guide to complementary feeding- who

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WH0/NHD100 1WHO/FCWCAH/OO 6Distr :GeneralOriginal: English

omplementary Feedingamily foods for breasged children

Depammt o Nutrition or Health and DevelopmentorldHealth 0lrganizai ion


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World Health Organization, 2000This document is not a formal publication of the World Health Organization WHO), and all rightsare reserved by the Organization. The document may, however, be freely reviewed, abstracted,reproduced and translated, in part or in whole, but not for sale nor for use in conjunction withcommercial purposes.The views expressed in documents by named authors are solely the responsibility of thoseauthors.Design and Layout by FSG MediMedia LtdPrinted in France


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AcknowledgementsSpecial thanks are due to the London School of Hygiene and Tropical Medicine, and particularly to AnnAshworth for her help in preparing and revising the text, and to Marilyn Aviles and Carol Aldous for the irassistance.

Thanks are also due to those who provided technical inputs and data, especially Hilary Creed Kanashirofrom the lnstituto de Investigacion Nutricional Lima, Peru), Marie-Claude Dop from the FrenchInstitute for Scientific Research for Cooperative Development ORSTOM, Montpellier), Ann Burgessand Patrice Engle.

This document was prepared by Randa Saadeh from the Department of Nutrition for Health andDevelopment NHD) in close collaboration with Jose Martines from the Department of Child andAdolescent Health and Development CAH) with special inputs providedby FelicitySavage King CAH).

Special appreciation is expressed to all those in WHO regional offices and Unicef New Yorkwho commented extensively on the draft.


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ontentsIntroduction ............................................................................................................... 1Key recommendations ..............................................................................................2..................................................hat is complementaryfeeding? ................... 3Why are complementaryfoods needed? ..................................................................3When should complementary foods be started? ................... 6What are good complementaryfoods? ..................................................................... 8

The staple............................................................................................................................. 9Importance of feeding a mixture of complementary foods .................... .................. 12Pulses and oil seeds ......................... .......................................................................2Foods from animals .............................................................................................................14Dark-green leaves and orange-coloured vegetables and fruits ....................................... 17Oils, fats and sugars ............................................................................................................ 21

How complementary foods can fill the energy and nutrient gaps ............................22Which foods make good snacks? ...............................................33Drinks ................................................................................................................... 34How much food and how often? ..............................................................................35Encouragingyoung children to eat ................ ..........................................37Stopping breastfeeding ........................................................................................... 39..................................................................rotecting young children from disease 39...................................................................ow can food be kept clean and safe? 41Feeding during illness ............................................................................................. 43Feeding during recovery .........................................................................................4Helpingworking mothers 44Checking progress .................................................................................................. 44Meaning of words ................................................................................................... 46Annex 1 Good sources of important nutrients ................................................ 48Annex 2: Recipes for good mixed meals from four countries ..................................49Annex 3: Composition per 1009) of some foods 50Annex 4: Technical Data ........................................................................................ 51


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ntroductionBreast milk alone is the ideal start to a child s life. This bookdeals with the period when a child continues to receive breastmilk but alsoneeds increasing amounts of additional foods, beforeeventually changing to family foods alone. The book shows thatbreast milk can continue to be an important source of nutrientsuntil the child is at least two years old. It also shows how mixturesof family foods can meet the extra needs of young children duringthis vulnerable time. These foods, given in addition to breastmilk, are called complementaryfoods The process of feedingthem is called complementary eedingTo keep young chi ldren healthy dur ing th is per iod ,complementary foods should be nutritious, clean and safe, andfed in adequate amounts. They may be speciallyprepared foods, Breastmilk can continue to beor modified family meals. This book tells you when to start anim~ofiantsource fnutrientscomplementary feeding, what to give, how much, and how often. until the child is at least 2 years old.It also explains how to encourage young children to eat enough,how to keep their food clean and safe, and how to feed sickchildren. The book takes into account the results of recent studieson young child feeding, growth, and childhood illness includingdiarrhoea.The information in this book will help you to understand moreabout the nutritional value of foods available in your area andwill be useful when you advise and counsel families on childfeeding. Space is provided for notes on your local situation sothat you can adapt the feeding recommendations for thecommunities where you work. There is a section at the end (pages46-47 to explain the meaning of words that may be unfamiliar.The book is for everyone responsible for the health and nutrition \of young children, particularly health and nutrition workers, and Complementary feeding meansgiving other foods in addition totheir trainers. It will be of practical value for the in-service training breastof health workers, such as those taking the WHOJUNICEFcourses on the Integrated Management of Childhood Illness, andother counselling2or training courses3on breastfeeding.

IntegratedManagement of ChildhoodIllnessesWHO/CHD/97.3.BreasffeedingCounselling: TTraningCourse

WO/CHD/93.3,4,5 6.UNICEF/WUT793.1,2,3 4.HIV and Infant Feeding:A Training CourseWHO/

FCH/CAH/OO.2,3,4 5


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Key recommendationsBreast milk is the natural first food for babies and should be fedalone for at least months and i possible 6 months. However,after this period additional foods (complementary foods) areneeded. To make sure that young children grow well and stayhealthy, it is important to know which foods to give, how muchto give, and how often. Breast milk should be the main foodthroughout the baby s first year, and an important food duringthe second year. Breast milk continues to provide unique anti-infective factors that other foods cannot.The list below is to remind you of the m in messages to considerwhendiscussingcomplementaryfeedingwithparentsandotherscaringfor young children, or when training health workers. Why these


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omplementary

What is complementary feedingComplementaryfeeding means giving other foods in addition tobreast milk. These other foods are called complementaryfoods.During the period of complementary feeding, a baby graduallybecomes accustomed to eating family foods. At the end of thisperiod (usuallyataroundthe ageof years),breastmilk is entirelyreplaced by family foods, although a child may still sometimessuckle for comfort.There are two kinds of complementaryfoods:specially prepared foods andusual family foods that are modified to make them easy to eatand provide enough nutrients. Mashing a child s food makes

For example, a mother may specially prepare porridge for her if easier f eat.baby while the rest of the familyeat cassavaand groundnut stew.When the child is a little older, the mother will give the cassavamashed in the stew. Mashing modifies the consistency of thefamily food, making it easier for the child to eat. Family mealscan also be modified by adding something extra for exampleadding a piece of mango to give extra vitamin A or liver forextra iron, and oil or margarine for extra energy.

Why are complementaryfoods neededAs a baby grows and becomes more active, an age is reachedwhen breast milk alone is not sufficient to meet the child snutritional needs. So complementary foods are then needed tofill the gap between the total nutritional needs of the child andthe amounts provided by breast milk

In this book we focus on the complementaryfeeding of childrenaged 6 4 months who arebreastfed.Some children, for variousreasons,receive little or no breast milk at this age. Thismeans that their total energy and nutrient needshave to be provided by complementary oods andsome other source of milk, or from family foodsalone. The feeding recommendations n this bookmay need to be adapted for these children.Forexample,some childrenmay need larger amountsof family foods or may need to be fed morefrequently. Even so, much of the information n thebook is relevant to those feeding and caring forchildren who receive little or no breast milk.


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Figure 1 Energy required fop line) and the amount from breast milk.

The energy needed by achild increases as thechild becomes older;bigger and m ore active

mAge months)

Energy gapEnergy from breast milk

igure shows how the energy needed by a child the red line)increases as the child becomes older, bigger and more active. Italso shows how much of this energy is supplied by breastm lk ifa mother breastfeeds frequently the area shaded yellow). Notethat from months onwards there is a gap between the total energyneeds and the energy provided by breastmilk This gap gets biggeras the child gets older.This means:complementary foods are needed to fill the energy gapthe quantity of food needed increases as the child becomes

olderif the gap is not filled, the child will stop growing, or growslowly.


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Knowing othersstart complementary .foods too early or toolate helps you todecide how to counselthem. For example mothers oftenstart early because they think theydo not have enough breast milk.This may be because the babycries a lot. Once you understandtheir reasons you can giveappropriate advice. For examplelet the baby suckle more often orfor longer periods.Listening to mothers

iron, so the iron gap starts earlier. Give iron drops from 2months, if available.We could draw similardiagrams for all the nutrients. These wouldshow that:for most nutrients, the gap becomes larger as the child gets olderfor calcium, like iron, the gap is smaller in the second year,but it is still large.

and letting them knowhat you are interestedn how they feed theirbabies and askingquestions in a friendly way is animportant part of understandingtheir opinion and the things thatworry them and the difficultiesthey face.

In the diagrams, we show the needs of an average child, and thenutrients supplied by breast m lk from an average mother. Otherchildren of the same age may need slightly different amounts ofenergy and nutrients.Afew childrenhave higher needs and thereforelarger gaps than shown; a few have smaller needs and smaller gaps.But for all children, the most dacult gaps to fill reusually for:energyironzincvitamin A.

When should complementaryfoods be startedComplementary foods should be started when the baby can nolonger get enough energy and nutrients from breast m lk alone.For most babies this is between 4 and 6 months of age. This isalso the age when nerves and muscles in the mouth developsufficiently to let the baby munch, bite and chew. Before 4 months,babies push food out of their mouths because they cannot fullycontrol the movement of their tongues. At 4 6 months of age itbecomes easier to feed thick porridges, purees and mashed foodsbecause children:can control their tongues betterstart to make up-and-down munching movementsstart to get teethlike to put things in their mouthsare interested in new tastes.This is also the age when their digestive system is mature enoughto digest a range of foods.Starting complementary feeding too early or starting it too lateare both undesirable. Signs that a child is ready to start


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he following sections list the different kinds of family foodsand show how giving a mixture of these foods provides youngchildren with the energy and nutrients they need.

discussing which mixtures of foods make good meals, its helpful to start with the local staple and then decide whichther foods to add.

he staplecommunity has a staple food. It is the main food eaten.

are cereals suchas rice wheat,maize millet),mots suchs cassava, yam, potato) and starchy B i t s such as plantain and noodlesIn rural areas, families often spend much of their timerowing,harvesting, storing and processingthe staple food. In urban taple foods.reas the staple is often bought, and the choice depends partly onCooked staples can usually be mashed for example rice,cassava, potato), or softened in a small amount of liquidfor example bread and chapati). Staples re often milled to a lournd cooked to make a porridge for examplemaize millet).taples provide energy mostly from starch). Cereals also providebut cassava, sweet potato, banana, plantain and breadfruitvery little protein. Yam and potato have more proteinother roots, but not as much as cereals.taple foods are poor sources of iron, zinc and calcium. Cerealsphytates which may interfere with the absorption of iron, Listening toand calcium contained in the cereal and in other foods in the sugges tions is a good

Fresh roots such as cassava, potato) provide vitamin C, but way to know what ismade from staples have none. Only the yellow varieties of practical ndsweet potato and plantain are sources of vitamin A. acceptable.means:the staple must be eaten with other foods for a child to getenough nutrients.

Involve the wholefamily in thesediscussions if youcan. Grandmothersmay know about goodideas that were used in thepast. Listening to the opinionof husbands is good too. If theyknow you value their opinion andare prepared to listen to their pointof view they are more likely toaccept your suggestionsaboutcomplementary feeding.


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wit porridgesmade fromstaples alonecan be made from any staple. When flour or a grated

or starchy fruit is mixed with water and cooked to makethe starch absorbs water and swellsup. This makes thef it is too thick, it is difficult for a young child

eat. So large amounts of water are often added to keep thethin. But this dilutes all the nutrients in the staple.

are wateryhave a low energy concentrationhave a low nutrient concentration.

e is a similar problem with soups. Although they may contain

, it is still not enough to meet

baby's stomachcan hold 200mlof food

hin watery food

chi d cannotmanage this

With thin porridge or soup, a childneeds to eat bowls at each meal.This is impossible, so his needs arenot met.

familiesin your areafeed thinporridge? If so,you can suggestne or more of the following ways to make a more energy- andporridge:cook with less water and make a thicker porridge. Porridgeshould be too thick to drink So feed thick porridge with aspoonreplace some or all) of the water with milkadd extra energy and nutrients to enrich thick porridge. Forexample add m lk powder and sugar or margarine or ghee);or add groundnutpaste peanutbutter) or sesame seed pasteadding fattyloilyfoods makes thick porridge softer and easierto eat margarine/gheetoast cereal grains before grinding them into flour. Toastedflour does not thicken much, so less water is needed to make Add extra energy and nutrientsporridge. to enrich thick porridge.

families n your area give soups? f so, you can advise them to:take out a mixture of the solid pieces e.g. staple, beans,meat, vegetables) and mash to a thick puree. Soften with alittle margarineor oil for extra energyfeed this mixture to the child instead of the liquid the bestpart of the soup is the solid ingredients in it).your area, if cereal grains are germinated sprouted) before


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Now look at the foods you have circledI Which pulses and oil seeds are commonly eaten in your area?2 Are they fed to young children? YES NO

If no what are the reasons?

3 How are the circled foods prepared for the family?4 Are these foods easy for young children to eat and digest? YES 0 NO

If no discuss with families how they could be prepared in a more suitable way:For example:

boil peas or beans then sieve to remove coarse skinsremove skins by soaking raw seeds and then rubbing the skins off beforecookingtoast or roast nuts and seeds and pound to a paste.

Which ways would most families prefer?

5 Have you circled any foods that are high in fat? 0 YES 0 NOThese make good complementary foods because they are rich in both proteinand energy:

oods from nim lsFoods from animals, birds and fish including shellfish)are rich sources of many nutrients but are often expensive.Their flesh meat) and organsloffal suchas liver, heart, blood), aswell asmilk yoghurt, cheese andeggs aregood sourcesofprotein.The flesh and organs of animals, birds and fish, and foodsprepared with blood, are the best sourcesof iron nd zinc.This isbecause iron and zinc in these foods are very well absorbed. Theredder the flesh and organs when raw, the more iron they containsee Box 1, p19).


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1. Which dark-green leaves and orange-coloured vegetables and fruits grow inyour area?

Note: oranges, despite their colour; are not a rich source of vitamin A)2. Are any considered unsuitable for young children? YES NOIf so, why?

3. Can families suggest ways to make these foods more suitable for children?

4 For the foods you have circled, write the months of the year when they areavailable

5. Are there any months when none of these foods is available? YES NOIf so, which months are these?

6 And can you help families overcome this lack?For example:

ask an agricultural officer which dark-green leafy plants or orange-colouredvegetables and fruits grow best in different seasonssuggest families fence a small area close to the house and plant fast-growingvegetablesuse waste water for watering.

ook at the ones you have circled


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he amount of iron that a child athe amount of iron in the foodr the type of iron iron from meat aplants, milk and eggs)

absorption and others interfere)whether the child is anaemic I-- : : - ---

Flesh of birds, especially dark meaFoods fortified with iron such as

ish and other seafoodecreased by dreas and coffee

the absorption of iron from eggs, milk and plant foods. Foods richvitamin C include guava, mango, orange and other citrus fruits,.and pineapple see Anne


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Adding jiwit half a small orange)has a small effect on the energy and protein gapsimproves the absorption of iron in the rice and beanshas only a small effect on the vitaminA gap.Ifwehadusedmango paw-paw orpassion fruitinstead of orangethesewould have provided lots of vitaminA aswell asvitaminCNext let us turn to the evening meal. Figure 5 showshowmuchof the gaps are filledwhen we combine the staple animal fooddark-green leafy vegetable.

Eveningmeal rice ish green leaves)First look at the top section ofFigure5 This is the sameas in themidday meal and showshow the gaps are filledby 3 tablespoonsof rice and a teaspoon of fat.The middle section of Figure 5 shows what happens to the gapswhen fish is eaten with the rice.Adding ish 1 rounded tablespoon)has a small effect on the energy gapfills the protein gaphas a small effect on the iron gaphas no effect on the vitaminAgapwehad chosen smallfish that are eaten whole with their liversthese would have filled some of the vitamin A gap. Adding fishimproves the absorptionof iron from the plant foods in this meal.The lower section of Figure 5 shows what happens to the gapswith the dark-green leaves in this meal:Adding dark-green leaves 1 rounded tablespoon)has very little effect on the energy gapprovides someproteinprovides some ironprovides lots of vitaminA and completelyfills the gap.


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5 Percentage of a day s needs at 12-23 months that can be met by breast milk and a evening meal ofrice + fish + green leaves.100 ,+ otalI needed

itamin

RiceBreast--., .

otalneeded

Rice.

Rice and fish.Breastmilk

z e d ///d/P

FishRice

0 Energy Protein Iron Vitamin A

Rice, fish and green leaves.


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Figure 7 The morning meal the midday meal the evening meal containing liver

0 - nergy Protein Iron Vitamin

iver

Rice

Breast milk 1

Now let us look at Figure 7 to see what happens when a childeats the morning meal this midday meal and the evening mealcontaining liver.igure 7 shows that with 3 meals:there is still a small energy gapthe protein gap is filledthe iron gap is filledthe vitamin gap is filled.


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Poor value snacks are ones that are high in sugar which rotsteeth) and low in nutrients. Examples are:fizzy drinks sodas)ice 1olliesAollipopssweetslcandies.uestions

7 Which foods are used as snacks for young children in your area?

2 Which are of poor value?

3 Which are good?

4 Are there other foods that could make good snacks?

rinksFamilies should know that:drinks for young children must be clean and safe. So, boil

water or make it safe some other way, for example using aspecial filter) and boil milk if not pasteurised.Wash theoutside of fruit before juicingdrinks should not replace solid food or breast milk. If drinksare given with a meal, it is best to leave most until the end,otherwise the child may not want to eatteas and coffee reduce iron absorption. Drinks should not begiven with a meal, or during hours before a meal, orhours after it.


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How much food and how oftenThe taste of a new food may surprise a child. Advise mothers to:

start by giving one or two teaspoons twice a daygradually increase the amount and variety (by 9 months, achild should be eating a variety of family foods).

It takes time for a young child to learn how to use hisher lips toclear food off the spoon, and how to move the new food to theback of the mouth, ready for swallowing. Some food may rundown the chin, or be spat out. Tell families to expect this t He p and encourage a chi,ddoes not mean that the child dislikes the food. Withencouragement andpatience a child soon learns how to eat newfoods and enjoy new tastes.As the child becomes older, suggest that families:

continue to breastfeed oftenincrease the amounts of food given at mealtimes and give asmuch as the child will eat with active encouragementgradually increase the number of meals. Give complementary When working outfoods three times daily at 6 7 months, increasing to at least suggestyou will want otherfive times 3 meals and snacks) by 2months health workers toat first, make the food soft; later, mash it or cut into small accept them too sopieceshelp and encourage the child to eat.igure1 gives an examplein whichhealth workers set out theirfeeding recommendations.Note they use words and pictures to:describe the changing pattern of feeding as children growolderrecommend frequent breastfeeding for two yearssuggest what complementary foods to give, how much, andhow oftenuse locally available mixtures of foodsshow families actively encouraging their children to eat.

Would something like this be helpf .1for families in your area?

involve them when making plans.You will also want families to beable to select an appropriate optionfor their circumstances. So beforefinally deciding discuss your ideaswith families who have youngchildren and ask if they thinkfamilies will want and be ableto follow the suggestions.

By the age of 9 months, a child can eat severalspoonsful orabout half a cupfulJat each meal.As shown in Figures 4 9 by the second year achild can eat several large spoonsful, or a smallbowl, at each meal.


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Figure 10 Feeding recommendations during sicknessand health on the mother s counselling card.Up to monthsof age

Breastfeedas often as the childwants day and night, at least8 times in24 hours.months up to 6months

Breastfeedas often as the child wants day and night, at least 8 times in24 hours.Only give other foods if the child:appears hungry after breastfeedingoris not gainingweight adequately.If so, add complementaryfoods listed under 6 months up to 12months).Give these foods 1 or times per day after breastfeeding.6 months up to 2 monthsBreastfeedas often as the child wants.Give adequate servings of:thick porridgemade out of either maize or cassava ormillet or soya; add sugar and oil mixedwith either milkor pounded ground nutsmixturesof mashedfoods made out of either matookeor potatoesor cassava or posho maize or millet) orrice; mix with fish or beansor pounded ground

nuts; add green vegetables.Give meals per day if breastfed.Give 5 meals per day if not breastfed.Give nutritioussnacks betweenmeals like egg, banana or bread.2 months up to yearsBreastfeedas often as the child wants.Give adequate servings of:mixturesof mashed foods made out of either matookeor

potatoesor cassavaor posho maizeor millet) or rice; mix withfish or beans or pounded ground nuts; add green vegetablesthick porridge madeout of either maize or cassava or milletor soya; add sugar and oil mixedwith either milk or poundedground nuts.Give meals per day and 2 snacks.

2 years and olderGivefamily foods at 3 meals each day Also, twicedaily, give nutritioussnacks between meals, such as:bananas,eggs or bread.

Adapted from CHD 996 997 Report (WHO ICHDl98.5).Division o f Child Health and Development, Familyand Reproductive Health, World Health Organization.


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eaning of wordsAbsorbed iron: this is the iron that passes into the body after it has been released from food during

digestion. Only a small proportion of the iron present in food is absorbed. The rest is excreted inthe faeces.Active encouragement:assistance given to encourage a child to eat. This includes praising, talkingto the child, helping the child put food on the spoon, feeding the child, making up games.Antibodies: substances produced by the body to attack bacteria and viruses that might get into thebody. Antibodies are passed from a mother to her baby in breast milk and so breastfeedinghelpsprotect babies from infection.Antibodies are also called immunoglobulins.Anti infective factors:substancesthat prevent infection. These include antibodies.Anti nutrients:substancesthat interfere with the absorptionor utilisationof nutrients. Examplesarephytates in cereals and tannins in tea which reduce the absorption of iron from eggs, milk and

plant foods.Chapati:a flat bread made by mixing whole wheat flour with water and then shaping pieces of thedough into flat circles and baking on a griddle (hot metal sheet). Traditionally eaten in India andPakistan.Colostrum: he first m lk hat mothersproducebeforethemainflowof breastmilkbecomesestablished.Deficiency: shortage of a nutrient that the body needs.Family foods: foods that are part of the family meals.Fermented foods: foods that are soured. For example, yoghurt is fermented milk. Another exampleis fermented cereals made by mixing cereal flour with water and then leaving for 2 or days. In

this process, microorganismschange some of the starch into other substances. These substancescan be beneficial and kill pathogens that may be contaminating the food. So food that has beenfermented is often safer than other food. Fermenting cereals breaks down the phytates in thecereal and allows more iron, zinc and calcium to be absorbed.

Filtered water: water purified and made safe by passing it though a special filter to remove germsand dirt.

Fortified foods: these are foods that have certainnutrients added to improvetheir nutritionalquality.An example is the addition of vitamins and iron to milled flour so that the nutrients removedduringmilling are restored to their originalcontent.Another exampleis the additionof vitaminsAand D to margarine so that it has the same vitamin value asbutter.Germinated seedslflour: seeds that have been soaked and allowed to sprout. Seeds may be soaked

in water for 24h and then covered with a damp cloth for 48h. The sprouted seeds can be dried andmilled to make germinatedflour. f a little of this flour is added to warm thick porridge it makesthe porridge soft and easy to eat.


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guide to complementary feeding- who

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