Complementary Feeding

K G Dewey, University of California—Davis, Davis, CA, USA

© 2005 Elsevier Ltd. All rights reserved.

Introduction

Complementary feeding has been defined as

.. .the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk.

In the past, such foods were often called 'weaning foods.' However, the term 'complementary foods' is preferred because weaning implies the cessation of breastfeeding, whereas the goal is that such foods should complement breast milk, not replace it. Breast milk alone is generally sufficient to meet the nutrient needs of infants during the first 6 months of life, but after that time infants need additional sources of nutrients. The World Health Organization (WHO) recommends exclusive breastfeeding for 6 months and continued breastfeeding thereafter (along with the provision of safe and appropriate complementary foods) until 2 years of age or beyond. Therefore, the period of complementary feeding usually refers to the age range of 6-24 months. This is a critical time because it is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses such as diarrhea.

In 1998, WHO and UNICEF jointly published a document entitled Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge, which provided background information to assist in the development of scientifically based feeding recommendations and intervention programs. In 2003, an update to that document was published (see Further Reading), and a separate document entitled Guiding Principles for Complementary Feeding of the Breastfed Child was published by the Pan American Health Organization and WHO (see Table 1). This chapter will summarize the information presented in these three documents.

Age of Introduction of Complementary Foods

In 2001, the WHO Expert Consultation on the Optimal Duration of Exclusive Breastfeeding reviewed the evidence regarding the age of introduction of complementary foods and concluded that exclusive breastfeeding for 6 months is beneficial for both the infant and the mother. Risks arising from the early introduction of complementary foods include reduced breast-milk intake and a higher incidence of infant gastrointestinal infections. On a population basis, there is no adverse effect on infant growth of waiting to

Table 1 Guiding principles for complementary feeding of the breastfed child

1. Duration of exclusive breastfeeding and age of introduction of complementary foods

Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed.

2. Maintenance of breastfeeding

Continue frequent on-demand breastfeeding until 2years of age or beyond.

3. Responsive feeding

Practice responsive feeding, applying the principles of psychosocial care. Specifically: (a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; (b) feed slowly and patiently, and encourage children to eat, but do not force them; (c) if children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement; (d) minimize distractions during meals if the child loses interest easily; (e) remember that feeding times are periods of learning and love - talk to children during feeding, with eye-to-eye contact.

4. Safe preparation and storage of complementary foods

Practice good hygiene and proper food handling by (a) washing caregivers' and children's hands before food preparation and eating, (b) storing foods safely and serving foods immediately after preparation, (c) using clean utensils to prepare and serve food, (d) using clean cups and bowls when feeding children, and (e) avoiding the use of feeding bottles, which are difficult to keep clean.

5. Amount of complementary food needed

Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding. The energy needs from complementary foods for infants with 'average' breast-milk intake in developing countries are approximately 200 kcal day-1 at 6-8 months of age, 300 kcal day-1 at 9-11 months of age, and 550 kcal day-1 at 12-23 months of age. In industrialized countries these estimates differ somewhat (130, 310, and 580 kcal day-1 at 6-8, 9-11, and 12-23 months, respectively) because of differences in average breast-milk intake.

6. Food consistency

Gradually increase food consistency and variety as the infant gets older, adapting to the infant's requirements and abilities. Infants can eat pureed, mashed, and semi-solid foods from the age of 6 months. By 8 months most infants can also eat 'finger foods' (snacks that can be eaten by children alone). By 12 months, most children can eat the types of foods consumed by the rest of the family (keeping in mind the need for nutrient-dense foods, as explained in #8 below). Avoid foods that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, and raw carrots).

7. Meal frequency and energy density

Increase the number of times that the child is fed complementary foods as he/she gets older. The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding. For the average healthy breastfed infant, meals of complementary foods should be provided two or three times per day at 6-8 months of age and three or four times per day at 9-11 and 12-24 months of age. Additional nutritious snacks (such as a piece of fruit or bread or chapatti with nut paste) may be offered once or twice per day, as desired. Snacks are defined as foods eaten between meals - usually self-fed, convenient, and easy to prepare. If energy density or amount of food per meal is low, or the child is no longer breastfed, more frequent meals may be required.

8. Nutrient content of complementary foods

Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible. Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used (see #9 below). Fruits and vegetables rich in vitamin A should be eaten daily. Provide diets with adequate fat content. Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. Limit the amount of juice offered to avoid displacing more nutrient-rich foods.

9. Use of vitamin-mineral supplements or fortified products for infant and mother

Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed. In some populations, breastfeeding mothers may also need vitamin-mineral supplements or fortified products, both for their own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast milk. (Such products may also be beneficial for pre-pregnant and pregnant women.) 10. Feeding during and after illness

Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied, appetizing, favorite foods. After illness, give food more often than usual and encourage the child to eat more.

Reproduced from Pan American Health Organization/World Health Organization (2003) Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC: Pan American Health Organization.

introduce complementary foods until 6 months, and the risk of micronutrient deficiencies is very low among full-term infants of normal birth weight whose mothers are well-nourished. Although iron deficiency may occur prior to the age of 6 months in infants whose iron reserves at birth are low (e.g., low-birth-weight infants and those whose mothers were iron deficient during pregnancy), the recommended approach is to provide medicinal iron drops from 2-3 months of age to such infants, rather than introducing complementary foods. Zinc status may also be marginal in low-birth-weight infants, and deficiency can be prevented by using zinc supplements. When the mother's diet is poor, the concentrations of certain vitamins (e.g., vitamin A and many of the B vitamins) and trace elements (e.g., iodine and selenium) in breast milk may be lower than desirable. In such situations, improving the mother's diet or giving her micronutrient supplements are the preferred approaches, rather than providing complementary foods to the infant before the age of 6 months.

At 6 months of age, infants are developmentally ready to consume complementary foods and can benefit from the additional nutrients that they provide. Continued breastfeeding is recommended because breast milk remains an important source of energy, fat, protein, and several micronutrients. In addition, continued frequent breastfeeding beyond 6 months protects child health by reducing the risk of diarrhea and other infections in disadvantaged populations and by delaying maternal fertility (thereby increasing the interval before the next pregnancy among women who do not use other forms of contraception).

Nutrient Needs from Complementary Foods

The amounts of nutrients provided by breast milk can be estimated by multiplying average breast-milk intake by the concentration of each nutrient in human milk. By subtracting these values from the total recommended nutrient intakes (RNIs) one can derive estimates of the amounts of nutrients needed from complementary foods after 6 months of age. Using this approach, Table 2 lists these estimates for three age ranges: 6-8 months, 9-11 months, and 1223 months. In this table, the RNIs for energy and protein are taken from the update report on complementary feeding published in 2003, and the RNIs for micronutrients are taken from the most recent FAO/ WHO estimates or the US dietary reference intakes. The estimated amount of each nutrient provided by breast milk is based on the average milk intake during each of the age intervals, calculated separately for infants in developing countries and in industrialized countries, using data from the studies compiled in the 1998 WHO/UNICEF document. Because of differences between developing and industrialized countries in average milk intake and in the assumed breast-milk concentration of vitamin A, the estimated amount of each nutrient provided by breast milk may vary. Within each column of Table 2, the first value listed refers to developing countries, and the second value refers to industrialized countries.

The first row of Table 2 shows the total energy requirements and the estimated amounts of energy obtained from breast milk and required from complementary foods at each age. In developing countries, the average expected energy intake from complementary foods is approximately 200kcal (837kJ) at 6-8 months, 300kcal (1256 kJ) at 9-11 months, and

550kcal (2302 kJ) at 12-23 months. These values represent 33%, 45%, and 61% of total energy needs, respectively. In industrialized countries, the corresponding values are approximately 130kcal (544 kJ) at 6-8 months, 310kcal (1298 kJ) at 9-11 months, and 580kcal (2428kJ) at 12-23months (21%, 45%, and 65% of total energy needs, respectively). Of course, these values will differ if the child is consuming more or less breast milk than the average.

The second row of Table 2 shows the same estimates for protein. Assuming average breast-milk intake, the amount of protein needed from complementary foods increases from about 2gday-1 at 6-8 months to 5-6gday_1 at 12-23 months, with the percentage from complementary foods increasing from 21% to about 50%. The remaining rows show the estimates for the key vitamins and minerals. For vitamin B12 and selenium, the amounts needed from complementary foods prior to 12 months are zero because human milk contains generous amounts of these nutrients if the mother is adequately nourished. For the other micronutrients, the percentage of the RNI needed from complementary foods varies widely. At 6-8 months, for example, complementary foods need to provide less than 30% of the RNI for vitamin A, folate, vitamin C, copper, and iodine but more than 70% of the RNI for niacin, vitamin B6, vitamin D, iron, and zinc. The values for the amount of niacin needed from complementary foods are high in all age intervals (75-88% of the RNI), but, because niacin needs can also be met by the contribution of tryptophan in the diet, niacin is not likely to be a limiting nutrient among infants who receive adequate protein. Similarly, the percentage of vitamin D needed from other sources is very high (more than 92%) because there is relatively little vitamin D in human milk; however, it should be noted that adequate exposure to sunlight can meet the child's needs for vitamin D even if complementary foods are not rich in this nutrient.

Complementary foods need to provide relatively large amounts (at least 80% of the RNI in all age intervals) of iron, zinc, and vitamin B6. Because the amount of iron in human milk is very low (even though what is present is well absorbed), it is likely to be one of the first limiting nutrients in the diets of infants who rely predominantly on breast milk.

Fat is not listed in Table 2 because there is uncertainty about the optimal intake of fat during the first 2 years of life. Dietary lipids are important not only as a source of essential fatty acids but also because they influence dietary energy density and sensory qualities. Breast milk is generally rich in fat (approximately 30-50% of energy) relative to most complementary foods, so as breast-milk intake

Table 2 Recommended nutrient intakes, average amount provided by breast milk, and amount needed from complementary foods at 6-8 months, 9-11 months, and 12-23 months

6-8 months 9-11 months 12-23 months

Table 2 Recommended nutrient intakes, average amount provided by breast milk, and amount needed from complementary foods at 6-8 months, 9-11 months, and 12-23 months

6-8 months 9-11 months 12-23 months

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