Complementary Feeding

by Dr. Aravind A

The birth of a baby is one of the most joyous occasions for a family, a time for forming new bonds and renewing old ones. A newborn baby places great responsibility on the parents, particularly the mother, as the most important task of feeding the infant falls on her. Human Breast milk is uniquely tailored to meet the health needs of a newborn baby with breast feeding recognised as being the most important factor for the normal growth and development of an infant. It provides unmatched health benefits for not only the babies and their mothers, but also for families, communities and society in general. The World health organisation, the Indian Government and paediatric associations like the Indian Academy of paediatrics (IAP) have strived to help mothers initiate and sustain exclusive breast feeding from birth to 6 months, both in the community and in hospitals with maternity services through initiatives such as the ‘Baby Friendly Hospital Initiative’ (BFHI) based on “Ten Steps to Successful Breastfeeding”. The objective is to improve breastfeeding practices, as breastfeeding is linked to better nutrition, health and greater well-being for children and mothers.

Optimal growth and development of a child is fundamentally dependent on appropriate nutrition during infancy and early childhood, particularly if the child is to realise its full human potential. For achieving such a level of growth and development, the period from birth to two years of age is crucial. Several studies have shown that failure to provide adequate nutrition during this period leads to faltering growth, nutritional deficiencies, delayed mental and motor development and predisposition to childhood illness like diarrhoea and respiratory infections. This affection of growth is irreversible after a child reaches 2 years of age. Inadequate or inappropriate nutrition during this period also lays the foundation for lifestyle diseases in adulthood such as diabetes, hypertension and obesity.

Sadly, it is estimated that only 1 in 4 infants is exclusively breastfed, as recommended, by the time they are 6 months old. In India, this rough estimate is about 20 million children not receiving exclusive breastfeeding (EBF) for the first six months. Further, about 13 million children do not get good, timely and appropriate complementary feeding along with continued breastfeeding.

COMPLEMENTARY FEEDING

Beyond 6 months of age, breast feeding alone is insufficient to meet the nutritional requirements, thus necessitating the introduction of other foods and liquids to meet this demand. This process is referred to as ‘Complementary feeding’ and is generally intended for infants from 6 to 24 months of age. This will meet the rule of optimal nutrition during the “1000 days” from the time of conception through to 2 years of life with exclusive breast feeding for 6 months followed by complementary feeding till 2 years of age along with continued breastfeeding.

Previously, the term “weaning” was used for the process of introducing suitable semi-solid food; this term is no longer used, the term complementary feeding is more appropriate, as breastfeeding remains an important nutritional contribution well beyond the first year of life.

GUIDING PRINCIPLES FOR COMPLEMENTARY FEEDING

Optimal complementary feeding depends not only on what is fed, but also on how, when, where, and by whom the child is fed.

1. WHEN TO START?

The right age for starting complementary feeds is when the baby is around 6 months. Factors for choosing this age include the following:

  • Coordinated movements of the jaw, mouth and tongue appear at this age which helps in swallowing solid foods; there is also less spitting out of solids.
  • The child develops neck/head control and hand-to-mouth coordination, enjoying mouthing and biting.
  • Cereals and pulses are digested by the maturing intestine.

It is noted that a child tends to become a poor chewer and a picky eater later if complementary feeds are not introduced at this age.

2. WHAT FOODS TO CHOOSE?

Staple foods which form the bulk of home-based diets such as that based on rice & wheat are commonly used as initial complementary feeds. These are easily available, affordable, and culturally acceptable and should comprise cereal: pulse mixture in the ratio of 2:1.

Foods such as seasonal fruits, green leafy vegetables, milk and milk products, pulses/ legumes, animal foods, oil/ butter, and sugar/ jaggery are added gradually to make the foods more energy dense. As a general rule, if nuts are included in the diet, it is advisable to use them in powdered form, to avoid small bits getting stuck in the airway which may cause the child to choke.

RIGHT FOODSFOODS TO BE AVOIDED
Combination of cereals and pulses staple foods such as idli, dosa, ragi, chapati/ roti, with oil/ ghee, and some amount of sugarRefined food products such as biscuits, breads, pastry, chocolates, cheese, softy, ice cream, doughnuts, cakes, etc.
Mashed banana, other pulpy fruits (e.g., mango, papaya), sweet potato, and potatoTinned foods, packaged or stored foods, artificially cooked foods with preservatives or chemicals
Milk-based cereals preparationsFruit juices and fruit drinks
Sprouts, pulses, legumes, almonds, raisinsCommercial breakfast cereals

3. HOW TO FEED? RESPONSIVE FEEDING

Feeding an infant can be very challenging, and it is often difficult to initiate or sustain complementary feeds. They need assistance appropriate for their age and developmental needs to ensure that they consume adequate amounts of complementary food. This is called responsive feeding.

The principle of responsive feeding helps in overcoming these challenges. This includes:

  • Feeding infants directly, interacting with the infant and maintaining eye-to-eye contact
  • Feeding slowly, patiently and trying different methods of encouragement when refusing some foods
  • Recognise hunger and satiety cues
  • Trial with combinations – when certain foods are refused, try different combinations, tastes, textures
  • A safe, protected environment is essential for feeding
  • Minimise distractions if the infant seems to be losing interest in feeding easily
  • In older children, it is always preferable to encourage self-feeding even though they may spill the food.

Avoid inappropriate feeding practices:

  • Avoid comparison with other children or even siblings regarding the choice of food
  • Forced feeding, threatening and punishment are discouraged as they affect the formation of good feeding habits.

4. SAFE PREPARATION AND STORAGE

Hygienic and safe preparation of foods is paramount to prevent infections, the risk of which increases after 6 months of age, as the intake of complementary foods increases. This is primarily related to the increased risk of microbial contamination of foods, particularly with the use of feeding bottles.

The guiding principles for the safe preparation and storage of foods include:

1. HAND HYGIENE – caregivers’ and children’s hands should be washed and cleaned before food preparation and eating.

2. CLEAN UTENSILS – should be used both for preparing and storing foods; spoons, cups, and bowls used for feeding should also be clean.

3. PROPER PREPARATION AND SAFE STORAGE – foods should ideally be freshly prepared, but if for later use, they should be stored safely. This includes -

  • Using fresh ingredients for the preparation of foods
  • Prevent contamination of the water used for drinking and preparation of food
  • Perishable foods (meat, milk, etc.) and prepared food should be stored in a refrigerator
  • When stored for a prolonged period, reheat the food before consumption so as to kill the contaminating germs
  • Storage space should be free from insects, pests such as rats, mice, cockroaches, flies, and dust.

5. QUANTITY

Complementary feeding should start with feeds in small quantities while maintaining breast feeding after the age of 6 months. This could be as much as 2–3 tablespoon-full between 6-8 months; then 1/2 cup or bowl (about 125ml) till the age of 1 year followed by 3/4 full bowl between 1-2 years of age.

6. FREQUENCY

Complementary feeds could be given as 2–3 meals along with frequent breastfeeding during the first 2-3 months after initiation. Up to the age of 1 year, 3 meals per day can be given with continued breastfeeding and 1–2 additional snacks. Older children will accept 3-4 meals per day and for those not being breastfed, additional 1–2 cups of milk plus 1–2 extra meals daily can be given.

7. FOOD CONSISTENCY

Infants can eat pureed, mashed and semi-solid foods beginning at six months. By 8 months most infants can also eat “finger foods” (snacks that can be eaten by children alone). At 9 to 10 months of age, introduce lumpy or granular foods and most tastes. By 12 months, most children can eat the same types of foods as consumed by the rest of the family.

Food consistency and variety can be increased in a gradual manner as the child grows older. Foods such as nuts and grapes should be avoided under the age of 1 year to prevent the risk of choking.

Remember, if foods of inappropriate consistency are offered, the child may be unable to consume more than a trivial amount, or may take so long to eat that food intake is compromised.

Complementary feeding 
6 months
  • Introduce home-based foods.
  • 1-2 teaspoons at a time.
  • Gradual increase in quantity and frequency.
6-8 months
  • Begin with mashed foods or thick porridge.
  • In the beginning, 2–3 tablespoon-full.
  • Daily 2–3 meals along with frequent breastfeeding.
9-11 months
  • Mashed foods, finely chopped, and foods that can be picked up by baby.
  • Daily 3 meals with continued breastfeeding plus offer 1–2 additional snacks.
  • 1/2 cup/bowl (125 mL).
12-24 months
  • Staple family foods, mashed or chopped (if required).
  • Daily 3–4 meals with continued breastfeeding plus 1–2 additional snacks.
  • 3/4 to one cup/bowl (250 mL).
  • Those not being breastfed, give additional 1–2 cups of milk plus 1–2 extra meals daily.

8. IMPROVING ENERGY DENSITY

As infants are only able to accept small quantities of feeds, the energy density of foods can be improved by different methods. These could be

  • By the addition of sugar / or jaggery and ghee/butter/oil.
  • By making food which is thick in consistency, thereby providing more calories. The thickness should be such that the food stays or just drips from a tilted spoon without running off.
  • Use of cooking methods such as milling, germination, and fermentation of different food items.
  • Use of Malted foods, which are energy dense. ‘Malting’” is the process of germinating whole grain (cereal or pulse), which is then dried and powdered.

9. DIET DIVERSITY

Nutritional requirements are often not met through staple foods alone, hence, the use of different combinations of foods is recommended. This is called Dietary Diversity, which ensures at least one animal-source food and one fruit or vegetable in the diet, in addition to staple foods.

The various food groups are:

 FOOD GROUPSExamples
1Grains, roots, and tubersRice, wheat, maize, jowar, ragi, potato, sweet-potato, etc.
2Legumes and nutsPulses, nuts, oil seeds, dry fruits.
3Vitamin-A-rich fruits and vegetablesOrange/yellow/green vegetables or fruits such as mango, carrot, papaya, and tomato.
4Other fruits and vegetablesLocally available, fresh fruits and vegetables, preferably seasonal and inexpensive.
5Dairy productsMilk, curd, yoghurt, butter, and paneer.
6Eggs 
7Flesh foodsMeat, fish, poultry, and organ meats.

The use of at least 4 of these food groups is recommended for meeting daily energy requirements.

feeding_steps

10. FORTIFICATION OF COMPLEMENTARY FOODS

Certain important micronutrients such as iron, zinc and calcium are found in insufficient quantities in breast milk as well as plant-based foods. Besides improving the mothers’ diet, use of fortified complementary foods or vitamin-mineral supplements such as iron-fortified foods, iodized salt, and vitamin A-enriched food is encouraged.

COMMERCIAL FOODS

A few important pointers to note regarding commercial foods include

  • Avoid foods with an excess of sugar, salt, and trans-fatty acids.
  • Avoid ready-made, processed commercial food
  • Excessive juice consumption can decrease the child’s appetite for other foods and may cause loose stools. Hence, its use should be limited or discouraged.

FEEDING DURING AND AFTER ILLNESS

During illness, feeding becomes even more challenging due to reduced appetite, preference for favourite foods, irritability of infants etc. It is important to maintain adequate fluid intake and include frequent breastfeeding during illness, infants and children are encouraged to eat a variety of soft foods, particularly their favourite foods. During recovery, children can be offered more quantity to help meet increased energy demands.

Summary

Age RangeFeeding recommendations
Breast feeding 
  • At Birth
  • Initiate Breastfeed within 1 hour of life.
  • Do not give water, other fluids, honey or food.
  • Exclusive breastfeeding till 6months.
  • 6-24 months
  • Complementary feeding + continued breast feeding.

PRINCIPLES OF COMPLEMENTARY FEEDING

Timely
  • Introducing complementary feeds at an age when the infant is developmentally ready and breastfeeding alone no longer meets energy requirements.
Adequate
  • Appropriate quantity and variety of foods used alone or in combination to meet energy requirements.
Safe
  • Safely procured food products; safety during storage, cooking and feeding the infant.
  • Clean Hands and Clean utensils.
Properly fed
  • Practice responsive feeding.
Age appropriate
  • The consistency, quantity and frequency of feeding should be consistent with the age of the infant.

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