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
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)“.
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.2. 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. Strategies to prevent malnutrition during transition
The three important strategies are
- Continued breastfeeding
- Introducing vegetable protein early (pulses)
- 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.
- 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).
- Feed slowly and patiently, and encourage children to eat, but do not force them.
- 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).
- Minimize distractions (especially mobile phone or TV) 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. 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
- Washing caregivers’ and children’s hands before food preparation and eating
- Storing foods safely and serving foods immediately after preparation. This reduces the chance of contamination with germs.
- Using clean utensils to prepare and serve food
- Using clean cups and bowls when feeding children, and
- 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.
Link for the books on complementary feeding