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Complementary Feeding - Ideal Characteristics, When to Start, and Sequence of Introduction

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Infants need complementary feeding around six months of age due to increasing demands for energy and nutrition. Read this article to know more.

Written by

Dr. Afsha Mirza

Medically reviewed by

Dr. Veerabhadrudu Kuncham

Published At December 19, 2022
Reviewed AtDecember 19, 2022

Introduction:

Around six months, the baby’s nutritional requirements increase, and breastmilk cannot fulfill these dietary needs. The baby needs additional food, which is called complementary food. Around this age, the baby is developmentally ready to take the complementary foods in their diet. This period is known as complementary feeding. If not done, it can lead to malnutrition.

What Is Complementary Feeding?

Breast milk alone is insufficient for a baby's nutritional requirements, so there will be a need for other foods apart from breastfeeding. The transition period from only breastfeeding to family foods is 6 to 23 months.

What Are the Ideal Characteristics for Good Complementary Feeding?

  • Timely: Only breastfeeding is insufficient to meet the infant's nutritional requirements.

  • Adequate: It must provide the required energy, proteins, and nutrients to meet the baby's dietary requirements.

  • Safe: The food must be hygienic and served with clean hands and utensils.

  • Appropriate: The food of proper texture for the age of the child.

What Is the Critical Period?

The period from birth to two years is a 'critical window' for promoting optimal growth. It is challenging to reverse stunting.

  • Immediate: Illness with morbidity and mortality, delayed development.

  • Long-Term: Impairments in intellect, work capacity, and reproductive outcomes.

When to Start?

The age of complementary feeding is around six months because requirements of energy, protein, and other nutrients like iron, zinc, etc., cannot be met by breast milk alone. After four months, gastrointestinal and renal functions are mature. After five months - Tongue thrust relaxation is lost, the baby starts sitting with support in the mother's lap, good head and neck control, and the baby will open its mouth for food and can reach for objects. So, very early introduction of complementary foods (before four months of age) increases the risk of childhood obesity, respiratory symptoms, and allergic diseases like eczema. If one delays complementary feeding beyond six months, there is a higher chance of malnutrition and iron deficiency anemia.

According to the European society for pediatric gastroenterology, hepatology, and nutrition, complementary feeding must be started by 17 to 26 weeks. Developmentally ready itself is not an indication to start complementary feeding. Feeding recommendations are for populations, but each child should be managed as an individual, but this can only be done with a healthcare provider consultation. Proposals should be based on developmental readiness, nutritional status, health status, and the family's economic and sociocultural attitude toward diet.

How Much Complementary Food Can Be Given to a Child?

  • Six hundred kilocalories/day - 6 to 8 months of age (200 kilocalories purely from complementary feeding).

  • Seven hundred kilocalories/day - 9 to 11 months of age (300 kilocalories purely from complementary feeding).

  • Nine hundred kilocalories/day - 12 to 23 months of age (550 kilocalories purely complementary feeding).

This principle should be based on responsive feeding, and how one delivers this much food depends on energy density and meal frequency.

On Which Factors Do Meal Frequency and Energy Density Depend?

2 to 3 times/day - for 6 to 8 months, 3 to 4 times/day for 9 to 11 months, and 4 to 5 times/day for 12 to 24 months with 1 to 2 nutritious snacks/day. Gastric capacity is 30 grams/kilogram of body weight. The minimum energy density is 0.8 kilocalories/gram. All Variables depend on breast milk intake, number of feedings, and energy density of the feeds.

How Can Mothers Make Complementary Foods Energy Dense?

Adding fats (oil or ghee), sugar, or jaggery (in developing countries, malnutrition includes energy deficit; hence, sugar is permitted). Malted foods (germinating cereal or pulse, drying, and grinding) reduce viscosity so a child can eat more. It is also known as amylase-rich flour, and by preparing thick mixtures.

What Is the Minimum Acceptable Diet or MAD?

Minimum dietary diversity includes grains, roots, tubers, legumes and nuts, dairy products, meat, fish, poultry, eggs, vitamin A-rich fruits and vegetables, and other fruits and vegetables. Out of these, if one gives the baby four out of seven groups per day, the child is taking their minimum dietary diversity diet. Minimum meal frequency and minimum dietary diversity, if both these criteria are met, is called a minimum acceptable diet (MAD).

What Is an Individual Nutrient Composition?

  • Lipids: 30 to 45 percent. With low breast milk intake, lipid proportion needs to be higher.

  • Protein: 8 to 15 percent. Protein-energy ratio of foods need to be considered: The quality and adequacy of proteins. It depends on protein quality: plant protein will require more. A high protein diet during complementary feeding is linked to future adiposity.

  • Micronutrients: 97 percent of iron, 86 percent of zinc, 81 percent of phosphorus, 76 percent of magnesium, 73 percent of sodium, and 72 percent of calcium during 9 to 11 months are expected from complementary foods. Iron deficiency anemia represents the end of iron deficiency. Heme iron intake is low; nonheme iron has low bioavailability and is often paired with foods containing phytate. Foods containing heme iron as the first foods, combining iron-rich cereals with vitamin c rich food, iron fortification/supplementation.

What Is Food Consistency?

Gradually increase food consistency and variety. Pure, mashed, and semisolid at six months, finger foods at eight months, and family foods at 12 months. Avoid foods that may cause choking. Children who first received lumpy foods after ten months of age were more likely to have feeding difficulties at 15 months.

What Is the Sequence of Introduction of Complementary Foods?

  1. First Food: Since iron and zinc are critical, meat and grains are the best choices to start the process. First solid foods are boiled without salt/sweeteners/flavors/preservatives. One food at a time at intervals of two to three days so that in a short span, the infant will be consuming the primary food groups (meat, cereals, vegetables, fruits, and legumes).

  2. Water: Water needs are influenced by thermoregulation and physical activity. Milk is 88 percent water. Additional water intake during the second half of infancy is unnecessary until all three recommended daily complimentary meals are introduced. Non-breastfed infants require 400 to 600 milliliters/per day in temperate climates and 800-1200 milliliters/per day in the tropics.

  3. Vegetarian Diets: Critical nutrients are B12, vitamin D, iron, omega-3 fatty acids, and zinc. Planned lactovegetarian diets are acceptable, and only vegan diets lead to growth failure and deficiencies.

  4. Allergenic Foods: Delayed introduction of potentially allergenic foods may increase the risk of allergy. Potential food allergens are recommended when complementary feeding begins, one food at a time. The timing of gluten introduction has no bearing on coeliac disease and can be introduced from the beginning.

  5. Milk: Breastmilk ideally should continue for two years and beyond. Doctors do not recommend whole animal milk before one year of age. In non-breastfed infants, animal-source foods become more critical- 200 to 400 milliliters/day or 300 to 500 milliliters/day.

What Is Baby-Led Weaning?

It emphasizes self-feeding instead of spoon-feeding by caregivers. Baby-led introduction to solids (BLISS) encourages the consumption of iron and energy-rich foods without the risk of choking.

What Are the Foods to Avoid during Complementary Feeding?

  • Small, hard foods may cause choking (such as whole nuts, seeds, hard lollies, raw carrots, and apple chunks).

  • There is no need to add sugar or salt to foods; they can cause tooth decay and do extra work for the baby's kidneys.

  • Cow's milk should not be given until 12 months of age. Some cow milk can be added to food for pureeing and mashing.

  • Honey is not recommended and can cause illness in babies younger than 12 months.

  • Avoid soft drinks, juice, tea, or coffee for babies. Breastmilk and water are the only fluids for the baby's needs.

What Is Responsive Feeding?

Encourage self-feeding despite spillage, do not threaten or force feed, and minimize distractions while feeding. Feeding times are periods for learning and love.

What Are Supplements/Fortifications?

Vitamins and mineral supplements are given as needed, and supplemental iron for preterms after one month. Also, advisable for pregnant and lactating women.

Conclusion:

Provision of complementary foods, nutrition education, and maternal nutrition counseling. All these can lead to an increase in weight and height as well as reduce stunting. Good complementary feeding of the breastfed kid is required for optimal child development and growth. Thus, it is an important element for people's food protection and the evolution of countries. Health specialists should give mothers/caregivers unique suggestions for encouraging the beneficial complementary feeding of the breastfed youngster. It is up to the management to deliver satisfactory requirements for funding such an advancement.

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Dr. Veerabhadrudu Kuncham
Dr. Veerabhadrudu Kuncham

Pediatrics

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