Nutrition Publication

NNIW87 - Complementary feeding: Building the Foundations for Healthy Life

Editor(s): M. Makrides, R. Black, K. Ong. 87

The first1,000 days of an infant, the time period from conception until two years ofage, is the time in which the infant is the most vulnerable and which lays thefoundation to its future health. During this transitional period, infants alsoprogress from exclusively milk-based liquid diet to the family diet andself-feeding. Thus, the CF period is not just an important time to satisfy aninfant’s nutrition, but also a time to form healthy food preferences andfeeding practices and to further stimulate the infant’s ongoing, healthy development.

Related Articles

Complementary Foods: Guidelines and Practices

Author(s): M.J. Netting and M. Makrides

Complementary feeding, the transition from a breast milk based diet to inclusion of other sources of nutrition in an infant’s diet, is a major milestone in infant development. This transition period is important as it is a time when infants are vulnerable to developing nutritional deficiencies and occurs during a developmental stage when important food related behavioural patterns are being established.

As under- and over- nutrition may coexist in children from the same country it is important that advice provided by complementary feeding guidelines meets the needs of all children helping them to grow and develop into healthy adults.   

Many consistent and important themes emerge when comparing complementary feeding guidelines from different countries:

  • Complementary foods at, or around six months of age
  • Continued breastfeeding
  • Nutrient dense complementary foods
  • Hygienic food practices
  • Development of feeding skills that foster long term healthy eating habits
  • Prevention of non-communicable diseases such as obesity

Complementary feeding guidelines that promote good eating during the first year and beyond recognise that nutrition, particularly during the first 1000 days, has an important influence on immediate growth and development, but also an important role in setting up taste preferences and behavioural patterns which inform an infant’s susceptibility to development of disease later in life. However, guidelines in many countries are not always followed, particularly during the second year of life and innovative methods are needed to increase compliance. 

Complementary Feeding, Micronutrients and Developmental Outcomes of Children

Author(s): J.F. Gould

The period of complimentary feeding (six-24 months of age) can be a challenging and vulnerable time for infant nutrition due to disproportionately high requirements for metabolic processes, rapid developmental processes, and limited gastric capacity. This is a period of crucial brain development where high caloric intake is necessary to allow synaptogenesis (creation of channels between neurons for communication), and maintenance of established synapses, myelination (laying the myelin sheath around neuronal axons), and every day psychological functioning. Key nutrients needed for infant brain development include iron (required for oxygen provision to metabolise energy), fatty acids (to make cellular membranes and myelin) and protein (for structural support, such as in myelin). Deficiencies in key nutrients during the complimentary feeding period have been consistently linked to child development outcomes. Observational studies have consistently demonstrated links between nutrient deficiencies and impairments in intellectual abilities, work capacity, behavioural functioning and even delayed mental and motor development. Yet results from a number of interventions using food, individual nutrients or multiple micronutrients with child development assessments are mixed, possibly partly due to differences in interventions (nutrients and timing), populations, baseline nutrient status, sample sizes, attrition and method of assessment.   

Advancement in Texture in Early Complementary Feeding and the Relevance to Developmental Outcomes

Author(s): J.R. Green, M. Simione, B. Le Révérend, E.M. Wilson, B. Richburg, M. Alder, M. Del Valle and C. Loret

A child’s transition to independent eating is a protracted process that progresses over the course of many years. Although major health agencies, such as the World Health Organization, now offer clear guidance when to begin introducing solids, advice about how to safely transition to progressively challenging foods is varied and comes from a staggering number of sources. The resulting conflicting views have promoted parental confusion and anxiety about what foods are appropriate and when to advance to new textures. Efforts to develop science-based recommendations for complementary feeding include research on the development of chewing motor skills. Chewing development is an essential aspect of feeding readiness that is often overlooked by agencies developing recommendations for complementary feeding, and little is known about the development of chewing motor skills and how children learn to accommodate foods with varying textures. Such information is essential for designing developmentally appropriate foods, minimizing food aversions, providing caregivers science-based guidance regarding the safety and appropriateness of new foods, and identifying children at risk for choking or feeding impairments.

Update on Timing and Source of ‘Allergenic’ Foods

Author(s): D.J. Palmer

As the prevalence of food allergies in many communities continues to rise, the question of when in infancy to introduce any solid foods, or specific ‘more allergenic’ foods, as a food allergy prevention strategy has been debated. Observational studies have found that introducing any solid foods prior to four months of age was associated with increased risk of allergic disease. Hence the current allergy prevention consensus recommendation is that the introduction of any solid foods should commence after 4 months of age. Over recent years, several randomised controlled trials have been conducted to investigate the ‘ideal’ timing of introduction of some specific ‘more allergenic’ foods (including peanut and egg) into infant diets. To date the results from three of these trials have determined that there is no reason to delay the introduction of the ‘more allergenic’ foods into the infant’s diet after solid foods have commenced. However these trials have also highlighted the finding that some infants are sensitized to food allergens before any known ingestion in solid foods. Thus future research needs to focus on strategies to prevent early life food allergen sensitization prior to complementary feeding.

Flavor and Taste Development in the First Years of Life

Author(s): E.S. Ross

Across the first four years of life, infants transition from a diet of liquids to solid foods. Flavor preferences affect the acceptance of novel foods. Fetuses experience flavors in the uterine environment, and some preferences appear to be innate. Sweet and salty foods tend to be accepted by most newborns, while bitter tastes are rejected. Breast fed infants appear to have an advantage over formula fed infants, as their exposure to a varying flavor profile is influenced by the mother’s diet. Infants are fairly accepting of novel foods, but rejection of new foods increases across the initial years of life. Children learn to accept novel foods through a variety of experiences, provided within social contexts. Some children are more accepting of various sensory inputs present during mealtimes. Parents report a greater challenge getting multiple taste exposures when their child exhibits less sensory adaptability. The number of foods eaten as a young child has a strong influence on the food repertoire later in childhood. Foods eaten by parents significantly predict the number and types of foods eaten by children. Strategies to help parents be more successful in achieving taste exposures in a positive social environment need to be identified.

Patterns of Growth in Early Childhood and Infectious Disease and Nutritional Determinants

Author(s): R.E. Black

The physical growth of young children in low- and middle-income countries is reduced compared to international standards. The deviations in growth in both weight and height are greatest in the first two years of life and this has serious consequences for child mortality, development, adult stature and health. The determinants of these patterns of growth faltering include intergenerational factors, such as maternal height, short birth interval and conditions in pregnancy, including maternal underweight and anemia. These factors contribute to fetal growth restriction and premature delivery, which put many infants on a different growth trajectory. Exposure after birth to microbes resulting in diarrhea and febrile infectious diseases and poor quality diet further compromise growth. Determinants of growth faltering after birth vary by setting and are not independent of each other. For example the adverse effects of diarrhea on growth may be mitigated by a high quality diet. Global estimates suggest that 25% of stunting can be attributed to fetal growth restriction and even more in countries in South Asia with a high prevalence of low birth weight. Infectious diseases may contribute a similar amount and subclinical enteric infections can result in intestinal dysfunction with adverse effects on nutrition and growth. Dietary factors, especially consumption of complementary foods of insufficient quality, have a paramount role in growth faltering in the critical period of infancy.

Measuring Infant and Young Child Complementary Feeding Practices: Indicators, Current Practice and Research Gaps

Author(s): M.T. Ruel

The publication of the WHO infant and young child feeding (IYCF) indicators in 2008 equipped the nutrition and broader development community with an invaluable tool for measuring, documenting and advocating for faster progress in improving these practices in low and middle income countries (LMICs).  The indicators, with 5 of them focusing on complementary feeding (CF) practices, were originally designed for population-level assessment, targeting, monitoring and evaluation. This chapter takes stock of where we are with the existing CF indicators: it reviews how the indicators have been used, what we have learned and what their strengths and limitations are; and it suggests a way forward. We find that the indicators have been used extensively for population-level assessments, country comparisons, and to track progress. They have also been adopted by researchers in program impact evaluations, and in research seeking to understand the determinants and consequences of poor CF practices for child growth and development outcomes. In addition to generating a wealth of knowledge and unveiling the severity of the global problem of poor CF practices in LMICs, the indicators have been an invaluable tool to raise awareness and call for urgent action on improving CF practices at scale. The indicators have strengths and limitations, which are summarized in the chapter. Although enormous progress has been achieved since the indicators were released in 2008, we feel it is time to reflect and re-visit the CF indicators, improve them, develop new ones and promote their appropriate use.  Better indicators are critically important to stimulate action and investments in improving CF practices at scale.

Evidence for the Effects of Complementary Feeding Interventions on the Growth of Infants and Young Children in Low- and Middle-Income Countries

Author(s): R. Heidkamp

As momentum for investment in early childhood nutrition grows, so does the evidence base for the effectiveness of complementary feeding interventions. The aim of this chapter is to review the current state of the evidence for the impact of two categories of interventions (nutrition education alone, provision of food or nutrient supplements with or without education) on linear and ponderal growth of children 6-23 months in LMIC. Pooled effect sizes from three recent systematic reviews consistently suggest a modest but significant effect of both types of complementary feeding interventions on weight and length gain. Interpretation of these pooled estimates is limited by the variability in intervention design and inconsistency in reporting of growth outcomes across the relatively small number of rigorous controlled trials currently available in the literature.

Results with Complementary Food Using Local Food Ingredients

Author(s): T. Ahmed, M. Islam, N. Choudhury, I. Hossain, S. Huq, M. Mahfuz and S. Alam Sarker

Appropriate complementary food is a must for optimum growth of infants and children. The food should have diversities and be given in sufficient quantities 2-4 times a day depending upon age. Poverty, food insecurity, lack of awareness regarding choice of nutritious food ingredients are deterrents to optimum complementary feeding. In Bangladesh, 77% of children do not receive appropriate complementary food, and hence, the high prevalence of childhood malnutrition. We developed ready to use complementary food (RUCF) using locally available food ingredients – rice-lentil and chickpea, conforming to standard specifications. These foods were found to be acceptable by children and their mothers compared to Pushti packet, the cereal based supplement used in the erstwhile National Nutrition Program of Bangladesh. In a cluster-randomized community based trial in rural Bangladesh among more than 5000 children, the efficacy of rice-lentil and chickpea based RUCF was compared with another commonly used supplementary food called WSB++ and a commercial product called Plumpy’doz. Deceleration in length for age was significantly lower (by 0.02–0.04/month) in the rice-lentil, Plumpy’doz, and chickpea groups compared to control at 18 months of age. Weight for length Z score decline was lower only in Plumpy’doz and chickpea groups. WSB++ was not different from the control. In children who received chickpea RUCF or Plumpy’doz, the prevalence of stunting was lower by 5–6% at 18 months. These foods can be used to prevent or treat malnutrition among children particularly those from food insecure households.

Fortification of Complementary Foods: A Review of Products and Program Delivery

Author(s): L.M. Neufeld, S. Osendarp and W. Gonzalez

Fortified complementary foods (FCF) and home fortificants – single sachet micronutrient powders (MNP) or small quantity lipid-based nutrient supplements (SQ-LNS) to be added to a child’s food immediately before consumption – have been shown to be efficacious to improve the micronutrient status and some functional outcomes in children 6 to 23 months of age. The objective of this paper is to describe and discuss the latest advances related to the composition and delivery of fortified complementary food products, including home and commercial fortification. For FCF and MNPs there is guidance to ensure that products are safe and aligned with recommendations. Impact however, can be achieved only if adequate attention is paid to program design and implementation, including the choice of delivery platform, and ensuring availability, accessibility, acceptability, coverage, and utilization by the target population. Well-targeted programs such as social protection programs, health services, community-based vendors (referred to as market-based), child health weeks, and emergency programs have all been used as delivery platforms for FCF and MNPs. To date, guidance for formulation and programmatic experience with the distribution SQ-LNS is limited. An in-depth understanding of the local context and culture and the design and implementation of program components, including behavior change interventions that respond to those can increase program coverage and product utilization. Using rigorous process evaluation would permit adapting programs to increase potential for impact, strengthen the evidence related to how programs work and permit the development of program guidance that is better informed to increase effective implementation.

Ying Yang Bao: Improving Complementary Feeding for Chinese Infants in Poor Regions

Author(s): J. Huo

YYB as complementary food supplement has rapidly developed in China as a nutrition improvement method for the infant and young children in poor rural regions. YYB study initialed back to 2001 by ILSI, China CDC and Nestle. In 2008, the establishment of national standard for complementary food supplement stimulated implementation of about 15 nutrition intervention projects in poor rural counties in which YYB was applied to the infant and young children as home fortification food. Data accumulated in different studies showed that YYB enhanced the growth for both anthropometry and cognition, and decreased anemia rate significantly for infant aged from 6 to 24 months. Chinese government has launched a project named Improving Children’s Nutrition in Poor Rural Regions from 2012. The project has now covered more than 4 million of 6-24 months infants in 341 counties in 21 provinces in western and meddle regions. It is recognized nutrition intervention in the early life is rather an opportunity for a better whole life. YYB practice in China might present an experience for better nutrition in early life for developing countries.

Healthy Growth and Development

Author(s): K.K. Ong

Observational and experimental studies indicate a remarkably consistent association between rapid growth and weight gain during infancy and higher risks for obesity in later childhood and adult life. This association appears to be equally relevant to breastfed and formula milk fed infants, and in small for gestational age and normal birth weight infants. Type of infant milk feeding, energy intake and milk nutrient composition are important determinants of infant growth and weight gain. There is also accumulating evidence that genetic factors related to adult obesity susceptibility act in the central nervous system to regulate intrinsic levels of infant appetite and satiety, and they impact on infant dietary behaviours to influence growth and weight gain. These genetic factors indicate an early life trajectory to later obesity that starts with rapid infancy gains in weight, length, fat mass and lean mass, before the subsequent emergence of high BMI and adiposity. Better understanding of the anthropometric, metabolic and behavioural correlates of this trajectory will inform early life prediction and preventive strategies against obesity and related metabolic disorders.

Responsive Feeding: Strategies to Promote Healthy Mealtime Interactions

Author(s): M.M. Black and K.M. Hurley

Responsive feeding is a derivative of responsive parenting that has been applied to infant and young child feeding. With a theoretical basis in the reciprocal interactions between parents and children, responsive feeding is particularly relevant during complementary feeding as young children progress from an exclusively milk-based liquid diet to the family diet and self-feeding. The period of complementary feeding includes multiple developmental changes that may threaten a successful transition and lead to growth and feeding problems. In spite of high rates of global childhood underweight, stunting, overweight, and obesity, and the inclusion of responsive feeding in the World Health Organization’s Global Strategy for Infant and Young Child Feeding, there have been few intervention trials of responsive feeding. The aim of the paper is to examine how parents and young children navigate the progression in feeding, with an emphasis on complementary feeding and to address the following topics: 1) navigating the progression of feeding development, 2) provision of responsive feeding, 3) preventing or resolving growth and feeding problems, 4) responsive feeding research, and 5) strategies to promote healthy mealtime interactions. To advance responsive feeding research and practice, clarity is needed in both measurement and intervention strategies, guided by the reciprocity between parent and child interactions inherent in the theoretical basis of responsive feeding.

Complementary Feeding in an Obesogenic Environment: Behavioral and Dietary Quality Outcomes and Interventions

Author(s): L.A. Daniels

The WHO infant feeding guidelines, including those for complementary feeding, are very prescriptive, largely based on the outcomes of exclusive breast feeding and have a bias to under nutrition. Consideration of longer term outcomes related to over-nutrition, the predominant nutrition problem in affluent countries, is limited. Compared to the ongoing and often zealous debates regarding the short- and long-term benefits of exclusive breast feeding to 6 months in affluent countries, exposures (particularly feeding practices) and outcomes related to complementary feeding, independent of exclusive breast feeding, have received little attention. In this context, consideration of a broader range of outcomes (e.g. food preferences, energy intake regulation, dietary quality, eating behaviours) that potentially mediate the associations between infant feeding and long term obesity and chronic disease outcomes is required. The aim of this paper is to (i) consider the impact of CF on outcomes relevant to child obesity risk, (ii) provide an overview of the NOURISH trial, the first large trial to evaluate an intervention that specifically targeted CF feeding practices (‘how’), including reporting long term outcomes.