Complementary Feeding

A Research-Based Guide

Claire Tuck

• Publisher: CRC Press
• Year: 2022
• Print ISBN: 9781908911933
• eBook ISBN: 9781000605266
• Edition: 1
• Topic: Medicine
• Subtopic: Service Industry

Specifically designed for health visitors, general practitioners, nurses, dietitians and nutritionists, this is the first book to clarify the suggested balance of different foods and food groups needed to provide a healthy diet in infants.
It interprets government recommendations and current research to give health professionals completely up-to-date, highly detailed advice in a practical, easy-to-read format. Tables and figures are widely used to illustrate complex concepts and aid understanding. It is ideal as a daily reference. Healthcare policy makers and shapers will also find much of interest to assist in the provision of new guidance.

CHAPTER 1

When to introduce solids

Key facts

1. 1. Complementary feeding means introducing solids to an infant’s milk diet.
2. 2. The current recommendation is to start introducing solids at 6 months but there is flexibility to start earlier, dependent upon the individual needs of each infant.
3. 3. While research unequivocally shows that solids should not be introduced until after 4 months of age, debate continues regarding the ideal recommended age of introduction of solids, because of the limited evidence of benefits of exclusive breastfeeding to 6 months, relative to 4–6 months, in developed countries.
4. 4. Breastfeeding has been shown to provide sufficient energy for normal growth and to meet recommended energy requirements for most infants at 6 months of age.
5. 5. Breastfeeding is associated with a reduced risk of gastrointestinal infection in both developing and developed countries.
6. 6. There is currently a lack of data regarding the most appropriate time to introduce solids, including gluten, in terms of minimising the risk of development of allergies and coeliac disease.
7. 7. While breastfeeding has been shown to be protective against overweight and obesity, there appears to be no association between the timing of introduction of solids and overweight or obesity in infancy.
8. 8. An infant’s iron stores at birth are positively related to maternal iron stores. Infants with low iron stores at birth appear to have a greater risk of iron deficiency anaemia at 6 and 12 months than infants whose iron stores are replete at birth.
9. 9. Based on a limited number of studies, exclusive breastfeeding to 6 months is associated with a low risk of iron deficiency anaemia in developed countries, but a higher risk of iron deficiency anaemia in developing countries.
10. 10. Vitamin D is recommended as a supplement from 6 months of age if <500 mL per day of infant formula is consumed (all breastfed infants from 6 months; from 1 month if the vitamin D status of the mother is questionable).

WEANING AND COMPLEMENTARY FEEDING

Weaning, in its true sense, is the cessation of breastfeeding, while complementary feeding means introducing solid food to an infant’s milk diet while still giving milk.¹ These two terms are often incorrectly interchanged. Initially, complementary feeding involves getting the infant used to different tastes and textures, food being given on a spoon or by allowing the infant to self-feed.

THE UK RECOMMENDATION FOR INTRODUCING SOLID FOODS

The Department of Health (DH)² recommends that solid foods are introduced at 6 months of age, later than the previous DH recommendation of between 4 and 6 months.³ This 6 months (26 weeks) recommendation followed new guidance from the World Health Assembly⁴ and a new global strategy on infant feeding by the World Health Organization (WHO).⁵

The DH recommendation² is for all infants, whether breastfed or formulafed, exclusive breastfeeding being recommended until the introduction of solids. This 6 months recommendation does, however, suggest a flexible approach to the timing of introduction of solids: ‘all babies are individuals and will require a flexible approach to optimise nutritional needs’,² and ‘if an infant is showing signs of being ready to start eating solids (taking an interest in what the family is eating, picking up and tasting food) then they should be encouraged’.² Interestingly, these signs are no longer included as signs that an infant is ready for solids (see Chapter 2).

EVIDENCE RELATING TO THE 6-MONTH EXCLUSIVE BREASTFEEDING RECOMMENDATION

Evidence relating to the 6-month exclusive breastfeeding recommendation² focuses largely on energy and growth, risk of gastrointestinal infection, overweight and obesity, and the development of allergies.

Energy and growth

A WHO-commissioned Cochrane review⁶ compared exclusive breastfeeding for 3–4 months versus 6 months. Only two of the 20 studies were randomised intervention trials, both of which were carried out in developing countries. One study in Belarus found less morbidity from gastrointestinal infection in infants exclusively breastfed for 6 months than in those exclusively breastfed for 3 months. The review concluded that there was no difference in growth between infants exclusively breastfed for 3–4 months versus 6 months.⁶ That is, breast milk provided enough energy for growth for 6 months in infants from a developing country, where birthweight and thus energy requirements are less than those in the United Kingdom.

An update of this review,⁷ which included 11 studies from developed countries, found no difference in weight or length gain between infants exclusively breastfed for 6 months versus 3–4 months, larger sample sizes being required to confirm these findings. A small UK study⁸ found that breast milk production at 6 months provided adequate energy intake⁹ and enabled normal infant growth.

It therefore appears that breastfeeding to 6 months provides adequate energy intake for most infants in developing and developed countries.

Risk of gastrointestinal infection

The WHO-commissioned Cochrane review⁶ showed that only one study in Belarus found less morbidity from gastrointestinal infection in infants exclusively breastfed for 6 months than for 3–4 months. A later study conducted in Mexico¹⁰ found that infants predominantly breastfed for 6 months had a significantly lower incidence of gastrointestinal infection at 6 months than non-predominantly breastfed infants (partially breastfed and formula-fed combined). Similarly, a reduced risk of gastrointestinal infection was found from 6 months of exclusive breastfeeding versus 3–4 months among infants from Belarus, Nigeria and Iran.⁷ These studies support the protective effect of 6 months of exclusive breastfeeding on risk of gastrointestinal infection in developing countries.

A further review by Duijts et al.¹¹ found that a longer duration of exclusive breastfeeding had a protective effect on risk of gastrointestinal infection in industrialised countries, the authors concluding that further research was needed to determine the optimum duration of exclusive breastfeeding on protection from infectious diseases.

While it is recommended to introduce solids at 6 months because of a reduced risk of gastrointestinal disease, there is limited evidence for a reduced risk in developed countries.

Overweight and obesity

A meta-analysis of 33 studies¹² found that breastfeeding appeared to protect against overweight and obesity in children and adolescents, but not in adults; however, most studies were observational and therefore were prone to bias. Several studies have found a greater protective effect against overweight and obesity associated with a longer duration of non-exclusive breastfeeding,¹³ while others have found no protective effect of a longer duration (average of 3 months) of breastfeeding.¹⁴ These studies do not appear to have compared the effect of 6 months of exclusive breastfeeding relative to 4–6 months of exclusive breastfeeding on later risk of overweight and obesity.

De Kroon et al.¹⁵ found a significant inverse relationship between duration of exclusive breastfeeding (zero to 6 or more months) and body mass index, waist circumference and waist-to-hip ratio among Dutch adults aged 18–28 years. While body mass index decreased by 0.14 kg/m² per month of exclusive breastfeeding,¹⁵ it is unclear whether this decrease was significant each month, and whether the decrease following 6 months of exclusive breastfeeding was significantly greater than that following 4–5 months of exclusive breastfeeding.

A recent systematic review found no association between the timing of introduction of solids and obesity in infancy and childhood...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• About the author
• Acknowledgement
• Dedication
• List of tables and figures
• List of symbols and abbreviations
• Summary of key facts
• 1 When to introduce solids
• 2 How to introduce solids
• 3 The dietary requirements of infants
• 4 Meeting dietary requirements
• 5 Food intake: food groups and portion sizes
• Appendix
• Index