Infant and Young Child
When breastmilk is no longer enough to meet the nutritional needs of the infant, complementary foods should be added to the diet of the child. The transition from exclusive breastfeeding to family foods, referred to as complementary feeding, typically covers the period from 6 to 18-24 months of age, and is a very vulnerable period. It is the time when malnutrition starts in many infants, contributing significantly to the high prevalence of malnutrition in children under five years of age world-wide. WHO estimates that 2 out of 5 children are stunted in low-income countries.
Complementary feeding should be timely, meaning that all infants should start receiving foods in addition to breastmilk from 6 months onwards. It should be adequate, meaning that the nutritional value of complementary foods should parallel at least that of breastmilk. Foods should be prepared and given in a safe manner, meaning that measures are taken to minimize the risk of contamination with pathogens. And they should be given in a way that is appropriate, meaning that foods are of appropriate texture and given in sufficient quantity.
The adequacy of complementary feeding (adequacy in short for timely, adequate, safe and appropriate) not only depends on the availability of a variety of foods in the household, but also on the feeding practices of caregivers. Feeding young infants requires active care and stimulation, where the caregiver is responsive to the child clues for hunger and also encourages the child to eat. This is also referred to as active or responsive feeding.
WHO recommends that infants start receiving complementary foods at 6 months of age in addition to breastmilk, initially 2-3 times a day between 6-8 months, increasing to 3-4 times daily between 9-11 months and 12-24 months with additional nutritious snacks offered 1-2 times per day, as desired.
Inappropriate feeding practices are often a greater determinant of inadequate intakes than the availability of foods in the households. WHO has developed a protocol for adapting feeding recommendations that enables programme managers to identify local feeding practices, common problems associated with feeding, and adequate complementary foods. The protocol builds upon available information and proposes household trials to test improved feeding recommendations. WHO recommends that the protocol be used to design interventions for improved complementary feeding, and is included as part of adaptation process of the Integrated Management of Childhood Illness strategy.
Research has shown that caregivers require skilled support to adequately feed their infants. Guidelines for appropriate feeding are included as part of the Integrated Management of Childhood Illness guidelines and training course for first-level health workers. Extending these guidelines, WHO has developed the guide Complementary feeding: Family Foods for breastfed children that gives more detailed guidance for health workers on how to support complementary feeding. The guide is the basis of a 3-day training course for health professionals, which is currently under development.
The Global Consultation on Complementary Feeding, convened by WHO 10-13 December 2001, has resulted in updated recommendations for appropriate feeding practices and guidance for programme managers to put these into action. The background papers that informed this consultation are published in the Special Supplement of the Food and Nutrition Bulletin 2003; 24 (1) and provide an update to the WHO/UNICEF publication Complementary feeding of young children in developing countries: a review of current scientific knowledge, 1998, WHO/NUT/98.1.. The Guiding Principles for Complementary feeding of the Breastfed Child (2003) developed by the Pan American Health Organization, summarize the current scientific evidence for complementary feeding and are intended to guide policy and programmatic action at global, national and community levels.
Based on new knowledge, WHO is spearheading a global process for developing indicators to assess complementary feeding. An informal technical meeting to review and develop indicators for complementary feeding was held in Washington, 3-5 December 2002. The background paper Moving forward with complementary feeding: indicators and research practices guided participants in identifying possible indicators for further research or field validation. WHO in collaboration with partners is coordinating next steps to conduct validations. It is hoped that sufficient information will be available by the end of 2003 to allow for a consensus meeting to agree a new set of global indicators for assessing complementary feeding.
Protocol for Adapting Feeding Recommendations
Special Supplement of the Food and Nutrition Bulletin 2003
Complementary Feeding: Family Foods for Breastfed Children
Complementary Feeding of Young Children in Developing Countries
The Global Consultation on Complementary Feeding
Guiding Principles for Complementary feeding of the Breastfed Child
Informal technical meeting to review and develop indicators for complementary feeding
Moving forward with complementary feeding: indicators and research practices
List of documents