Complementary Complementary FeedingFeeding

DR. PRADEEP DUBEY , MD(Ped) DCH. CONSULTANT DEV. & NEURO PEDIATRICS

AADIGURU NEUROPEDIATRIC CENTRENEAR PREM MANDIR , WRIGHT TOWN JABALPUR

Children Under 3 years Who are Children Under 3 years Who are Underweight Underweight (NFHS-3, 2005-2006)(NFHS-3, 2005-2006)

Not a change over Not a change over seven yearsseven years

0-29 %

30-39 %

40-49 %

50 -100 %

Ranking by Children U-3 who are Ranking by Children U-3 who are underweight (NFHS-3)underweight (NFHS-3)

RankRank StatesStates % of Underweight% of Underweight

11 Madhya PradeshMadhya Pradesh 60.360.3

55 GujaratGujarat 47.447.4

66 Uttar PradeshUttar Pradesh 47.347.3

1212 KarnatakaKarnataka 41.141.1

2121 DelhiDelhi 33.133.1

2626 PunjabPunjab 27.027.0

INDIAINDIA 45.945.9

Under-5 deaths preventable through universal Under-5 deaths preventable through universal coverage with individual preventive interventionscoverage with individual preventive interventions

INDIA

Source: Jones et al. LANCET 2003;362:65-71

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

Breastfeeding

Complementary feeding

Clean delivery

Hib vaccine

Clean water, sanitation, hygiene

Zinc

Vitamin A

Antenatal steroids

Newborn temperature management

Tetanus toxoid

Antibiotics for PRM

Measles vaccine

Nivirapine and replacement feeding

Insecticide-treated materials

Antimalarial IPT in pregnancy

Inte

rven

tion

Percent

Complementary Feeding, 6-9 monthsComplementary Feeding, 6-9 months(NFHS-3, 2005-2006)(NFHS-3, 2005-2006)

Shown good change Shown good change in 7 years, national in 7 years, national average almost average almost doubleddoubled

Reaching Greens is a Reaching Greens is a challengechallenge

0-59 %

60-79 %

80-94 %

95-100 %

Ranking by Complementary Ranking by Complementary Feeding (NFHS-3)Feeding (NFHS-3)

RankRank StatesStates Complementary Complementary FeedingFeeding

11 KeralaKerala 93.693.6

22 SikkimSikkim 89.689.6

1111 HimachalHimachal 66.066.0

1515 DelhiDelhi 59.859.8

2525 PunjabPunjab 50.050.0

2727 Uttar PradeshUttar Pradesh 45.545.5

INDIAINDIA 55.855.8

Optimal Feeding Norms as per Optimal Feeding Norms as per National Guidelines on Infant and National Guidelines on Infant and

Young Child FeedingYoung Child Feeding Starting breastfeeding Starting breastfeeding

within one hour of birthwithin one hour of birth Exclusive breastfeeding Exclusive breastfeeding

for the first six monthsfor the first six months Introducing appropriate Introducing appropriate

and adequate and adequate complementary feeding complementary feeding after 6 months along with after 6 months along with Continued breastfeeding Continued breastfeeding for two years or beyondfor two years or beyond

Definition of Complementary Definition of Complementary feedingfeeding

The process of giving an The process of giving an infant other foods and infant other foods and liquids along with breast liquids along with breast milk or non-human milk milk or non-human milk as breast milk alone is no as breast milk alone is no longer sufficient to meet longer sufficient to meet the nutritional the nutritional requirements. requirements.

These foods should These foods should complement rather than complement rather than replace breastmilk.replace breastmilk.

Appropriate Complementary Appropriate Complementary FeedingFeeding

Timely:Timely: Introduced when need for energy Introduced when need for energy and nutrients exceeds that provided by BFand nutrients exceeds that provided by BF

Adequate:Adequate: Should provide sufficient Should provide sufficient energy, protein, and micronutrientsenergy, protein, and micronutrients

Properly Fed:Properly Fed: Active feeding method and Active feeding method and proper frequency according for ageproper frequency according for age

Safe:Safe: Should be hygienically prepared, Should be hygienically prepared, stored and fedstored and fed

Timing of Complementary Timing of Complementary FeedingFeeding

Soon after completing 6 months of ageSoon after completing 6 months of age Breast milk sufficient to promote growth and Breast milk sufficient to promote growth and

development till 6 monthsdevelopment till 6 months Energy and nutrient gap appears after 6 months Energy and nutrient gap appears after 6 months

and widens thereafterand widens thereafter Infant’s development and behavior makes him Infant’s development and behavior makes him

ready for other foodsready for other foods Holds objects (e.g. biscuit) and takes everything to Holds objects (e.g. biscuit) and takes everything to

mouthmouth Chewing movements startChewing movements start Tendency to push solids out decreasesTendency to push solids out decreases Eruption of teeth and beginning of biting movementsEruption of teeth and beginning of biting movements

Age of IntroductionAge of Introduction

00 269

451

746

0

200

400

600

800

1000

1200

0-3 mo 3-6 mo 6-9 mo 9-12 mo 12-24 mo

Energy Gap

Energy frombreastmilk

Energy NeedsEnergy Needs

Excl. Breastfeeding

Comp. feeding & continued BF

Timing of Complementary Timing of Complementary FeedingFeeding

Disadvantages of adding foods too soon Disadvantages of adding foods too soon Decrease the intake of breast milk resulting in a Decrease the intake of breast milk resulting in a

low nutrient dietlow nutrient diet Increase risk of illness esp. diarrheaIncrease risk of illness esp. diarrhea

Disadvantages of adding foods too late Disadvantages of adding foods too late Growth and development slows down or stopsGrowth and development slows down or stops Risk of deficiencies and malnutritionRisk of deficiencies and malnutrition

Importance of continued breastfeeding Importance of continued breastfeeding for 2 years and beyondfor 2 years and beyond

3755

7698

5

6345

242

95

0

20

40

60

80

100

120

Energy Protein Vit. A Vit. C Iron

% daily needs provided by 500ml breast

milk

Gaps to be filled by complementary foods

Energy and Nutrients from breastmilk

Why Continue Breastfeeding?Why Continue Breastfeeding? Vital source of energy (30-40%) and nutrients Vital source of energy (30-40%) and nutrients

into 2nd yr of lifeinto 2nd yr of life Key source of Key source of

Good quality proteins & essential fatty acidsGood quality proteins & essential fatty acids Micronutrients:Micronutrients:

45% of Vitamin A45% of Vitamin A 40% of calcium & riboflavin40% of calcium & riboflavin 95% of Vitamin C95% of Vitamin C

Fluids and nutrients during infectionFluids and nutrients during infection Associated with greater linear growthAssociated with greater linear growth Linked to lower risk of chronic diseases & Linked to lower risk of chronic diseases &

obesityobesity

Key Message-1 (Timely)Key Message-1 (Timely)

Complementary feeding should begin Complementary feeding should begin soon after completing 6 months of age soon after completing 6 months of age along with continued breastfeedingalong with continued breastfeeding

Adequacy (Quality)Adequacy (Quality)

Staples:Staples: Cereals (Rice, wheat, maize, millets) Cereals (Rice, wheat, maize, millets) and Legumesand Legumes

FatsFats (Vegetable oils/butter/ghee; 1g ~ 9 Kcal) (Vegetable oils/butter/ghee; 1g ~ 9 Kcal) and and sugarssugars to improve energy density and taste to improve energy density and taste

Foods of animal originFoods of animal origin (Milk, curd, eggs, meat, (Milk, curd, eggs, meat, fish) to provide good quality proteins, vitamin A fish) to provide good quality proteins, vitamin A and calcium.and calcium.

Vegetables and FruitsVegetables and Fruits to provide micronutrents to provide micronutrents e.g. iron and vitamins. Supplements e.g. iron e.g. iron and vitamins. Supplements e.g. iron might be required.might be required.

Other Attributes of Other Attributes of Complementary FoodsComplementary Foods

Right consistency Right consistency Soft Soft Easy to digestEasy to digest InexpensiveInexpensive Locally available Locally available Culturally acceptableCulturally acceptable Easily prepared at Easily prepared at

homehome

Variety of FoodsVariety of Foods

Start at 6 mo with small amounts of food; Start at 6 mo with small amounts of food; increase quantity with age, maintaining frequent increase quantity with age, maintaining frequent breast feedingbreast feeding

Increase food consistency & variety with ageIncrease food consistency & variety with age Can feed mashed & semi-solids (e.g. porridge) at 6 Can feed mashed & semi-solids (e.g. porridge) at 6

mo; mo; Can feed finger foods by 8-9 moCan feed finger foods by 8-9 mo By 12 mo, family foods can be eatenBy 12 mo, family foods can be eaten

Combine foods (e.g. rice and legumes) to Combine foods (e.g. rice and legumes) to provide good mixture of amino acidsprovide good mixture of amino acids

Foods to AvoidFoods to Avoid

Tea & coffee:Tea & coffee: interfere with iron interfere with iron absorptionabsorption

Aerated beverages:Aerated beverages: No nutritional value No nutritional value Too much sugary drinks & Fruit juices:Too much sugary drinks & Fruit juices:

cause decreased appetite for other cause decreased appetite for other nutritious foods and also may cause loose nutritious foods and also may cause loose stools.stools.

Nuts:Nuts: may cause choking may cause choking

Stomach sizeStomach size

Adequacy (Frequency and Amount)Adequacy (Frequency and Amount)6-12 months6-12 months

Give at least one katori (150-200 mL) serving* at a time ofGive at least one katori (150-200 mL) serving* at a time of Khichdi or dalia or sooji (semolina) with added oil/ghee Khichdi or dalia or sooji (semolina) with added oil/ghee Mashed roti/rice/bread mixed in thick dal or sweeetened Mashed roti/rice/bread mixed in thick dal or sweeetened

undiluted milkundiluted milk Add cooked/pureed vegetables or meat also in the Add cooked/pureed vegetables or meat also in the

servings servings Sevian/dalia/halwa/kheer/biscuits prepared in milk or any Sevian/dalia/halwa/kheer/biscuits prepared in milk or any

cereal porridge cooked in milk cereal porridge cooked in milk Mashed boiled/fried potatoes Mashed boiled/fried potatoes Mashed banana/cheeko/ mango/ papayaMashed banana/cheeko/ mango/ papaya

*3 times per day if breastfed;*3 times per day if breastfed;5 times per day if not breastfed5 times per day if not breastfed

Frequency and Amount (1-2 yrs)Frequency and Amount (1-2 yrs)

Offer food from the family potOffer food from the family potGive at least 1½ katori (250 mL) serving* at a time of:Give at least 1½ katori (250 mL) serving* at a time of: Mashed roti/rice/bread mixed in thick dal with added Mashed roti/rice/bread mixed in thick dal with added

ghee/oil or khichri with added oil/ghee. ghee/oil or khichri with added oil/ghee. Add cooked vegetables/meat also in the servings Add cooked vegetables/meat also in the servings Mashed roti/ rice /bread/biscuit mixed in sweetened Mashed roti/ rice /bread/biscuit mixed in sweetened

undiluted milk undiluted milk Egg preparations/ soft meat pieces without bonesEgg preparations/ soft meat pieces without bones - Sevian/dalia/halwa/kheer prepared in milk or any - Sevian/dalia/halwa/kheer prepared in milk or any

cereal porridge cooked in milk ORcereal porridge cooked in milk OR Fruits (banana/cheeko/apple/orange/mango/papaya) Fruits (banana/cheeko/apple/orange/mango/papaya)

* 5 times per day.* 5 times per day.

Amounts of foods to offerAmounts of foods to offer

AgeAge TextureTexture FrequencyFrequency Amount of each Amount of each mealmeal

6 months6 months Soft porridge, well Soft porridge, well mashed vegetable, meat mashed vegetable, meat fruit fruit

2 times per day plus 2 times per day plus frequent breastfeedsfrequent breastfeeds

2-3 tablespoonfuls2-3 tablespoonfuls

7-8 months7-8 months Mashed foodsMashed foods 3 times per day plus 3 times per day plus frequent breastfeedsfrequent breastfeeds

Increasing gradually Increasing gradually to more than 3/4 of to more than 3/4 of katori (150ml)katori (150ml)

9-11 months9-11 months Finely Finely choppedchopped or or mashed foods, and foods mashed foods, and foods that baby can pick upthat baby can pick up

3 meals plus 1 snack 3 meals plus 1 snack between meals plus between meals plus breastfeedsbreastfeeds

a full katori (200ml)a full katori (200ml)

12-24 months12-24 months Family foods, Family foods, chopped chopped or mashedor mashed if necessaryif necessary

3 meals plus 2 3 meals plus 2 snacks between snacks between meals plus meals plus breastfeedsbreastfeeds

more than katori more than katori (250ml)(250ml)

Ensure AdequacyEnsure Adequacy Growth Monitoring: Growth Monitoring:

Measure weight and Measure weight and length periodically and length periodically and interpret by plotting in interpret by plotting in growth curves.growth curves.

Investigate causes of Investigate causes of poor growth: Dietary poor growth: Dietary history; evaluate for any history; evaluate for any illness.illness.

Counsel Counsel mother/caregivers on mother/caregivers on growth, feeding and growth, feeding and caring practicescaring practices

Key Message-2 (Adequacy)Key Message-2 (Adequacy)

Complementary foods should be of right Complementary foods should be of right consistency, energy dense and the variety consistency, energy dense and the variety to provide all nutrient demands of a to provide all nutrient demands of a growing child.growing child.

Feeding TechniquesFeeding Techniques

Feed infants directly & assist older Feed infants directly & assist older toddlers eat; toddlers eat; be sensitive to hunger & be sensitive to hunger & satiety cuessatiety cues

Feed Feed patientlypatiently; encourage, but don’t force; encourage, but don’t force If child refuses, experiment with If child refuses, experiment with different different

food combinationsfood combinations, tastes, textures, tastes, textures Minimize distractions during mealsMinimize distractions during meals TalkTalk to child during feeding; maintain to child during feeding; maintain eye eye

contactcontact

Responsive feedingResponsive feeding

Suitable Feeding SituationSuitable Feeding Situation

Key Message-3 (Properly Fed)Key Message-3 (Properly Fed)

Child should be fed patiently giving Child should be fed patiently giving adequate attention and timeadequate attention and time

SafeSafe

Unhygienic feeding Unhygienic feeding the risk of infectious illness (esp. the risk of infectious illness (esp.

diarrhea) compromising nutritional statusdiarrhea) compromising nutritional status Undermines the parents’ confidence Undermines the parents’ confidence

leading to delay in CFleading to delay in CF

Ensuring Food HygieneEnsuring Food Hygiene

Washing caregiver’s and child’s hands before Washing caregiver’s and child’s hands before preparing, handling and eating foodpreparing, handling and eating food

Clean water and raw materials to cook foodClean water and raw materials to cook food Storing foods safely: Keeping food covered and Storing foods safely: Keeping food covered and

serving shortly after preparationserving shortly after preparation Use clean utensils to prepare & serve foodUse clean utensils to prepare & serve food Use clean bowls & cups when feeding childUse clean bowls & cups when feeding child No feeding bottles No feeding bottles

Key Message-4 (Safety)Key Message-4 (Safety)

Foods should be prepared, stored and fed Foods should be prepared, stored and fed hygienically to the children.hygienically to the children.

Feeding the child who is illFeeding the child who is ill

Encourage the child to drink and to eat - Encourage the child to drink and to eat - with lots of patiencewith lots of patience

Feed small amounts frequentlyFeed small amounts frequently Give foods that the child likesGive foods that the child likes Give a variety of nutrient-rich foodsGive a variety of nutrient-rich foods Continue to breastfeed Continue to breastfeed

Feeding during RecoveryFeeding during Recovery

Feed an extra meal Feed an extra meal Give an extra amountGive an extra amount Use extra rich foodsUse extra rich foods Feed with extra patienceFeed with extra patience Give extra breastfeeds as often as child Give extra breastfeeds as often as child

wantswants

Key Message-5 (During Illness)Key Message-5 (During Illness)

Continue feeding during illness and Continue feeding during illness and increase during convalescence.increase during convalescence.

Key MessagesKey Messages

Complementary feeding should begin soon after Complementary feeding should begin soon after completing 6 months of age along with continued completing 6 months of age along with continued breastfeedingbreastfeeding

Complementary foods should be of right consistency, Complementary foods should be of right consistency, energy dense and the variety to provide all nutrient energy dense and the variety to provide all nutrient demands of a growing child.demands of a growing child.

Child should be fed patiently giving adequate attention Child should be fed patiently giving adequate attention and timeand time

Foods should be prepared, stored and fed Foods should be prepared, stored and fed hygienically to the children.hygienically to the children.

Continue feeding during illness and increase during Continue feeding during illness and increase during convalescence.convalescence.

Thank YouThank You