A Solid Start: Complementary Feeding

By 6 months of age, calories provided by breastmilk is no longer sufficient to meet the nutritional requirements of an infant.1

Complementary feeding (CF) is defined as the process of giving nutrient and energy containing foods and liquid to an infant aside from breastmilk. By 6 months of age, calories provided by breastmilk is no longer sufficient to meet the nutritional requirements of an infant.1 This period is critical because this is necessary not only for physical growth but also for nutritional and developmental reasons. It is an important stage in the transition from milk feeding to family foods.2 Feeding problems in childhood take root from poor complementary feeding. Based on the WHO Philippine data, 91% of Filipino infants are started on CF by 6-8mos, 81% are given food 2-4x a day, 63% get to eat a diverse diet of at least 4 food groups a day. And only half of Filipino infants meet the minimum acceptable diet. 1

Energy Requirement:3

Based on the 2002 Recommended energy and nutrient intake (RENI) per day, 560 kcal of energy should be provided for infants from birth to 5 months old and at 6-12 months an infant should have 720 kcal of energy.

Protein. By 6 months of age, the average requirement for protein per kg is about two thirds that for a newborn infant. Based on the RENI, proteins should provide 10-15% total dietary energy.

Fat. Recommendations for fat intake for infants should be 30-40%.

Carbohydrates. The major source of energy comes from carbohydrates which should provide 55%-70% of total calorie intake.

When to start CF:

Exclusive breastfeeding from birth to 6 months of age and introduce complementary foods at 6 months of age (180 days) while continuing breastfeeding is recommended. Introduction before this age tends to displace breastfeeding.1

What is Responsive Feeding:

Infants should be fed directly while assisting older children. This is called responsive feeding. Parents or guardians are encouraged to feed slowly and patiently and encourage children to eat. 1

The caregiver should practice good hygiene. Proper food handling, storing foods safely and serving foods immediately after preparation. Clean utensils are used to prepare and serve food and in feeding children.

Types of food:

Give a variety of single-ingredient fruits, vegetables, grains and meats, in any order, to allow for the infant to become accustomed to diverse flavors and textures. This should be offered multiple times over several days (> 8 exposures). 4

Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used. 1

It is inappropriate, during the first year of age, to add salt to food, due to a possible increase in risk of hypertension in later age. 5 Addition of sugar is also not recommended. 1,2

Amount of food:

For 6-8 months old infant, start with thick porridge, well mashed foods at 2-3 tsp per feed, then gradually progress to finely chopped foods. Offer ½ of a 250 ml cup per day for 9-11 months old. For infants 12-23 months old, they should be given family foods, chopped or mashed if needed, approximately ¾ to full 250 ml cup per day.1 The principles of responsive feeding should always be remembered.

There is a critical window for introducing lumpy solid foods at around 10 months of age, if these are not introduced at this age, it may increase the risk of feeding difficulties. 1

Frequency of feeding:

At 6-8 months old, 2-3 meals per day may be offered. For infants 9-23 months, they should be given 3-4 meals a day. Snacks may be offered at 1-2x a day depending on the infant’s appetite. As the child gets older, increase the number of feeding times. 1

Sources of nutritious food:

Various foods should be given to the child to ensure that nutrient needs are met. Four out of the 7 food groups per day and all food groups in a week should be offered. The following may be eaten daily by the child, such as meat, poultry, fish or eggs. When infants reached the age of 7-8 months, they should be already consuming foods from the seven food groups.

The sources of protein, zinc and iron are from animals or fish; calcium and protein are found in dairy products; pulses are good sources of protein and some iron; foods rich in carotene and also vitamin C are orange-colored fruits and vegetables; and fats and oils are sources of energy and essential fats. 1

Allergy-preventing diet:

Food restrictions have no allergy-preventing effect. According to studies, there is no evidence that delaying foods like peanut, eggs or fish beyond 4-6 months prevents atopic disease. No evidence to withhold giving of any food to prevent allergy for as long it is during the recommended age of complementary feeding. 1,4

Fresh Cow’s Milk:

Fresh cow’s milk is not recommended in the first year of life. It has been associated with low-grade intestinal blood loss. The main reason for delaying introduction is to prevent iron deficiency because cow’s milk is a poor iron source.2

Evidence is not convincing that cow’s milk intake can affect linear growth and later blood pressure and risk of obesity. The consideration has been that low-fat milk may limit energy intake and thereby growth. 2

Sugary drinks:

Sugary drinks, like soda should be avoided. No juice should be offered before 6 months of age and preferably completely avoid until the infant is at least 12 months of age. 4

References

1 WHO Guiding Principles for Complementary Feeding of the Breastfed Child.

2 Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition. Journal of Pediatric Gastroenterology and Nutrition. 2008; 46:99–110.

3 Recommended energy and nutrient intakes for Filipinos 2002. Asia Pac J Clin Nutr 2008;17(S2):399-404.

4 American Academy of Pediatrics, Updates in Infant Nutrition. October 2017.

5 Dewey KG, Brown KH. Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr Bull, in press

6 Strazzullo P, et al. Nutr Metab Cardiovasc Dis 2012;22

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