Complementary Feeding

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Exclusive (or Full) Breastfeeding (EBF)

This is defined as when all fluid, energy, and nutrients come from breast milk, with the exception of small amounts of medicinal supplements. It's noted that this method results in minimal pathogen exposure.

Almost EBF

This refers to the use of water or other non-nutritive liquids in addition to exclusive breastfeeding.

Partial BF

This is defined as mixed feeding with breast milk plus non-human milk, some solids, and other fluids as sources of energy and nutrients.

Period of Complementary Feeding (CFg)

This is defined as the time when other foods or liquids are given along with breast milk. It's noted that this was previously referred to as the "weaning period".

Complementary Foods (CFs)

These are defined as foods or liquids other than breast milk given to young children during the period of complementary feeding.

Transitional Foods (TF)

These are described as nutrient-dense complementary foods designed to meet the nutritional needs of the child.

Weaning

This is defined as the complete cessation of any breastfeeding.

Complementary foods are defined by the WHO as any food or liquid other than breast milk.

ESPGHAN suggested that the term should be applied to foods and liquids other than breast milk and infant formula.

Complementary feeding is required in the second part of the first year for:

Nutritional purpose
Developmental purpose

Complementary feeding is defined as the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk.

The target age range for complementary feeding is generally taken to be 6 to 24 months of age, even though breastfeeding may continue beyond two years.

Too Early

Should not be introduced before 17 weeks, as it can be associated with the risk of:

Infections
Obesity
Allergies

Too Late

Later than 26 weeks can predispose to:

Malnutrition
Nutritional deficiencies

To ensure that the nutritional needs of an infant are met, the complementary foods must be:

Timely – Introduced when the need for energy and nutrients exceeds what can be provided through breastfeeding.
Adequate – Provide sufficient energy, protein, and micronutrients to meet a growing child’s nutritional needs.
Safe – Hygienically stored, prepared, and fed with clean hands using clean utensils and not bottles and teats.
Properly Fed – They are given consistent with a child’s signals of appetite and satiety, and meal frequency and feeding methods actively encourage the child, even during illness.

1. Duration of Exclusive Breastfeeding and Age of Introduction of Complementary Foods

Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed.

2. Maintenance of Breastfeeding

Continue frequent, on-demand breastfeeding until 2 years of age or beyond.

3. Practice Responsive Feeding, Applying the Principles of Psychosocial Care

Feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues.
Feed slowly and patiently, and encourage children to eat, but do not force them.
If children refuse many foods, experiment with different food combinations, tastes, textures, and methods of encouragement.
Minimize distractions during meals if the child loses interest easily.
Remember that feeding times are periods of learning and love—talk to children during feeding, with eye-to-eye contact.

4. Safe Preparation and Storage of Complementary Foods

Practice good hygiene and proper food handling by:

Washing caregivers’ and children’s hands before food preparation and eating.
Storing foods safely and serving foods immediately after preparation.
Using clean utensils to prepare and serve food.
Using clean cups and bowls when feeding children.
Avoiding the use of feeding bottles, which are difficult to keep clean.

5. Amount of Complementary Food Needed

Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding.
The energy needs from complementary foods for infants with "average" breast milk intake in developing countries are approximately:
- 200 kcal per day at 6-8 months of age
- 300 kcal per day at 9-11 months of age
- 550 kcal per day at 12-23 months of age
In industrialized countries, these estimates differ somewhat (130, 310, and 580 kcal/day at 6-8, 9-11, and 12-23 months, respectively) because of differences in average breast milk intake.

6. Food Consistency

Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities.

Infants can eat pureed, mashed, and semi-solid foods beginning at six months.
By 8 months, most infants can also eat "finger foods" (snacks that can be eaten by children alone).
By 12 months, most children can eat the same types of foods as consumed by the rest of the family, keeping in mind the need for nutrient-dense foods.

7. Meal Frequency and Energy Density

Increase the number of times that the child is fed complementary foods as he/she gets older.

The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding.
For the average healthy breastfed infant, meals of complementary foods should be provided:
- 2-3 times per day at 6-8 months of age
- 3-4 times per day at 9-11 and 12-24 months of age
Additional nutritious snacks (such as a piece of fruit, bread, or chapatti with nut paste) can be offered 1-2 times per day, as desired.

8. Nutrient Content of Complementary Foods

Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish, or eggs should be eaten daily, or as often as possible.

Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used.
Vitamin A-rich fruits and vegetables should be eaten daily.
Provide diets with adequate fat content.
Avoid giving drinks with low nutrient value, such as tea, coffee, and sugary drinks like soda.
Limit the amount of juice offered to avoid displacing more nutrient-rich foods.

9. Use of Vitamin-Mineral Supplements or Fortified Products for Infant and Mothers

Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed.
In some populations, breastfeeding mothers may also need vitamin-mineral supplements or fortified products, both for their own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast milk.

10. Feeding During and After Illness

Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied, appetizing, and favorite foods.
After illness, give food more often than usual and encourage the child to eat more.

Inadequate knowledge about appropriate foods and feeding practices is often a greater determinant of malnutrition than the lack of food.
To achieve appropriate complementary feeding practice, the following should be put in place:

Accurate information and skilled support from the family, community, and health care system.
Diversified approaches to ensure access to foods that adequately meet the energy and nutrient needs of growing children, such as the use of home- and community-based technologies to enhance nutrient density, bioavailability, and the micronutrient content of local foods.
Providing sound and culture-specific nutrition counseling to mothers of young children and recommending the widest possible use of indigenous foodstuffs to help ensure that local foods are prepared and fed safely in the home.
The agriculture sector plays an important role in ensuring that suitable foods for use in complementary feeding are produced, readily available, and affordable.
Low-cost complementary foods, prepared with locally available ingredients using suitable small-scale production technologies in community settings, can help meet the nutritional needs of older infants and young children.
Industrially processed complementary foods also provide an option for some mothers who have the means to buy them and the knowledge and facilities to prepare and feed them safely. Processed-food products for infants and young children should, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission and adhere to the Codex Code of Hygienic Practice for Foods for Infants and Children.

Mothers, fathers, and other caregivers should have access to objective, consistent, and complete information about appropriate feeding practices, free from commercial influence.
In particular, they need to know about:
- The recommended period of exclusive and continued breastfeeding.
- The timing of the introduction of complementary foods; what types of food to give, how much and how often, and how to feed these foods safely.
Mothers should have access to skilled support to help them initiate and sustain appropriate feeding practices, and to prevent difficulties and overcome them when they occur.
Knowledgeable health workers are well placed to provide this support, which should be a routine part not only of regular prenatal, delivery, and postnatal care but also of services provided for the well baby and sick child.
Community-based networks offering mother-to-mother support and trained breastfeeding counselors working within, or closely with, the health care system also have an important role to play in this regard.

Basic Mix

Consists of 2 ingredients, described as the simplest.

Includes a staple food plus plant or animal protein.
Example given: maize pap + soybean flour or a pap mix + milk.

Multi Mix

Contains at least 4 basic ingredients.

Includes a staple food + plant or animal protein + vegetable + fat + fruit.
Example given: rice + beans + green leafy vegetables + palm oil.