Complementary feeding occurs when children receive foods to complement breast milk or infant formula (1, 2). Ideally, it begins at 6 months of age and continues to 24 months or beyond, reflecting the World Health Organization’s recommendations for exclusive and continued breastfeeding (3). In practice, however, in many cases exclusive breastfeeding ends earlier than 6 months and continued breastfeeding ends prior to the second birthday. The complementary feeding period occurs during a “window of opportunity” for the prevention of stunting and promotion of optimal growth, health and behavioural development (4, 5). Complementary foods and beverages and feeding patterns may also affect susceptibility to noncommunicable diseases later in life (6). This is relevant globally, though may be particularly so in middle- and high-income countries. A 2011-2012 nationally representative survey in the United States found that 8.1 percent of children less than 2 years of age were already above the 95th percentile and 7.2 percent were at or above the 97.7th percentile for weight based on their length (7).

Ensuring that a child’s nutritional needs are met during the complementary feeding period requires that the foods introduced are timely – meaning introduced when energy and nutrient needs exceed that provided by breast milk, adequate – meaning they provide sufficient energy, protein and other essential macronutrients, and micronutrients to meet nutritional needs, safe – meaning they are hygienically stored and prepared and fed with clean hands and clean utensils and not bottles and teats, and responsively fed – meaning they are fed consistent with a child’s signals of hunger and satiety (3). They should also be properly fed – meaning that meal frequency and feeding method, such as actively encouraging the child, even during illness, to consume sufficient food using fingers, spoon or self-feeding are suitable for their age. Other important aspects of complementary feeding and foods include attention to food consistency that reflects a child’s ability to chew and swallow, adequate meal frequency, energy density and nutrient content, and use of vitamin and mineral supplements or fortified products when necessary (1).

Complementary feeding practices in low- and middle-income countries are poor (8, 9). An Analysis of 46 nationally representative surveys in low- and middle-income countries between 2002 and 2008 showed that half of children 6-24 months of age met the recommended minimum daily numbers of meals, and less than one-third met the minimum criteria for daily dietary diversity, defined as receiving 4 of 7 food groups. Only one in five breastfed children satisfied the criteria for minimum acceptable daily diet. Intake of unhealthy or “junk” foods, which are high in free sugars, fats and/or salt/sodium, is observed with increasing frequency throughout the world, including in low- and middle-income countries. In sub-Saharan Africa, between 11 and 40 percent of children 6-23 months of age received a food with high sugars content the previous day (10). In several countries, sugary food consumption has increased over time. In Uganda, between 2006 and 2011 sugary food consumption increased 114 percent in 5 years, from 8.4 percent in 2006 to 18.0 percent in 2011. In Egypt, it more than doubled in 8 years, from 24.5 percent in 2005 to 52.7 percent in 2008 (11).

The effectiveness of interventions to improve complementary feeding and healthy growth of infants and young children, which have focused on nutrition education and/or the provision of foods, is mixed (12, 13). A systematic review in 2008, concluded that educational interventions with a strong emphasis on feeding nutrient-rich animal source foods may be more likely to show an effect on child growth than interventions with more general messages about complementary feeding (13). However, in food insecure populations, complementary feeding interventions that include provision of food, in addition to nutrition education, may be more effective. Micronutrient interventions have negligible impact on child growth, though can be effective at improving iron and vitamin A status. More recently, a review of 16 randomized controlled or quasi-experimental studies showed that nutrition education in food secure populations had a positive effect on height though not on stunting prevalence (12). The provision of complementary foods in food insecure populations was associated with significant improvements in height but not stunting prevalence. Large complementary feeding interventions with a strong evaluation component are rare; a recent well-executed intervention that combined intensive counselling by frontline health workers and a nationwide mass media campaign had a large positive impact on complementary feeding but not growth (14).

References

1. Pan American Health Organization/World Health Organization. Guiding principles for complementary feeding of the breastfed child. Washington DC: Pan American Health Organization; 2003.

2. Perez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the RWJF HER Expert Panel on Best Practices for Promoting Healthy Nutrition FP, and Weight Status for Infants and Toddlers from Birth to 24 Months. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals Duram, NC: Health Eating Research, 2017. (http://healthyeatingresearch.org)

3. Global Strategy for Infant and Young Child Feeding. Geneva: World Health Organization; 2003.

4. Clinton HR. 1000 Days to Change the Future: Making Malnutrition History; May 21, 2012. (https://feedthefuture.gov/article/secretary-clinton-video-address-1000-days-event-chicago)

5. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013; S0140-6736(13)60937-X.

6. WAdair LS. How could complementary feeding patterns affect the susceptibility to NCD later in life? Nutrition, Metabolism & Cardiovascular Diseases. 2012;22:765-9.

7. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association 2014;311(8):806-81.

8. Lutter CK, Daelmans B, de Onis M, Kothari M, Ruel MT, Arimond M, et al. Undernutrition, poor feeding practices and low coverage of key nutrition interventions. Pediatrics. 2011;128(6):e1-e10.

9. Lutter CK, Lutter R. Fetal and early childhood undernutrition, mortality and lifelong health. Science. 2012;337(1495-1499).

10. Huffman SL, Piwoz EG, Vosti SA, Dewey KG. Babies, soft drinks and snacks: a concern in low- and middle-income countries? Maternal & Child Nutrition 2014;10(562-74).

11. Kavle JA, El-Zanaty F, Landry M, Galloway R. The rise in stunting in relation to avian influenza and food consumption patterns in Lower Egypt in comparison to Upper Egypt: results from 2005 and 2008 Demographic and Health Surveys. BMC Public Health. 2015;15 (285):1-18.

12. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;http://dx.doi.org/10.1016/S0140-6736(13)60996-4.

13. Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2008;4(Suppl 1):24-85.

14. Menon P, Nguyen PH, Saha KL, Khaled A, Sanghvi T, Baker J, et al. Combining intensive counseling by frontline workers with a nationwide mass media campaign has large differential impacts on complementary feeding paractices but not on child growth: results of a cluster-randomized program evaluation in Bangladesh. J Nutr. 2016; 146(10):2075–2084.

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Conflict of interest statements were collected from all named authors and no conflicts were identified.