COMPLEMENTATY FEEDING: PRINCIPLES AND PRACTICES (Part 2)
From the age of six months to 24 months, infants enter a particularly vulnerable period of
complementary feeding during which they make a gradual transition to eating family foods
(Dewey & Brown, 2003). However, this period is often characterised with a decline in the children’s nutritional status due to inadequate feeding, and the deficits that occur are difficult to compensate for later in life (Dewey & Brown, 2003; FAO, 2015). Poor breastfeeding and
complementary feeding practices, coupled with high rates of infectious diseases, are the
main proximate causes of malnutrition during the first two years of life (WHO, 2009). Infants are particularly susceptible to malnutrition if the complementary foods given are of low nutrient density, have a low bioavailability of micronutrients and are introduced too early or too late in small amounts or not frequent enough (WHO, 2013). In addition, premature
cessation or low frequency of breastfeeding also contributes to insufficient nutrient and energy intake hence further compromising the infants’ nutritional status (WHO, 2009).
Infants are particularly vulnerable to malnutrition during the transition period, when
complementary feeding is introduced. There is need to ensure that their nutritional needs are
met during this time and this requires complementary feeding to be timely, adequate and safe.
Providing complementary foods timely means that the food should be introduced when the
energy and nutrient needs of the infants exceed what can be provided through exclusive
breastfeeding.
Adequate and safe complementary feeding is when the food given provides sufficient energy, protein and micronutrients to meet the growing infant’s nutritional needs. The food has to be hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats. The child has to also be properly fed, where the infant is given food consistent with their signals of appetite and satiety, and the meal frequency and
feeding method should be suitable for their age; also encouraging the child to eat sufficient
food even during illness (WHO, 2005). These principles will be discussed.
Principles for complementary feeding
Adequate complementary feeding with the right quality and quantity of food is essential for the growth and development of children (Jones et al., 2003). To ensure adequate complementary feeding, the WHO developed guiding principles for complementary feeding of children (WHO, 2009; WHO, 2015). The principles are as follows:
(i) Introducing complementary foods at six months of age while continuing to
breastfeed. At six months, breast milk alone is not enough to provide all the required
nutrients for the infant hence it is important to introduce complementary food.
Inappropriate timing where the foods are introduced too late or too early deprives
the infants of optimum nutrition leading to undernutrition and increased morbidity
and mortality (Hazir et al, 2011). Supplementing breast milk before the child is six
months old is also discouraged because it may inhibit breastfeeding and expose the
infant to illness. At six months, breast milk should be supplemented by other liquids
and eventually by solid or mushy food to provide adequate nourishment (NSO &
ICF-International, 2016; WHO, 2015).
(ii) Continuing frequent, on-demand breastfeeding until two years of age or beyond.
Continued breastfeeding protects the child’s health by delaying maternal fertility
post partum and hence allowing longer breastfeeding for the child (Victora & Barros, 2000). Longer duration of breastfeeding has been linked to reduced risk of childhood chronic illnesses (Davis, 2001) and obesity (Butte, 2001). Breast milk is an important source of energy and nutrients in children aged six to 24 months especially during illness. Breast milk also reduces mortality among children who are malnourished (WHO, 2003).
(iii) Providing safe and adequate complementary foods starting with small amounts and
increasing the quantity as the child gets older while maintaining breastfeeding frequency. Since the energy requirements of the child increases during this time, there is need to provide complementary foods that will meet the energy needs of the child to ensure optimum child growth. The energy needs of an infant are 600 kilocalories (2520 Kilojoules) per day for a child six to eight months, 700 kilocalories (2940 Kilojoules) per day for a child nine to eleven months, and 900 kilocalories (3780 Kilojoules) per day for a child 12 to 23 months. To ensure that the energy needs are met, food should be offered to the child based on the principles of responsive feeding while ensuring that energy density and meal frequency are
adequate (WHO, 2003; WHO, 2009) .
(iv) Practising responsive feeding
Optimal complementary feeding depends not only on what is fed but also on how, when, where and by whom the child is fed (Pelto et al. 2002). Responsive feeding is important. Responsive feeding is a technique in which infants are fed when they express hunger, instead of being forced to keep to a feeding schedule. Using this technique the infant is fed directly while being sensitive to their hunger and satiety cues. It is the caregiver’s responsibility to watch for and respond to an infant’s cues for hunger and to be responsive to the infant’s cues for satiety. Infants should be fed until they indicate they are full and to never be forced to eat. The child should be fed slowly and patiently and be encouraged to eat. If they refuse many
foods, the caregiver has to experiment with different food combinations, tastes and methods of encouragement while talking with the children during feeding with eye to eye contact (WHO, 2003; WHO, 2005).
(v) Food consistency
Food consistency and variety should be increased as the infant gets older while
adapting to the infant’s requirements and abilities. Infants can eat mashed and semisolid
foods at six months and by eight months they can eat finger foods. Finger foods are snacks that can be eaten by the child alone. At 12 months, most children can eat the same types of food consumed by the rest of the family while ensuring that the food provided is nutrient dense. It is important to include a variety of foods when preparing complementary food for infants to ensure that their nutritional needs are well provided for (WHO, 2005; WHO, 2009).
(vi) Meal frequency and energy density
The number of times that the child is fed complementary foods should be increased as the child 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 an average healthy breastfed infant, complementary meals should be provided two to three times per day at six to eight months of age, and increasing feeding to three to four times per day at nine to eleven months and 12 to 24 months of age, while providing additional nutritious snacks one to two times per day, as desired. Snacks are the foods that are eaten between meals and are usually self-fed by the child. They are generally convenient and are easy to prepare. Examples of nutritious snacks for the child are fruits or bread with peanut paste (Brown, Dewey & Allen, 1998; WHO, 2003).
For an average non-breastfed infant, meals which includes milk only feeds, other foods and combinations of milk feeds and other foods should be provided four to five times per day with additional nutritious snacks offered one to two times per day as desired. The appropriate number of feedings depend on energy density of the food. If the energy density of the food or the amount of food per meal is low, more frequent meals are required (WHO, 2005).
(vii) Providing a variety of nutrient-rich foods. Due to the rapid rate of growth and development during the first two years of life, nutrient needs per unit body weight of infants and young children are very high. As such, attention should also be paid to the nutrient content of the food for complementary feeding to ensure that the infant’s nutrient requirements are met. Providing fortified complementary food or vitamin-mineral supplements for the infants and young children as needed is also encouraged (WHO, 2009).
Breast milk has relatively low amounts of several minerals, such as iron and zinc. Therefore the child needs to eat meat, poultry, fish or eggs daily or as often as possible because they are rich sources of these minerals. Milk and milk products are rich sources of calcium and they should also be consumed often. A diet that does not contain animal source foods cannot meet all nutrient needs of the child at this age (NSO & Macro, 2011; WHO, 2003).
If milk products and other animal source foods are not eaten in adequate amounts, both grains and legumes should be consumed daily if possible within the same meal to ensure adequate protein quality. Similarly, if milk products are not consumed in adequate amounts, other foods that contain relatively large amounts of calcium such as fish should be consumed. Other foods such as soybeans, cabbage, carrots, papaya, dark green leafy vegetables, guava and pumpkin are also useful additional sources of calcium (Owino, Amadi, Sinkala, Filteau & Tomkins, 2008; WHO, 2003).
The diet also needs to have an adequate fat content. Consumption of foods or paste made from groundnuts and other nuts and seeds is important. The child’s daily diet should also include vitamin A rich foods (dark coloured fruits and vegetables, vitamin A fortified oils) and vitamin C rich foods consumed with meals to enhance iron absorption (WHO, 2003).
(viii) Practising good hygiene and proper food handling
Ensuring safety of complementary foods provided to the child is also important to prevent infections and diarrhoea. This can be done by washing caregivers’ and children’s hands before food preparation and eating, storing foods safely and serving foods immediately after preparation; using clean utensils to prepare and serve food; using clean cups and bowls when feeding children, and avoiding the use of feeding bottles which are difficult to keep clean (WHO, 2009).
(ix) Appropriate feeding during child illness
It is also important to increase fluid intake of the child during illness and more frequently
Breastfeed the child. The child should also be encouraged to eat soft foods and their favourite foods so that they are able to replace the nutrients loss. After illness, the infant and child should be given food more often than usual and be encouraged to eat more (WHO, 2005).
Following these principles will ensure that a child is adequately breastfed and receives nutritious and safe complementary foods hence reducing incidences of malnutrition.
Infant and young child feeding in developing countries
Globally, many infants and young children do not receive optimal feeding. For instance,
worldwide, only 39% of children aged between zero and sixth months were breastfed
exclusively in 2014 (IFPRI, 2016). Providing age appropriate complementary feeding also
remains a challenge, especially in low income countries (Bhutta, Ahmed, Black, Cousens,
Dewey, Giugliani, Haider, Kirkwood, Morris & Sachdev, 2008). This is evidenced by a
remarkable increase in the levels of child undernutrition from the age of six to 24 months in
developing countries (UNICEF, 2011). In many countries less than a fourth of infants aged
between six to 24 months meet the criteria of dietary diversity and feeding frequency that are
appropriate for their age (Black et al., 2013). Sub-optimal IYCF practices have been reported in Malawi that include delayed initiation of breastfeeding, early introduction of foods before six months for breastfeeding children and inappropriate complementary feeding (low frequency of meals per day, provision of thin porridge and giving of meals that predominantly consist of plant foods whose nutrient quality is low) (Mtimuni, Bader, Palma & Dop, 2008). In Malawi exclusive breastfeeding is widely practised with up to 61% of infants under six months of age being exclusively breastfed in 2015. However, the proportion of children who are exclusively breastfed decreases sharply with age from 81% for infants zero to one month to 69% for infants two to three months and 34% in infants aged four to five months (NSO & ICF-International, 2016). This trend is true for most of the African countries (NSO & ICF-International, 2016).
