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Complementary feeding

Complementary feeding is the process starting when breastmilk alone is no longer sufficient to meet the nutritional requirements of an infant and when other foods and liquids along with breastmilk are needed. The age range for complementary feeding is generally 6-24 months.

A period of vulnerability and opportunity

  • Greatest vulnerability to malnutrition and infection. Nutritional needs for growth and development between 6-24 months of age are greater per kilogram of body weight than at any other time of life. Growth faltering occurs mainly in the first two years of life in all regions of the world. Insufficient nutrient intake and illness resulting from the introduction of pathogens in contaminated foods and feeding bottles are major causes of malnutrition.
  • Brain and body development. Good nutrition is essential at this time to ensure healthy brain and body development.
  • Long-term, irreversible consequences. Poor feeding practices and low quality food can affect future learning ability, economic productivity, immune response, and reproductive outcomes. Children who are undernourished before they reach their second birthday and later gain weight rapidly after the age of two years are at high risk of nutrition-related chronic disease as adults.
  • Window of opportunity. Nutrition interventions during this period can lead to great benefits. Feeding practices appropriate for the child’s age, nutritionally adequate foods, and continued breastfeeding can ensure optimal growth and development.

Assessment of chronic malnutrition

  • Becoming malnourished is a process resulting from insufficient nutrient intake, inadequate care, and infectious disease. The usual way to assess chronic nutritional deficiencies in children 6-24 months old is to measure height and compare it with the standard for children of the same age.
  • Too short for age (stunting). Approximately 165 million children are stunted. The quality and quantity of foods fed to a child, illness, the child’s appetite, caregiver behaviors, and food and water safety affect child growth. Stunting is seldom reversed in later childhood and adolescence and is associated with poor performance in school and lower adult wages.

Read Alive & Thrive’s Technical Brief, “Why stunting matters”  Note: we have other relevant briefs on complementary feeding.

Challenges to good nutrition in children 6-24 months olds

The challenges are context specific, but many are common across settings, including:

Household and family factors. Maternal nutritional status before and during pregnancy, poverty, household food insecurity, low caregiver education, inadequate child stimulation and activity, and water, sanitation, and hygiene contribute to child malnutrition and illness.

Read Alive & Thrive’s Technical Brief, “Early childhood growth: How do nutrition and infection interact?”

Poor feeding practices

  • Poorly timed introduction of complementary foods (too early or too late)
  • Infrequent feeding (children need to be fed frequently throughout the day because of their small stomach size)
  • Poor feeding methods, hygiene, and child care practices
    • Unsupervised feeding
    • Lack of interaction between caregiver and child
    • Unhygienic food preparation and storage and unclean feeding utensils
    • Bottle-feeding

Poor dietary quality. The diets of children 6-24 months old are often characterized by:

  • Too little variety
  • Inappropriate consistency (food is too thin or too thick)
  • Too few essential vitamins and minerals, especially vitamin A, iron, zinc, and calcium
  • Too few essential fatty acids
  • Too few calories among non-breastfed infants

Changing requirements. As the child ages, feeding practices must change in response to the child’s changing nutritional requirements, motor skills, and maturing digestive and immune systems.

Labor, time, and resource constraints. Animal-source foods are rich in protein, fat, and micronutrients, but their cost limits consumption. Commercial, fortified food products are often beyond the reach of the poor. A growing proportion of people in developing countries live on less than $2 per day, with little disposable income to purchase fortified products. At the same time, studies consistently show that poor families spend significant resources on soft drinks and street foods of low nutritional value, suggesting that there is some spending flexibility and a demand for time-saving, convenient foods.

Prevention of undernutrition in children 6-24 months old

Improving nutrition in this age group requires a combination of strategies.

  • Protect, promote, and support breastfeeding. Breastfeeding remains an important source of energy, fat and essential fatty acids, protein, protective factors, and some essential vitamins and minerals for older infants and young children. Breastmilk helps with the absorption of nutrients.
  • Promote healthy growth, focusing on the most powerful behavioral determinants. A mother is more likely to adopt a behavior with knowledge of the recommended practice, belief that it will result in something she wants, perception that it is the “new norm,” and confidence that she has the skills and an environment that allow her to adopt the practice.  Assessments should be conducted to identify nutritional gaps in local diets and beneficial and detrimental feeding practices. They should be followed by trials of options for improving the diet and feeding practices, identification of priority audiences, and effective strategies for reaching these audiences.
  • Provide timely and targeted counseling on feeding practices. Optimal complementary feeding depends not only on what is fed, but also on how, when, where, and by whom the child is fed. One key strategy is skilled, timely, and targeted counseling on recommended feeding practices. Quality counseling often requires improving the capacity of health care providers and community health workers to counsel, demonstrate, coach, and address specific concerns of mothers and others in the household.
  • Enhance access to nutritionally adequate complementary foods and/or fortified products to enrich home-prepared foods. Education alone to improve the use of available foods can be highly effective in some settings, but fortified foods and food assistance may be needed to prevent and treat stunting where food insecurity is a major constraint. Opportunities to address longstanding barriers to improved nutrition include “quick-to-prepare” fortified porridges, lower-priced lipid-based nutrient supplements such as fortified peanut-based spreads, and micronutrient powders that can be added to home-cooked complementary foods.  Guidance should be followed on the appropriate marketing of complementary foods.
  • Prevent and treat common early childhood illnesses. Reducing the frequency and duration of illness and promoting increased food intake after illness is an important strategy for improving growth.
  • Assess contextual factors that can advance or impede progress when designing strategies to reduce stunting.  Stewart et al. [1] characterize these factors as political economy, health and health care, education, society and culture, agriculture and food systems, and water, sanitation, and environment.

[1] Stewart CP, Iannotti L, Dewey KG, Michaelsen KF, Onyango AW. Contextualising complementary feeding in a broader framework for stunting prevention. Maternal and Child Nutrition (2013), 9 (Suppl. 2), pp. 27-45.