Complementary feeding

When breast milk 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
WHO/NHD/J. Muriel

Complementary feeding should be timely, meaning that all infants should start receiving foods in addition to breast milk from 6 months onwards. It should be adequate, meaning that the complementary foods should be given in amounts, frequency, consistency and using a variety of foods to cover the nutritional needs of the growing child while maintaining breastfeeding.

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 for the age of the child and applying responsive feeding following the principles of psycho-social care.

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 breast milk, 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 Infant and Young Child Feeding counselling course, the Complementary feeding counselling course, the Integrated Management of Childhood Illness guidelines and training course for first-level health workers. 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 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, while the Guiding Principles for feeding the non-breastfed child 6-24 months of age (2005) provide guidance for feeding children who are not receiving breast-milk.

Based on new knowledge, WHO in collaboration with partners developed updated indicators on infant and young child feeding, including complementary feeding As a result there are three publication available: definitions, measurement and country profiles.

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