The same article is available in Nepali and Hindi also

    The first 1000 days of life i.e, the 270 days (or 9 months)  in the mother’s womb  and the first two years after birth is the critical period for feeding.  Adequate nutrition by appropriate complementary feeding during this period is fundamental to the development of each child’s full human potential. After a child reaches 2  years of age, it is very difficult to reverse malnutrition and  stunting (shortness) that has occurred earlier.

     The immediate consequences of poor nutrition during these formative years include a higher likelihood of serious illness  and delayed mental and motor milestones (like delayed walking and/or talking).  In the long-term, early nutritional deficits are linked to impairments in intellectual performance, work capacity, reproductive outcomes, and overall health during adolescence and adulthood.

     In this article, I shall discuss optimal strategies for starting complementary feeds after 6 months of exclusive breastfeeding and also feeding in infants (first one year of life) and young children. It is important to use the term “complementary feed” and avoid “weaning food”, as the goal is to complement the breast milk not to wean off from it.

The principles of complementary feeding

1. The transition from exclusive breastfeeding to family food

complementary feeding child

     The child should be given breast-milk exclusively till the end of six months (180 days). Read “Breastfeeding-Benefits, effective methods and 2 most common challenges”. Complementary food should then be introduced at exactly 6 months, preferably with energy-dense, homemade food. The earlier introduction is  often  due  to  ignorance. There is a chance of contamination  and  infection  during food preparation. However, contamination  is virtually impossible in breast milk. The  introduction of complementary feed before 6 months increases the odds of infection in this immunologically vulnerable age group. 

    On the other hand breast milk alone is insufficient after 6 months of age.  Babies start putting everything into their mouth around this age, making them prone to gut infections anyway. Delayed introduction of complementary feeds leads to growth faltering and malnutrition. Children are most likely to become malnourished during this transition period. As discussed earlier malnutrition during this period has adverse developmental outcomes.  

      In the initial few months of complementary feeding (between 6 to 9 months),  breast  milk  should  continue  to  be  the  main  food  of  the  baby. To  minimize  interference  with  normal  breastfeeding,  complementary food should  be  given between  breastfeeds.  Breastfeeding  should  continue  for  as  long  as  feasible,  at least till two  years  of  age.  This  is  important  as  the  first  two  years  is  a  period  of rapid  brain  growth  and  breast  milk  contains  factors  essential  for  brain  growth  and development.

      The  best first  cereal for complementary feeding is  rice, as it  is easily digestible and  gluten  free. Gluten is a type of protein found in grains like wheat, rye, spelt, and barley. This protein causes problems for people with  health conditions like wheat allergy, celiac disease, and gluten sensitivity.  Since at 6 months it is difficult to know if the baby has any of these diseases, it is better to avoid these cereals initially. In  any  case,  it  is  better to start  from  single  cereal food   followed  by  multi  cereals  and then  cereals-pulse  combination. In  cereal-pulse combination, nutrients absent in the cereal would be available in pulse and vice versa. 

    Once the baby has starting taking rice well, the mother  can  make  different  combination  with  wheat,  pulse, vegetables.  They  should  be  easily  available and acceptable to parents.   Tubers,  fruits,  biscuits,  and  banana  powder  are can  also be used as complementary  foods. Frequent  feeding  is  desirable  as  it  aids  in  good  acceptance  by  the  infant.

Template  schedule for the  transition  

At  6  months  of  age: A rice cereal-based  porridge  enriched  with  jaggery/sugar,  oil/ghee and animal milk  can  be started.  Start  with  1-2  spoonfuls  and  gradually  increase  to  1/2  to  1  cup  per day  in  1-2  servings  in  addition  to  breastfeeding.

At  6—9  months  of  age:  After  6  months  of  age,  introduce  mashed  items  from  the family  pot  enriched  with  jaggery/sugar  and  oil/ghee.  Mashed  rice  with  pulses, mashed  tubers  and  vegetables,  soups,  mashed  fruits,  biscuits,  egg  yolk  followed by eggwhite (egg white is allergenic in some children, introducing in this order might reduce allergy),  can  be  given  4-5  times  a  day.

At  9-12  months  of  age:  After  9  months,  introduce  soft  food  that  can  be  chewed, avoiding  hot  spices.  Roti  and  other  hard  items  can  be  made  soft  by adding  little  milk.  Food  from  family  pot  can  be  given  4-6  times  a day  gradually  increasing  the  quantity. It is essential to introduce wide variety of food items early. Read “Food Fussiness in Children (10 counter-intuitive ways of breaking your child’s poor eating habits)“.complementary food pyramid

     By  one  year  of  age,  the  baby  should  be taking  everything  cooked  at  home and preferably by himself or herself.  This  is  called  ‘family  pot  feeding’.  A  one- year-old child should eat half of what the mother eats. During this period,  vegetables,  especially  green  leafy vegetables,  seasonal  fruits,   fish,  meat  etc. Should also be introduced to  the  baby.

    It  is  essential  to  switch  over  gradually  to  the  usual  family  food and also to self feeding.  Family food  can  be given  in  a  thickened  and  mashed  form  from  the  family  pot  without  adding  hot spices.  Provide  little  extra  oil  or  ghee,  green  leafy  vegetables  and  seasonal  fruits to  the  baby.  The  infant  should  grow  up,  accustomed  to  the  traditional  foods. A  new  food  should  be introduced  in  the  morning  session  and  only  one  item  should  be  introduced  at  a time.

Feeding toddlers (1-3 years of age): A  toddler  needs  more  than  half  the  food  that  the  mother  eats.  This  should  be given  in  frequent  servings over 5 to 7 meals (in contrast to 3 meals on adults). As  toddlers  are  more  interested  in  play  and  as  they have  a  normally reduced appetite  and  slower  growth  rate than  infants,  they  must  be coaxed  to  eat.  Eating  while  playing,  group  eating  and  eating  from  a  special  vessel ‘Akshayapatra’,  into  which  pieces  of  food  stuff  can  be  added  on,  may  be  adopted. They often enjoy eating from their own special vessel.complementary feeding and food fussiness2. Ensuring adequate energy and improving nutrient composition of complementary feed

       Energy dense means small amount of food should provide high amount of  energy. Energy density can be increased by increasing oil (or fat content) in food as fat  gives higher calorie per gram (9 kcal/gm) compared to carbohydrates (3.4 kcal/gm) and proteins (4 kcal/gm). This can be done by making parantha  instead of  roti  and serving fried rice in place of boiled rice and omelets in place of boiled eggs. Adding sugar/jaggery and ghee/butter/oil before serving also increases energy density.

      Energy density can also be maintained by avoiding excessive dilution of food  items with water.  Foods like porridge must be thick in consistency thick enough to stay on the spoon without running off when the spoon is tilted.  High energy density and frequent feeding of small volume as opposed to three large meals in adults take care of small stomach size in these children.

      Foods can also be enriched by making a fermented porridge, use of germinated or sprouted flour, and toasting grains before grinding. Soaking  and  malting  of  grains  will  increase  digestibility  and  vitamin  content. Sprouting  or  germination  will  enhance  vitamin  content.  Fermentation  enhances  vitamin  C  and  digestibility;  e.g.,  curd/yogurt.  It  also  increases  shelf-life.  The  once  a day  introduction  of  instant  food (like cerelac) could  reduce calorie gap if it exists.  They may also provide some vitamins and minerals. making food energy dense nutrient richStrategies to prevent malnutrition during transition

The  three  important strategies are 

  1. Continued breastfeeding
  2. Introducing vegetable  protein early (pulses)
  3. Animal protein (eggs/ meat)

  The utilization  of  supplementary  feeding  programmes like  ICDS (Integrated Child Development Services) helps to follow these strategies. Those  who  do  not  avail of this  facility  should arrange  extra  feeding  either  in  the  play  school  in  the  form  of  group  eating  or  at home  using  the  ‘Akshayapatra’.

Home-made vs Instant complementary foods

     Complementary  foods  can  be  home  made  or  instant  foods (eg cerelac).  Homemade   foods   are  economical,  easily  available,  culturally  accepted,  and  closer  to  family  food, and  versatile. On the other hand,  instant foods  offer balanced  nutrient  content  as  per  the  recommendations. Each  type  of  complementary  foods  (homemade  or  instant) should  be  analyzed  for  the advantages  and  disadvantages

     A reasonable  combination  of  homemade  and  instant foods  may  get  the  best  result  in  prevention  of  vitamin or mineral deficiencies  and the development of healthy family food habits. However, excessive focus on nutrient intake baby is not of much benefit. The focus should be more on giving a variety of food items in an adequate amount throughout the day.

3. Responsive feeding

Effective feeding for the long term needs psycho-social care. Responsive feeding is the best method to follow.

  1. Feed infants directly and assist  older children. Beginning from 1 year of age, assist alone, do not completely spoon-feed. Read “Food Fussiness in Children (10 counter-intuitive ways of breaking your child’s poor eating habits)” When  they feed themselves, be sensitive to their hunger and satiety cues. Respect your child’s appetite (or lack of one).
  2. Feed slowly and patiently, and encourage children to eat, but do not force them.
  3. If  children refuse to eat many  different food items, experiment with different food combinations, tastes, textures, and methods of encouragement. You may also encourage your child by talking about a food’s color, shape, aroma, and texture (not whether it tastes good). 
  4. Minimize distractions (especially mobile phone or TV) during meals if the child loses interest easily.
  5. Remember that feeding times are periods of learning and love – talk to children during feeding, with eye to eye contact. Also, your aim should be long term good feeding behavior, not finishing a meal.

4. Safe preparation and storage of complementary foods

 Practice good hygiene and proper food handling by

  1. Washing caregivers’ and children’s hands before food preparation and eating
  2. Storing foods safely and serving foods immediately after preparation. This reduces the chance of contamination with germs.
  3. Using clean utensils to prepare and serve food
  4. Using clean cups and bowls when feeding children, and
  5. Avoiding the use of feeding bottles, which are difficult to keep clean. You should rather use a bowl and spoon or  a cup.

The peak incidence of diarrhea is during the second half-year of infancy, as the intake of complementary foods increases and the baby is still immunologically developing . Because they are difficult to keep clean,feeding bottles are a particularly important route of transmission of germs.

5. Feeding during and after illness

      During illness, the need for fluids is often higher than normal.   Sick children appear to prefer breast milk to other foods. Frequent breastfeeding ensures adequate fluid intake and also nutrition. Parents should also  encourage the child to eat soft,  varied, appetizing, favorite foods. After illness, the child should  be encouraged to eat food more often than usual to hasten recovery.  Extra food is needed until the child has regained any weight lost and is growing well again.

Links for the books on complementary feeding

This Post Has 2 Comments

  1. Avatar
    Dr Sanjeev Kumar Prasad

    Informative

  2. Avatar
    Priya

    Very well explained in simple words

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