News article

Tips For Introducing Solids To Infants In The Complementary Feeding Stage

Posted:  Monday, May 12, 2014

Introduction
The WHO recommends provision of exclusive breastfeeding for the first 4-6 months of life. After the age of 4-6 months, breast milk alone is inadequate to meet the increased nutritional needs of an infant. This nutritional deficit makes it necessary for the introduction of the more calorie dense solid and semi-solid foods while continuing breastfeeding. Complementary food is therefore any food other than breast milk or infant formula given to the infant to complement either of these. Nonetheless, introducing solids to infants is a common challenge to parents and communities. If not done well, complementary feeding (CF) can be an important cause of illness, poor growth or even mortality in the young child – particularly in resource limited settings. This brief communication discusses the “when,” ”what” and “how” of CF and draws mostly on WHO literature.1-7 The brief does not cover the relatively few infants who develop food intolerance or food allergy during CF. 

When Should CF be Introduced?
As indicated above, the timing for introducing solids is based on nutritional needs of the infant. It is facilitated by the natural growth and development attributes of the infant as most infants, will manifest the following by the age of 4-6 months: 
  1. Ability to sit up without support or minimal support
  2. Loss of  the extrusion reflex
  3. Interest in what parents or other members of the household are eating
  4. Eruption of  2 lower and upper incisors and ability to masticate soft solid food
  5. Good tongue coordination to transfer food to the oropharynx
  6. Have good coordination of swallowing
  7. Have  digestive enzymes capable to cope with the food that is offered
What is an Adequate Complementary Food? 
An adequate complementary food must meet certain minimum criteria that include the following: 
  • It must be adequate in energy, protein, fat and micronutrients
  • It must be easy for the infant to consume 
  • It must be free of contaminants both microbiological and chemical
  • It must contain  minimal amounts of  spices and salts
  • It must be available and easy to   easy to prepare 
Based on several factors including gastric capacity, and energy intake of 0.8Kcal/g of feed, WHO recommends 2 to 3 meals a day of CF between six and eight months of life , 3 to 4 meals daily between 9 and 24 months with additional snacks daily at 12 months. 

How Should the Complementary Food be Given? 
It is advised that the food should be introduced gradually, one at a time and in small quantities, allowing several days or weeks to elapse before introducing the next food. New food may not be accepted at first contact. It is not uncommon for new food to be offered several times before it is accepted. The consistency of the food should be appropriate for the developmental eating skills of the infant and should initially be semisolid and soft in the form of a puree. At eight months the infant can be given family food which are crushed, shredded, chopped or cut into pieces. By 12 months most infants eat the same food as other members of the family provided they have been adequately prepared for content and consistency. At this stage semi-solids are restricted. Food with sharp objects and that with hard consistency should be avoided because it could chock the child.  While use of culturally accepted utensils is acceptable, use of feeding bottles should be avoided. Besides being a source of infection, they could also precipitate ‘nipple confusion.’

Conclusion
Breastfeeding should be continued during the period of CF as summarized in the table below. The challenges posed by CF vary from one community to another and are largely predicated on socio-cultural circumstances. Poverty, ignorance and general food security and government interest play major roles. 
Ten steps to healthy feeding of infants younger than 2 years
 STEP  Details Recommendation
 1 Feed the infant exclusively with human milk up to 6 months. Do not offer water, tea or any other kind of   food
 2 After 6 months, gradually introduce other kinds of food. Keep providing human milk up to 2years or longer
 3 From six months give complementary food (cereals, vegetables, meat, fruits) three times daily if the child is being breast fed and five times a day if no longer breastfed
 4 Complementary food must be offered on demand, always respecting the child’s appetite
 5 Complementary food must be of the appropriate consistency and offered with spoon; in the beginning it should have a pasty consistency (porridge/ mashed food) and gradually it should get thicker up to the time when the child is able to eat a family meal
 6 Offer the child different kinds of food throughout the day. A varied diet is colorful
 7 Stimulate the daily intake of fruits and vegetables
 8 Avoid sugar, coffee, canned food, fried food, soft drinks, candies, salt and treats in the first year of life 
 9 Wash your hands before handling food; store the food appropriately
 10 Encourage the sick child to eat. Offer the usual and favorite meals and respect the child’s appetite

References
1. WHO/UNICEF. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva: World Health Organization, WHO/NUT/98.1,1998
2. Infant and Young Child feeding: Model Chapter for Textbooks for Medical students and allied Health Professionals. Geneva: World Health Organization 2009.Section3.   
3. Chritiana M G Monte, Elsa R J Glugliani. J Recommendations for the complementary feeding of breastfed child.  Pediatr (Rio J). 2004; 80(5 suppl): S131-S141
4. WHO/UNICEF. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva: World Health Organization. WHO/NUT/98.1,1998 
5. WHO. Complementary feeding: Family foods for breastfed children. Geneva. World Health Organization. WHO/NHD/00.1:WHO/FCA/CAH/00.6;2000
6. PAHO/WHO Complementary feeding of the breastfed child. Division of health promotion and protection. Report of the global consultation. Summary of the guiding principles. Food and Nutrition Bulletin, 2003; 24 (1)
7. Kathry G Dewey.  The Challenges of meeting nutritional needs of infants and young children during the period of complementary feeding: An evolutionary perspective. J. Nutr. 143: 2050-2054, 2013.