concerns of BLW may include:
  – Low iron and low energy intake due to the limited variety of iron-rich foods that babies can feed themselves. Closely monitor the infant’s growth and advise parents to provide iron-rich foods at every meal (43).
  – Risk for choking due to developmental readiness to self-feed whole foods. Provide information to parents on how to safely prepare foods and to avoid choking hazards to help minimize risk (43).

Responsive Feeding and the Division of Responsibility

• The development of healthy eating skills is a shared responsibility (4,8):
  – Birth to 6 months – Parents decide what milk source to provide. The infant, with infant-led or on-cue feeding, decides when, where and how much they are fed (4).
  – 6 months and older – Parents provide a selection of nutritious food and milk source and are beginning to be responsible for when and where the infant is fed (e.g. parent chooses when/where solids are offered, infant chooses when to breastfeed). The infant decides whether to eat and how much to eat (4).
  – By 12 months – Parents take over the responsibility for when and where the child is fed by providing regular meals and snacks. Parents need to trust the child’s ability to decide how much to eat and whether to eat (4).
• In a non-controlling, non-coercive environment, healthy children have the and ability to self-regulate the amount of food and energy consumed (22). Fluctuations in intake are normal and to be expected, as children have appetites that are appropriate for their age and growth rate (22). Children will eat less on some days and more on other days (8).
• Pressuring children positively or negatively will not help them eat more or less of certain foods. Pressure or praise may lead to negative attitudes about eating and poor eating habits (8). Pressuring or coercion may have short-term benefits but will make feeding more challenging and eating less rewarding (12). 
  – Positive pressure includes offering rewards, bribes (“if you eat your peas, you can have dessert”), praise (“you are a good girl for eating the peas”) or reminding a child to eat a certain food.
  – Negative pressure includes prodding, scolding, punishment, pleading, coercing (“clean your plate”)16 or using excessive verbal encouragement (“come on, you’ve tried it before”).
• Children do not have the cognition to understand the health properties or impacts of food, therefore food should not be classified as “healthy” or “unhealthy.” Use plain language to describe food by calling foods by their name (ex. calling a cookie a cookie, not a ‘treat’). Foods can be described in neutral terms (i.e. the strawberry is red, the soup is hot).

Food Insecurity

• Household food insecurity (HFI) in this document refers to the inadequate or insecure access to food due to financial constraints (45). It can range in severity from worrying about running out of food to, at the most extreme, not eating for a whole day or more due to lack of money (45). In 2022, the prevalence of children living in food-insecure households was 24.6% in Ontario (46).
• Groups at higher risk include: low income households, those living in rural or urban-rural mixed communities, households relying on social assistance or Employment Insurance, renter households, female lone-parent households, those likely to experience racial discrimination and oppression and exploitation, and children born outside of Canada (46,47).
• Food insecurity leaves a significant mark on children’s wellbeing. It is associated with childhood mental health problems, such as hyperactivity and inattention. Exposure to severe food insecurity (measured as child hunger) has been linked to increased risk of developing depression and suicidal ideation in adolescence and early adulthood (46).
• Use Poverty: A Clinical Tool for Primary Care Providers. Possible interventions include:
  – Encourage patients to speak to a social services worker, and complete appropriate forms in a timely manner. If they are pregnant, breastfeeding or providing formula they could qualify for a Special Diet Allowance if they currently receive social assistance. Consider not charging clients for filling out appropriate paperwork.
  – Connect your patients to free community tax clinics. Filed income tax returns are required to access many tax credits and benefit programs.
  – Share the Canada Benefits website with your clients. It provides a full listing of income and other supports.
  – Refer clients to 211ontario.ca or 2-1-1 for local community resources.
• Advocate for income-focused solutions by customizing and mailing this letter to MPs. Learn more by visiting No Money for Food is Cent$less.

Vegetarian and Vegan Eating

• When vegetarian and/or vegan diets are well-planned, they can meet nutritional needs.
• Children are at higher risk of being low in vitamin B12, iron, zinc, calcium, vitamin D, and omega-3 fatty acids, especially in vegan diets (48).
• Vegetarian diets may be lower in calories and may need extra sources of energy, including, soy products, avocado, soy and canola oils, nuts and nut butters (48).
• Offer commercial soy-based formula for vegan children under 24 months of age who are not breastfed (8).
• Refer client to a registered dietitian if the child is vegan or does not include milk or egg products in their diet (4).

Plant-Based Beverages

• Plant-based beverages are made from legumes (soy, pea), nuts (almond, cashew, coconut, macadamia), seeds (flax, hemp) or grains (oat, rice) (23).
• Store-bought plant-based beverages may be fortified. Homemade plant-based beverages are not fortified and are void of important nutrients (23).
• They are not equivalent to breastmilk, infant formula or 3.25% MF cow’s milk due to the lower protein, fat and calories and may not meet the needs for appropriate growth and development (23).
• For families wanting to offer a plant-based option, a commercial soy-based infant formula should be provided as a main milk source to a non-breastfed child under 24 months of age (8).

• If a child is 24 months of age or older, if a plant-based beverage is consumed, parents are advised to select an unsweetened option that is labelled as “fortified” and contains the following per 250 mL (23)
  -At least 6 g of protein,
  – At least 23% Daily Value (300 mg) of calcium,
  – At least 10% Daily Value (80 IU or 2 mcg) of vitamin D,
  – Less than 15% Daily Value (15 g) of sugar.

Note: The marketplace is changing. A plant-based beverage with a nutrient profile equivalent to 3.25% MF cow’s milk may be an alternative to 3.25% MF cow’s milk starting at 9-12 months of age. Consider referral to a registered dietitian.

Resources for Parents

Parents can call Health811 and speak to a registered dietitian for free by calling 8-1-1. Parents looking for breastfeeding support can contact their local public health unit’s breastfeeding clinic.

Health811 – Connect with a registered dietitian for free

Canada’s food guide

Health Canada – Infant Nutrition

UnlockFood.ca™ – Expert Guidance. Everyday Eating. Brought to you by Dietitians of Canada* Ellyn Satter Institute – Division of responsibility (sDOR)

Breastfeeding Matters: An Important Guide for Breastfeeding Families Infant Formula: What You Need to Know

Feeding Your Baby: A Guide to Help You Introduce Solid Foods

Nutri-eSTEP® – Nutrition Screening Tool for Toddlers and Preschoolers Raising Healthy Children Video Series

Food Safety Resources for Children Aged 5 and Under Healthy Vegan Eating

*Resource available in other languages

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