Food and Nutrition Bulletin

This paper provides an update to the 1998 WHO/UNICEF report on complementary feeding. New research findings are generally consistent with the guidelines in that report, but the adoption of new energy and micronutrient requirements for infants and young children will result in lower recommendations regarding minimum meal frequency and energy density of complementary foods, and will alter the list of “problem nutrients.” Without fortification, the densities of iron, zinc, and vitamin B₆ in complementary foods are often inadequate, and the intake of other nutrients may also be low in some populations. Strategies for obtaining the needed amounts of problem nutrients, as well as optimizing breastmilk intake when other foods are added to the diet, are discussed. The impact of complementary feeding interventions on child growth has been variable, which calls attention to the need for more comprehensive programs. A six-step approach to planning, implementing, and evaluating such programs is recommended.

Although many successes have been achieved in promoting breastfeeding, this has not been the case for complementary feeding. Some successes in promoting complementary feeding at the community level have been documented, but few of these efforts have expanded to a larger scale and become sustained. To discover the reasons for this difference, the key factors for the successful promotion of breastfeeding on a large scale were examined and compared with the efforts made in complementary feeding. These factors include definition and rationale, policy support, funding, advocacy, private-sector involvement, availability and use of monitoring data, integration of research into action, and the existence of a well-articulated series of steps for successful implementation. The lessons learned from the promotion of breastfeeding should be applied to complementary feeding, and the new Global Strategy for Infant and Young Child Feeding provides an excellent first step in this process.

We propose a set of “best-practice complementary feeding behaviors,” which were derived by combining principles of psychosocial care with current knowledge in nutritional sciences. We provide a theoretical rationale for assessing and describing complementary feeding practices in terms of what is fed, how food is prepared and given, who feeds the child, when food is fed (frequency and scheduling), and the feeding environment (where). We also discuss the significance of selected sociocultural determinants of these practices for the design of interventions. We then review 18 case studies in relation to these practices and their determinants. The exercise, in which we abstracted data from ethnographic reports, revealed areas of congruence and deviations from best-practice behaviors. The data on feeding practices are described with a common framework to facilitate comparison across sites. Key themes emerging from the studies include the significance of the larger family, the effects of competing maternal time demands, and the importance of parental perceptions and cultural constructs in affecting complementary feeding practices. Finally, we discuss the implications of the findings for future interventions.

Large numbers of infants and young children suffer from the short- and long-term health effects of poor breastfeeding and complementary feeding practices. Strategies to improve the availability of and access to low-cost fortified complementary foods can play an important corresponding role to that of behavior change in improving nutritional status of young children. However, the nutritional quality of complementary foods used in publicly funded programs is not always optimal, and such programs are costly and reach only a tiny fraction of those who could benefit. To broadly reach the target population, such foods need to be commercially available at affordable prices and promoted in a way that generates demand for their purchase. A sensible long-term policy for the promotion of low-cost fortified complementary foods calls for attention to their nutritional formulations and cost, the economics of production, and the legislative, regulatory, and competitive framework in which marketing occurs. This paper provides information on how to improve the nutritional formulations of fortified complementary foods and outlines the necessary conditions for a market approach to their production and promotion.

Plant-based complementary foods are the main source of nutrients for many young children in developing countries. They may, however, present problems in providing nutritionally adequate and safe diets for older infants and young children. The high starch content leads to low-nutrient diets that are bulky and dense, with high levels of antinutritive factors such as phytates, tannins, lectins, and enzyme inhibitors. Phytates impair mineral bioavailability, lectins interfere with intestinal structure, and enzyme inhibitors inhibit digestive enzymes. In addition, there is often microbial contamination, which leads to diarrhea, growth-faltering, and impaired development, and the presence of chemical contaminants may lead to neurological disease and goiter. The fact that some fruits containing carotenoids are only available seasonally contributes to the vulnerability of children receiving predominantly plant-based diets. Traditional household food technologies have been used for centuries to improve the quality and safety of complementary foods. These include dehulling, peeling, soaking, germination, fermentation, and drying. While modern communities tend to reject these technologies in favor of more convenient fast-food preparations, there is now a resurgence of interest in older technologies as a possible means of improving the quality and safety of complementary foods when the basic diet cannot be changed for economic reasons. This paper describes the biology, safety, practicability, and acceptability of these traditional processes at the household or community level, as well as the gaps in research, so that more effective policies and programs can be implemented to improve the quality and safety of complementary foods.