Complementary Feeding: Building the Foundations for a Healthy Life

R. E. Black, M. Makrides, K. K. Ong

• Publisher: S. Karger
• Year: 2017
• ISBN:
  9783318059564
• Topic: Medicina
• Subtopic: Medicina pediátrica

The complementary feeding period from 6 to 24 months is a crucial part of the first 1000 days of development. It marks the transition from exclusively milk-based liquid diet to the family diet and self-feeding. During this period, healthy food preferences and feeding practices are formed. The papers in this book were presented at the 87th Nestlé Nutrition Institute Workshop in Singapore, May 2016. Divided into three parts, they provide updates and recommendations, as well as insights into strategies and interventions, from all around the world. The first part addresses the role of complementary feeding in healthy development, focusing on food types and the timing of solid food introduction. The second part examines determinants of growth restriction and discusses effective interventions in infants and children in low- and middle-income countries. The last part focuses on development and 'programming' of behavioral and psychological aspects to prevent childhood obesity in high socioeconomic settings.

Update on Introduction of Complementary Feeding

Black RE, Makrides M, Ong KK (eds): Complementary Feeding: Building the Foundations for a
Healthy Life. Nestlé Nutr Inst Workshop Ser, vol 87, pp 1-12, (DOI: 10.1159/000449497)
Nestec Ltd., Vevey/S. Karger AG., Basel, © 2017

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Complementary Foods: Guidelines and Practices

Merryn J. Netting^{a, b} · Maria Makrides^{a, b}

^aChild Nutrition Research Centre, South Australian Health and Medical Research Institute (SAHMRI), and ^bDiscipline of Pediatrics, School of Medicine, The University of Adelaide, Adelaide, SA, Australia

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Abstract

Complementary feeding, the transition from a breast milk-based diet to inclusion of other sources of nutrition in an infant’s diet, is a major milestone in infant development. This transition period is important as it is a time when infants are vulnerable to developing nutritional deficiencies and occurs during a developmental stage when important food-related behavioral patterns are being established. As under- and overnutrition may coexist in children from the same country, it is important that advice provided by complementary feeding guidelines meets the needs of all children helping them to grow and develop into healthy adults. Many consistent and important themes emerge when comparing complementary feeding guidelines from different countries: complementary foods at or around 6 months of age; continued breastfeeding; nutrient-dense complementary foods; hygienic food practices; development of feeding skills that foster long-term healthy eating habits, and prevention of non-communicable diseases such as obesity. Complementary feeding guidelines that promote good eating during the first year and beyond recognize that nutrition, particularly during the first 1,000 days, has an important influence on immediate growth and development, but also an important role in setting up taste preferences and behavioral patterns which inform an infant’s susceptibility to development of disease later in life. However, guidelines in many countries are not always followed, particularly during the second year of life, and innovative methods are needed to increase compliance.

© 2017 Nestec Ltd., Vevey/S. Karger AG, Basel

Introduction

Complementary feeding, the transition from a breast milk-based diet to inclusion of other sources of nutrition in an infant’s diet, is a major milestone in infant development. This transition period occurs at a time when infants are vulnerable to developing nutritional deficiencies during a developmental stage when long-term behavioral patterns are being established. The complementary feeding period extends from the early initiation phase to establishing meal and food habits that will move with the infant into early childhood and beyond.

In low- and middle-income countries, the focus of complementary feeding recommendations is to prevent growth faltering caused by delayed complementary feeding or inadequate feeding practices, where too little food is offered or the food is of low nutrient density. This is in contrast to high income countries where malnutrition caused by improper feeding behavior and poor food choices may present as under- or overnutrition. There is an increasing body of evidence that early feeding, particularly during the first 1,000 days, plays an important influence in setting up food preferences and eating behaviors that will influence a child’s susceptibility to non-communicable diseases later in life. As such, it is important to provide guidelines that prevent chronic disease influenced by early nutrition.

We aim to compare official feeding recommendations as they apply in low-, middle- and high-income countries, and to discuss current evidence related to feeding practices as obtained from dietary intake surveys. The consequences of feeding complementary foods too early or too late will be discussed, and knowledge gaps and opportunities for further research identified.

Infant/Toddler/Child: Changing Requirements for Growth and Development

Breastfeeding is the gold standard for infant feeding, and it is encouraged for 2 years and beyond, as long as the mother and child desire [1]. However, at around 6 months of age, an infant’s requirements for energy, protein and other nutrients (particularly iron and zinc) cannot be met by breast milk alone [1]. At around the same time, infants begin to demonstrate signs that they are developmentally ready to begin eating solid foods as the tongue thrust reflex is lost and they start to show interest in the food that people around them are eating. Infants may watch when others are eating, opening their mouths for food, or they may reach for food on a parent’s or caregiver’s plate. Parents may naturally respond to these signs by offering the child a small amount of the food from their plate or by consciously making the decision to start to offer their child complementary foods. Foods offered may be home prepared or commercially available infant foods. Foods may be placed into the infant’s mouth using clean fingers, offered from a spoon, or the baby may be encouraged to feed itself. Regardless of which foods are given and the manner in which they are offered, the early feeding environment begins to establish longer-term attitudes and eating behaviors.

The appropriate timing of introduction to complementary foods is often called the ‘window of opportunity’. This window may be considered in terms of specific nutritional requirements at the time, as a developmental opportunity in terms of receptiveness to varied textures of foods [2], or may be considered as optimal timing of exposure to food allergens to foster development of immune tolerance [3].

Around a child’s first birthday, there is a relative (per kilo) drop in energy and protein requirements associated with decreased growth velocity. However, requirements for many micronutrients (specifically, vitamins B₁, B₂, B₃, B₆, B₁₂ and calcium) increase from the first to the second year, while needs for others (in particular iron, zinc and iodine) remain similar to those at 6-12 months [4, 5]. During this stage, the nutritional quality of the food in the child’s diet becomes even more important as relatively less food is required to maintain growth, for example per 100 calories of food, a 6- to 8-month-old breastfed infant’s iron requirement is estimated to be equivalent to 9 times that of an adult male [5].

In addition to meeting specific nutritional requirements, this time comes at a delicate developmental stage as the child begins to focus on development of gross motor skills and begins to assert independence. During the toddler period at 12-24 months of age, mealtimes may become difficult, and food neophobia may become an issue with many toddlers preferring familiar foods presented in the same way [6]. This, coupled with potential parental concern related to slow growth and perceived picky eating, can lead to a ‘perfect storm’ of control related to mealtimes and eating. When managing potential feeding issues, a balance between too-controlling and laissez-faire parenting leads to the best behavioral outcomes [7]. Parents can help young children develop good eating patterns by establishing a meal and snack time routine, offering a variety of foods as part of a healthy diet and allowing the child to control which foods from the meal or snack they eat in amounts that satisfy their appetite [8].

Eventually the toddler becomes a preschooler and then a school-age child. Optimal nutrition remains important during each of these stages as early eating habits often translate into lifelong eating patterns and eventually influence long-term health outcomes.

How Do We Meet These Changing Needs as Children Grow and Develop? Complementary Feeding Guidelines and Policies

Infant feeding guidelines, including instructions related to complementary feeding, are developed by many countries and are underpinned by the global nutrition strategies of the World Health Organization (WHO), which primarily aim to prevent undernutrition in low- and middle-income countries. The WHO advocates for exclusive breastfeeding for 6 months and complementary feeding from 6 months of age, with continued breastfeeding until 2 years of age. This advice has recently been strengthened b...