Complementary feeding

OBJECTIVE: To present an updated review about complementary feeding in infants and children under 2 years old. METHODS: Relevant materials from scientific journals, technical books and publications by international organizations were used. The most important source of data was a publication by the World Health Organization on complementary feeding carried out in Montpellier, France, in December 1995. RESULTS: In recent years, new findings on ideal infant feeding have buried former concepts and practices. The value of exclusive breast-feeding during the first months of life and the introduction of timely and adequate complementary feeding has been acknowledged. Complementary foods are defined as any solid or liquid foods with nutritional value other than breastmilk, offered to breast-fed infants It is recommended that complementary feeding be initiated around the 6th month of life. These foods should be rich in energy, proteins and micronutrients, free from contamination, easily digestible and in adequate amount. On recommending a healthy diet, the availability, accessibility and cultural values of food should be taken into consideration. CONCLUSION: Health professionals have an important role in the improvement of infant nutrition. Those in charge of child care have to be properly advised and warned of the importance of a healthy diet for current and future health status.     

Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe

Supplementation with lipid‐based nutrient supplements (LiNS) is promoted as an approach to prevent child undernutrition and growth faltering. Previous LiNS studies have not tested the effects of improving the underlying diet prior to providing LiNS. Formative research was conducted in rural Zimbabwe to develop feeding messages to improve complementary feeding with and without LiNS. Two rounds of Trials of Improved Practices were conducted with mothers of infants aged 6–12 months to assess the feasibility of improving infant diets using (1) only locally available resources and (2) locally available resources plus 20 g of LiNS as Nutributter®/day. Common feeding problems were poor dietary diversity and low energy density. Popular improved practices were to process locally available foods so that infants could swallow them and add processed local foods to enrich porridges. Consumption of beans, fruits, green leafy vegetables, and peanut/seed butters increased after counselling (P < 0.05). Intakes of energy, protein, vitamin A, folate, calcium, iron and zinc from complementary foods increased significantly after counselling with or without the provision of Nutributter (P < 0.05). Intakes of fat, folate, iron, and zinc increased only (fat) or more so (folate, iron, and zinc) with the provision of Nutributter (P < 0.05). While provision of LiNS was crucial to ensure adequate intakes of iron and zinc, educational messages that were barrier‐specific and delivered directly to mothers were crucial to improving the underlying diet.     

Breast-feeding in clinical practice

OBJECTIVE: To present an updated review on practical aspects of breast-feeding promotion and management. METHODS: Review of relevant publications from scientific journals, technical books and publications by international organizations. RESULTS: Nowadays, exclusive breast-feeding is recommended for a period of approximately 6 months, and maintenance of complementary breast-feeding should continue for 2 or more years. Despite abundant scientific evidence on the superiority of breastmilk over other types of milk, the number of women who breast-feed their infants according to present recommendations is still low. Health care providers can improve this scenario by encouraging breast-feeding and helping nurturing mothers to overcome breast-feeding hindrances. Therefore, health professionals must have the necessary knowledge and skills for managing the different stages of lactation. This way, they will be able to provide prenatal counseling, guidance and help during the breast-feeding initiation period, careful evaluation of breast-feeding techniques and adequate interventions in the event of any problems associated with breast-feeding. This article is concerned with some important topics related to breast-feeding in clinical practice. CONCLUSION: Breast-feeding is the ideal method for infant feeding, and it can certainly be facilitated by health care providers through adequate clinical practice.     

Causes of nutrition-related public health problems of preschool children: available diet

The primary goal of this review is to examine the timing and nature of dietary inadequacy during the first 5 years of life. An important issue is that many children in developing countries are already nutritionally depleted by the end of the first year of life, because maternal undernutrition can cause low fetal accumulation of nutrient stores and secretion of inadequate amounts of some micronutrients in breast milk. Improvement of maternal diet and micronutrient status is required to remedy this situation. During the period of complementary feeding, most households may be able to provide their young children with sufficient energy and protein from home-produced complementary foods, but many do not feed foods with an adequate energy density or a sufficient number of meals per day. Inadequate micronutrient intakes and resulting deficiencies are common in preschoolers because of a lack of sufficient animal source foods, and have been associated with delayed child development. Dietary diversity is an especially important determinant of micronutrient intakes when animal source food intake is low. Interventions with animal source foods have produced improvements in growth, micronutrient status, cognitive performance and activity of children. Although much is now known about the role of inadequate diets in preschooler malnutrition, on a global scale the ability of households to apply this knowledge to improve the diets of their children is still limited.     

Bases for adequate complementary feeding in infants and young children

Infants can be exclusively breast fed or formula fed for the first 6 months of life and their nutritional requirements are completely fulfilled. However, from 6 months onwards, human milk is not sufficient to supply all the nutrients necessary for infants and young children. Therefore, adequate supplementary feeding, in terms of both quantity and quality, should be provided. The present article aims to describe the scientific bases for practical recommendations on complementary feeding during infancy and early childhood, which may be useful to pediatricians and should serve to improve the health status of the infant population in Spain. In this sense, the new international recommendations for energy, protein and other nutrient requirements are reviewed. In Spain, the law applicable to manufacturing infant cereals and homogenized infant foods is that published by the European Union in specific directives. However, taking into consideration new advances in knowledge of nutritional requirements, we have considered a number of issues that could be relevant for the manufacture of these foods. Finally, we propose a series of basic principles that should serve as a guide for the complementary feeding of infants (whether breast fed, formula fed, or receiving mixed feeding) and young children. These recommendations are particularly addressed to pediatricians working in primary health services.     

Evaluation of the complementary feeding practices,dietary intake,and nutritional status of infants on a cow's milk protein elimination diet

ObjectiveTo evaluate the complementary feeding practices, food intake, and nutritional status of infants on a cow's milk protein elimination diet.MethodsA cross-sectional and observational study was conducted to compare infants aged 4–18 months who were on a cow's milk protein elimination diet with a control group of healthy infants without any dietary restrictions. General information on the child's health, demographic data, and food consumption were collected.ResultsThe study included 96 infants in the elimination diet group and 99 in the control group. In the elimination diet group, the median age (in months) of introduction of solid foods (5.0 × 4.0; p < 0.001) and water (5.5 × 4.0; p < 0.05) was later, consumption of soft drinks and industrialized cookies was less frequent (p < 0.05), and a lower index of complementary feeding inadequacies (2.75 × 3.50; p < 0.001) was observed. The elimination diet group presented lower individual values of Z scores for weight/age, weight/height, and body mass index/age, although they were fed with higher amounts of energy (117.4 × 81.3 kcal/kg of weight; p < 0.001) and macro-and micronutrients, except for vitamin A. In the elimination diet group, breast milk and its substitutes contributed to more than 67% of energy intake. Although calcium consumption was a deficit in 31.5% of the infants, none received supplementation.ConclusionInfants on an elimination diet presented more adequate complementary feeding practices and higher nutritional intake, despite lower body weight values.     

Nutritional problems related to food allergy in childhood

Food allergy is becoming an increasing problem worldwide with an estimated 6–8% of children affected at some point in their childhood. The perceived prevalence of food allergy is even higher with an estimated 20% of children adhering to some form of elimination diet. Against this background, accurate diagnosis is essential to prevent the imposition of unnecessarily restrictive diets on young children. Raising clinical awareness amongst health professionals as to the clinical characteristics, epidemiology, investigation, and management of food allergic disorders is key to tackling this growing problem. In this article, three separate cases of children with poor nutrition and secondary morbidity are presented, highlighting the varying scenarios in which these conditions can be encountered. In the first child, the features clinically displayed were hypocalcemic seizures and rickets due to prolonged breast feeding, poor weaning, and inadequate dietary supplementation. The second case reveals the dangers of complementary diagnostic allergy testing leading to poor nutrition as a consequence of an unsupervised elimination diet. The last report describes a child with multiple food allergies, failure to thrive, and protein losing enteropathy to highlight the diversity of nutritional problems faced by allergists and to underline the importance of specialist dietetic input in the management of a child with food allergy.     

Current trends in paediatric enteral tube feeding

The demand for enteral tube feeding in children is increasing globally. As our ability to manage complex medical conditions improves, so too does our understanding of the benefits of good enteral nutrition on health outcomes for these children. If oral feeding is not possible, an enteral tube can provide a viable alternative by delivering nutrition directly into the stomach or jejunum. The decision to recommend a child for long term tube feeding is complex and needs to be balanced against the potential risks. It is therefore essential that healthcare professionals keep up to date with the indications for referral, understand the current options available to children, and are able to identify common and serious problems that can arise following tube insertion. Healthcare professionals should also be aware of the debate surrounding the administration of blended feeds via the enteral tube. While some children may benefit from this practice, there are important considerations to be made for children receiving home blended feeds versus enteral formula. In this article, we review the indications for enteral tube insertion, device selection, complications and subsequent management. In addition, we review the logistics and implications for families and healthcare teams aiming to start blended tube feeding.     

Accelerating progress for complementary feeding in Kenya: Key government actions and the way forward

Optimal complementary feeding practices, a critical component of infant and young child feeding, has been demonstrated to prevent micronutrient deficiencies, stunting, overweight, and obesity. In Kenya, while impressive gains have been made in exclusive breastfeeding, progress in complementary feeding has been slow, and the country has failed to meet targets. Recent 2014 Kenya Demographic and Health Survey reveal that only 22% of Kenyan children, 6–23 months, met criteria for a minimum acceptable diet. This case study describes key actions for complementary feeding put in place by the Kenya Ministry of Health as well as approaches for improving and monitoring complementary feeding within existing health platforms. Experience from USAID's Maternal and Child Survival Program and Ministry of Health on development of 23 complementary feeding recipes through application of a national guide for recipe development and Trials of Improved Practices is described. Challenges in how to prepare, modify, and cook foods, including meat, for young children 6–23 months of age was relayed by mothers. Addressing cultural beliefs around complementary feeding meant providing reassurance to mothers that young children are developmentally able to digest fruit and vegetables and ready to consume animal‐source protein. Through the Baby Friendly Community Initiative platform, cooking demonstrations and key hygiene actions were integrated with complementary feeding messages. Future programming for complementary feeding should consider development of context specific counselling messages on consumption of animal source foods, strengthen production and use of local foods through agriculture‐nutrition linkages, and include complementary indicators through routine health monitoring systems to track progress.     

Breast-feeding: how and why to promote it

Breastfeeding promotion must be seen as a priority for the improvement of health and quality of life of children and their families. The strategies should vary according to the population, its culture, habits, beliefs, socio-economic level and other characteristics. Nevertheless, awareness of the importance of breastfeeding is crucial in any strategy. This review article aims to increase this awareness among health professionals. Epidemiologic evidences of the importance of breast feeding for the mother and child health are addressed. Emphasis is given to the impact of breastfeeding on infant mortality, morbidity and nutritional status, as well as on birth spacing. Further, this article discusses some breastfeeding promotion activities, specially educational programs for health professionals, pregnant women, parturients and general population. Changes in hospital routines, mass media,milk substitute marketing, protection of working mothers and community activities are also addressed.     

Effect of enhanced nutrition services with community-based nutrition services on the diet quality of young children in Ethiopia

Poor diet quality related to inadequate complementary feeding is a major public health problem in low and middle-income countries including Ethiopia. Low dietary diversity has been linked to negative health outcomes in children. To provide a package of interventions to close nutritional gaps through agriculture, the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme was set up as a multi-sectoral initiative and the results of combined effects of community-based and enhanced nutrition services, compared to community-based alone, on diet diversity and diet quality of complementary feeding of young children are presented. The study used pre- and post-intervention design. Baseline (n = 4980) data were collected from May to July 2016, and follow-up (n = 2419) data from December 2020 to January 2021. From 51 intervention districts having the SURE programme, 36 intervention districts were randomly selected for baseline and 31 for the follow-up survey. The primary outcome was diet quality: minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD). Comparing endline to baseline over the 4.5-year intervention, the use of standard community-based nutrition services of growth monitoring and promotion increased (16%–46%), as did enhanced nutrition services of infant and young child feeding counselling, and agricultural advising (62%–77%). Women involved in home gardening significantly increased (73%–93%); however, household production of food decreased yet consumption of most own-grown foods increased. Importantly, MAD and MDD increased four-fold. The SURE intervention programme was associated with improvements in complementary feeding and diet quality through enhanced nutrition services. This suggests programmes targeted at nutrition-sensitive practices can improve child feeding in young children.     

Infant and young child feeding in the Peruvian Amazon: the need to promote exclusive breastfeeding and nutrient-dense traditional complementary foods

The study objective was to understand the role of traditional Awajún foods in dietary quality and the potential impacts on growth of Awajún infants and young children 0-23 months of age. Research took place in April and May of 2004, along the Cenepa River in six Awajún communities. Anthropometry estimated nutritional status for 32 infants (0-23 months). Repeat dietary recalls and infant feeding histories were completed with 32 mothers. Adequacy of the complementary foods was compared with World Health Organization guidelines. Anthropometry indicated a high prevalence of stunting (39.4% of infants and young children), with nutritional status declining with age. Half of the Awajún mothers practised exclusive breastfeeding. Dietary recalls and infant food histories suggested that many of the infants were getting adequate nutrition from complementary foods and breastfeeding; however, there was variation in breastfeeding and complementary feeding practices among the mothers. Complementary feeding for young children 12-23 months generally met nutrient recommendations, but mean intakes for iron, zinc, calcium and vitamin A were inadequate in infants 6-11 months. Traditional foods provided 85% of energy and were more nutrient dense than market foods. Appropriate infant and complementary feeding was found among some women; however, given the range of feeding practices and introduction of market foods, health promotion targeting infant and young child feeding is warranted.     

Impact of flooding on feeding practices of infants and young children in Dhaka,Bangladesh Slums: what are the coping strategies?

Previous research has shown that urban slums are hostile environments for the growth of infants and young children (IYC). Flooding is a hazard commonly found in Dhaka slums (Bangladesh) which negatively impacts IYC's nutritional and health status. This paper aims 1) to identify the impact of flooding on IYC's feeding practices, and 2) to explore the coping strategies developed by caregivers. Qualitative data (participant observation and semi-structured interviews) and quantitative data (household questionnaire and anthropometric measurements) collected in slums in Dhaka (n=18 mothers, n=5 community health workers, and n=55 children) were analysed. The subjects of the interviews were mothers and Bangladesh Rural Advancement Committee (BRAC) community health workers living and working in the slums. Research findings showed that breastfeeding and complementary feeding practices for IYC were poor and inappropriate due to lack of knowledge, time, and resources in normal times and worse during flooding. One coping strategy developed by mothers purposely to protect their IYC's nutritional status was to decrease their personal food intake. Our research findings suggest that mothers perceived the negative impact of flooding on their IYC's nutritional health but did not have the means to prevent it. They could only maintain their health through coping strategies which had other negative consequences. The results suggests a holistic approach combining 1) provision of relief for nutritionally vulnerable groups during flooding, 2) support to mothers in their working role, 3) breastfeeding counseling and support to lactating mothers with difficulties, and 4) preventing malnutrition in under 2 year old children.     

Snack food and beverage consumption and young child nutrition in low‐ and middle‐income countries: A systematic review

Although snacks can provide important nutrients for young children during the complementary feeding period, the increasing availability of snack foods and sugar‐sweetened beverages (SSB), often energy‐dense and nutrient‐poor, in low‐ and middle‐income countries (LMIC) is a concern. Such foods may displace consumption of nutritious foods in contexts where diets are often nutritionally inadequate and the burden of childhood malnutrition is high. This systematic review summarizes literature on the contribution of snack food/SSB consumption to total energy intakes (TEI) of children below 23 months of age in LMIC and associations between this consumption and nutritional outcomes. It also identifies areas where further research is needed. A systematic search of Embase, Global Health, and MEDLINE for literature published in January 1990–July 2018 was conducted. This search yielded 8,299 studies, 13 of which met inclusion criteria: Nine studies assessed % TEI from snack foods/SSB, and four studies assessed associations between snack food/SSB consumption and nutritional outcomes. Average % TEI from snack foods/SSB ranged from 13% to 38%. Findings regarding associations with growth were inconclusive, and no studies assessed associations with nutrient intakes. Variation in measurement of consumption and definitions of snack foods and SSB limited study comparisons. Further research is needed to understand how consumption of energy‐dense, nutrient‐poor snack foods and SSB influences undernutrition and overnutrition among young children during the complementary feeding period in settings that are experiencing dietary transitions and the double burden of malnutrition.     

Informing infant and young child feeding programming in humanitarian emergencies: An evidence map of reviews including low and middle income countries

Around 200 million people were affected by conflict and natural disasters in 2015. Whereas those populations are at a particular high risk of death, optimal breastfeeding and complementary feeding practices could prevent almost 20% of deaths amongst children less than 5 years old. Yet, coverage of interventions for improving infant and young child feeding (IYCF) practices in emergencies is low, partly due to lack of evidence. Considering the paucity of data generated in emergencies to inform programming, we conducted an evidence map from reviews that included low‐ and middle‐income countries and looked at several interventions: (a) social and behavioural change interpersonal and mass communication for promoting breastfeeding and adequate complementary feeding; (b) provision of donated complementary food; (c) home‐based fortification with multiple micronutrient powder; (d) capacity building; (e) cash transfers; (f) agricultural or fresh food supply interventions; and (g) psychological support to caretakers. We looked for availability of evidence of these interventions to improve IYCF practices and nutritional status of infants and young children. We identified 1,376 records and included 28 reviews meeting the inclusion criteria. The highest number of reviews identified was for behavioural change interpersonal communication for promoting breastfeeding, whereas no review was identified for psychological support to caretakers. We conclude that any further research should focus on the mechanisms and delivery models through which effectiveness of interventions can be achieved and on the influence of contextual factors. Efforts should be renewed to generate evidence of effectiveness of IYCF interventions during humanitarian emergencies despite the challenges.     

Nutrition in children with neurodisability

Children with neurodisability are at risk of nutritional impairment due to a number of factors including feeding and swallowing difficulties, gastrointestinal disorders, disorders of movement and posture, immobility, medication, adverse food related sensory experience and behavioural feeding difficulties. Undernutrition has a negative impact on growth, general health indices, bone health, muscle strength, immunity and wound healing and brain and cognitive development. Regular multidisciplinary assessment including the routine measurement of body composition and micronutrient status are recommended to inform appropriate nutritional support and intervention. Intervention may include management of tone, posture and positioning for feeding, comorbid gastrointestinal disease, seizure management, alteration to medications or use of a sensory diet as well as changes to protein and energy intake, dietary fluid and fibre content, micronutrient supplementation, or establishment of an appropriate enteral feeding route in children unable to safely maintain nutritional needs orally. Children having nutritional support should have regular multidisciplinary follow up as clinically indicated, and when the clinical situation changes. This article aims to briefly review the most important aspects of nutrition in children with neurodisability and offer practical advice to health care practitioners involved in their care.     

Complementary food supplements to achieve micronutrient adequacy for infants and young children

Many children in developing countries survive on a nutritionally inadequate diet. Dietary inadequacies during the complementary feeding period can be prevented by using complementary food supplements (CFSs) such as water dispersible or crushable micronutrient tablets, micronutrient sprinkles added to food just before feeding, or fortified spreads added to food just before feeding or fed as a snacks. A meeting was convened to discuss technical and operational issues related to the development of these new approaches and to identify knowledge gaps. The technical issues covered: what micronutrients to include, tolerable upper intake limits, bioavailability, micronutrient and macronutrient stability, package systems and amounts, encapsulation technologies, methods to limit or eliminate allergens, bacterial and chemical contamination, interactions between CFSs and complementary foods, and flavoring agents. Operational issues included: identifying the market positioning of CFSs, cost positioning of CFSs, regulatory requirements, CFS production and technology transfer, quality assurance, and public-private sector partnership and coordination. Intervention trials are needed to determine the efficacy of CFSs in preventing micronutrient deficiencies. Other important knowledge gaps relate to technical and operational issues. Sprinkles and tablets are produced using well-known technologies, but further research is needed to modify them for use as CFSs. Spread development is not as advanced as sprinkle and tablet development, and further research is needed to improve the technology. Although none of the products is ready for widespread use, enough information is available to set research priorities and accelerate product development and implementation.     

Innovative optimization of ready to use food for treatment of acute malnutrition

Treatment of acute malnutrition typically requires the provision of ready‐to‐use food (RUF). Common RUF is effective but expensive, being manufactured from costly ingredients, and shipped worldwide from few global suppliers. I developed a linear programming tool to create RUF optimized for low cost using locally grown crops while maintaining necessary nutritional goals and other constraints. My tool utilizes a database of the nutritional value, price, and water efficiency of suitable ingredients and allows adjustment of constraints, including nutrients, flavour, and crop water efficiency. It is designed to (a) address nutrient requirements conforming to current standards and practice; (b) optimize RUF formulae for low cost using a wide range of ingredients for nutritional value and acceptability improvement; (c) ensure protein quality through protein digestibility corrected amino acid score; and (d) adjust RUF formulae according to locally grown crop selection, local prices, and crop water footprint. The tool creates formulae free of expensive dairy ingredients, ensuring desired protein digestibility corrected amino acid score by automatically balancing proteins with complementary quantities of essential amino acids. Using publicly available data with an application to Nigeria, my tool created RUF formulae suitable for local production using local crops to meet all nutrient requirements at a fraction of the ingredient cost and water footprint of current formulae, demonstrating the tool's effectiveness. Optimization of RUF for low cost using locally grown crops will facilitate local production and reduce ingredient as well as transport costs, so more patients can receive lifesaving treatment.     

Determinants of inappropriate complementary feeding practices in young children in India: secondary analysis of National Family Health Survey 2005-2006

In India, poor feeding practices in early childhood contribute to the burden of malnutrition as well as infant and child mortality. This paper aims to use the newly developed World Health Organization (WHO) infant feeding indicators to determine the prevalence of complementary feeding indicators among children of 6-23 months of age and to identify the determinants of inappropriate complementary feeding practices in India. The study data on 15,028 last-born children aged 6-23 months was obtained from the National Family Health Survey 2005-2006. Inappropriate complementary feeding indicators were examined against a set of child, parental, household, health service and community level characteristics. The prevalence of timely introduction of complementary feeding among infants aged 6-8 months was 55%. Among children aged 6-23 months, minimum dietary diversity rate was 15.2%, minimum meal frequency 41.5% and minimum acceptable diet 9.2%. Children in northern and western geographical regions of India had higher odds for inappropriate complementary feeding indicators than in other geographical regions. Richest households were less likely to delay introduction of complementary foods than other households. Other determinants of not meeting minimum dietary diversity and minimum acceptable diet were: no maternal education, lower maternal Body Mass Index (BMI) (<18.5 kg/m(2)), lower wealth index, less frequent (<7) antenatal clinic visits, lack of post-natal visits and poor exposure to media. A very low proportion of children aged 6-23 months in India received adequate complementary foods as measured by the WHO indicators.     

Exploring why junk foods are ‘essential’ foods and how culturally tailored recommendations improved feeding in Egyptian children

In Egypt, the double burden of malnutrition and rising overweight and obesity in adults mirrors the transition to westernized diets and a growing reliance on energy‐dense, low‐nutrient foods. This study utilized the trials of improved practices (TIPs) methodology to gain an understanding of the cultural beliefs and perceptions related to feeding practices of infants and young children 0–23 months of age and used this information to work in tandem with 150 mothers to implement feasible solutions to feeding problems in Lower and Upper Egypt. The study triangulated in‐depth interviews (IDIs) with mothers participating in TIPs, with IDIs with 40 health providers, 40 fathers and 40 grandmothers to gain an understanding of the influence and importance of the role of other caretakers and health providers in supporting these feeding practices. Study findings reveal high consumption of junk foods among toddlers, increasing in age and peaking at 12–23 months of age. Sponge cakes and sugary biscuits are not perceived as harmful and considered ‘ideal’ common complementary foods. Junk foods and beverages often compensate for trivial amounts of food given. Mothers are cautious about introducing nutritious foods to young children because of fears of illness and inability to digest food. Although challenges in feeding nutritious foods exist, mothers were able to substitute junk foods with locally available and affordable foods. Future programming should build upon cultural considerations learned in TIPs to address sustainable, meaningful changes in infant and young child feeding to reduce junk foods and increase dietary quality, quantity and frequency.