Monday, 30 October 2017

Complementary feeding refers to the transition from exclusive breastfeeding to family food which typically covers the period from 6 to 24 month of age even though breastfeeding may continue up to 2 years of age and beyond. That is how WHO defines complementary. Decades ago, the process of introducing semisolids and solids in to an infant’s diet used to be called ‘weaning’ or ‘supplementary’ feeding. Both imply that introduction of new foods will be at the expense of breast milk and it is that connotation that is avoided by the term ‘complementary feeding’. It is food added to the diet of the baby, without compromising on breast milk intake.

The timing of the complementary feeding is well defined now, after WHO put its stamp of approval on 6 months as appropriate time to start complementary feeds. Some developed countries still advise mothers to start complementary feeds anytime between 4 to 6 months, which however might not go so well for developing countries.

The General Rules To Be Followed For Complementary Feeds
  • Average stomach capacity of infants is about 250ml, increasing to 350ml at 24 months. The nutritional needs per feed of the growing baby should be packed into that volume.
  • Aim to hit 3 semi-solid feeds a day by 8 months in addition to mother’s milk.
  • Ideal energy density of the meal should be 1Kcal/gm. More than 1.5Kcal/gm predisposes to obesity.
  • 1.5 to 2gm/kg of protein is needed by the growing baby from 6 months through to 24 months. At least 50% of it should come from milk, the rest from semisolids include egg, fish and chicken are excellent sources of first class proteins for baby, provided it is culturally acceptable.
  • 20 to 25% of energy requirements should be through fats and not more than 10% of it should be from saturated fats.
  • Starting foods should be ideally similar in taste to milk for acceptability. Other flavors can be added sequentially to the diet from 7 months onwards.
  • Babies often refuse new foods initially, but will accept them when tried again. Up to 7 trails of a food can be tried before giving it up.
  • Expose babies to fruits and vegetables from 7 months onwards.
  • Proprietary branded foods can be tried, as they are wholesome and have the right texture. But, quickly wean the babies to home available foods once they learn to swallow and accept non-milk based flavors.
  • Strictly avoid low protein, high sugar foods as well as low nutritive value diets like – boiled apple, plain vegetable soups and mashed potatoes.

Two major studies were behind WHO directive to wait till 6months for the introduction of semisolids in to the infant’s diet.

  • One by Cohen, often called the Honduran study, looked at exclusive breast milk for 6 months and at introduction of high quality semisolids at 4 months, along with mother’s milk. They showed that introducing semisolids at 4 months did not result in any additional energy intake or weight gain for the infants, suggesting that semi-solids before 6 months did not benefit the babies nutritionally.
  • The other usually referred to as the Byelorussian study by Kramer, showed that introducing semisolids to babies at 4 months resulted in statistically significant increase in GI and respiratory infections, compared to exclusively breastfed babies, besides a small increase in atopy as well.
  • These and the Cochrane review by Kramer in 2002 on benefits of exclusive breast feeds till 6 months, led the present directive to start semisolids only at 6months.

Guidelines On Infant And Young Child Feeding
  • Timely introduction of complementary foods (solid, semi-solid or soft foods) at 6 to 8 months.
  • Age appropriate complementary feeding for children 6-23 months, while continuing breastfeeding.
  •  Children should receive food from 4 or more food groups –
Grains, roots and tubers, legumes and nuts
Dairy products
Flesh foods
Vitamin A rich fruits and vegetables
  • Fed for a minimum number of times
2 times for breastfed infants  6-8 months
3 times for breastfed children 9-23 months
4 times for non-breastfed children 6-23 months

  • Active feeding for children during and after illness

In conclusion, it can be said that infants are born with the ability to learn to like new foods. This ability seems to be maximal between 4 months to 2 years. This is the
window of opportunity to introduce complementary foods. Practices that favor the successful introduction of complementary foods include:

  • Exclusive breast-feeding for the first 6 months of life.
  • Timing of complementary feeding between 17 to 26 weeks, introduction of new flavors as early as possible and variety in food texture after around 6 months.
  • Early and repeated exposures to individual foods especially vegetables.
  • The taste properties of complementary foods are likely to impact acceptance. Appropriate cooking or preparation may increase acceptance. More exposure may be needed when the food is disliked.
Written By: Dr. Harman