• Appropriate complementary feeding promotes growth and prevents stunting among children 6–24 months. The period of complementary feeding is when other foods or liquids are provided along with breastmilk. Rates of malnutrition usually peak at this time with consequences that persist throughout life. Stunting is seldom reversed in later childhood and adolescence. Inadequate feeding of girl children also affects nutrient stores, subsequent reproductive health, and the to local conditions. risk of maternal mortality.
  
• Appropriate complementary feeding involves a combination of practices to maintain breastmilk intake and, at the same time, improve the quantity and quality of foods children consume. The 6– 11 month period is an especially vulnerable time because infants are just learning to eat and must be fed soft foods frequently and patiently. Care must be taken to ensure that these foods complement rather than replace breastmilk. For older infants and toddlers, breastmilk continues to be an important source of energy, protein, and micronutrients. Therefore, breastfeeding should continue through 24 months and beyond.
  
• Improving complementary feeding requires a combination of strategies. Energy intake can be increased by increasing breastfeeding frequency, increasing food portion sizes, feeding children more frequently, and/ or providing more energy-dense foods. Micronutrient intake can be increased by diversifying the diet to include fruits, vegetables, and animal products; using fortified foods; and/ or giving supplements. Choosing food combinations that enhance micronutrient absorption is also important.
  
• Programs to improve complementary feeding must conduct local assessments. These assessments will determine the appropriate emphasis to give each of the practices listed on the following pages. Local studies should identify local diets and current good practices to be supported, test options for improving the traditional diet and related feeding practices, and identify target audiences and effective strategies for reaching them.
  

• Continue frequent, on-demand breastfeeding, including night feeding for infants
  
• Introduce complementary foods beginning at six months of age
  
• Increase food quantity as the child ages– while maintaining frequent breastfeeding
  • Provide 6– 8 month old infants approximately 200 kcal per day from complementary foods.
  • Provide 9– 11 month old infants approximately 300 kcal per day from complementary foods.
  • Provide 12– 24 month old children approximately 550 kcal per day from complementary foods.
  • Local research is needed to determine the best combinations of foods and practices to achieve these levels of energy intake.
    
• Increase feeding frequency as the child ages
  • Feed 6– 8 month old infants complementary foods 2– 3 times per day.
  • Feed 9– 11 month old infants complementary foods 3– 4 times per day.
  • Feed 12– 24 month old children complementary foods 3– 4 times per day.
  • Offer nutritious snacks 1– 2 times per day, as desired.
    
• Gradually increase food consistency and variety as the child ages, adapting the diet to the infant's requirements and abilities
  • Feed mashed and semi-solid foods, softened with breastmilk, if possible, beginning at 6 months of age.
  • Feed energy-dense combinations of soft foods to 6– 11 month olds.
  • Introduce "finger foods" (snacks that can be eaten by children alone) beginning around 8 months of age.
  • Make the transition to the family diet at about 12 months of age.
    
• Diversify the diet to improve quality and micronutrient intake
  • Feed vitamin A-rich fruits and vegetables daily.
  • Feed meat, poultry, or fish daily or as often as possible, if feasible and acceptable.
  • Use fortified foods, such as iodized salt, vitamin A-enriched sugar, iron-enriched flour or other staples, when available.
  • Give vitamin-mineral supplements when animal products and/ or fortified foods are not available.
  • Avoid giving drinks with low nutrient value, such as tea, coffee and sugary beverages.
    
• Practice responsive feeding
  • Feed infants directly and assist older children when they feed themselves.
  • Offer favorite foods and encourage children to eat when they lose interest or have depressed appetites.
  • If children refuse many foods, experiment with different food combinations, tastes, textures, and methods for encouragement.
  • Talk to children during feeding.
  • Feed slowly and patiently and minimize distractions during meals.
  • Do not force children to eat.
    
• Practice frequent and responsive feeding during and after illness
  • During illness, increase fluid intake by more frequent breastfeeding, and patiently encourage children to eat favorite foods.
  • After illness, breastfeed and give foods more often than usual, and encourage children to eat more food at each sitting.
    
• Practice good hygiene and proper food handling
  • Wash caregivers' and children's hands before food preparation and eating.
  • Store foods safely and serve foods immediately after preparation.
  • Use clean utensils to prepare and serve food.
  • Serve children using clean cups and bowls, and never use feeding bottles.
    

Supporting advice for caregivers and families

• Make sure children's immunization schedules are complete by 1 year of age.
• Use ORT to rehydrate children during diarrhea.
• Give liquid iron supplements daily (12.5 mg/ day) to infants 6 months to 1 year of age if daily vitamin-mineral supplements or iron-fortified foods are not being given. If the prevalence of anemia is known to be very high (40 percent or more), continue supplementation until 24 months of age. For low birthweight infants, start supplementation at 2 months.
• Give semi-annual, high-dose vitamin A supplements after 6 months (100,000 IU for infants and 200,000 IU for children 12 months and older) in areas where vitamin A deficiency occurs.
• Seek appropriate health care for fever, diarrhea, respiratory infections, malaria, hookworm, and other infections.
• Encourage children's psycho-social development by providing them with opportunities for exploration and autonomy.
• Ensure adequate maternal nutrition and micronutrient status to improve women's health and support optimal breastfeeding.
• Give mothers a high-dose vitamin A supplement (200,000 IU) immediately after delivery or within 8 weeks post-partum in areas where vitamin A deficiency occurs.
• Practice family planning that does not interfere with breastfeeding to space children and allow for maternal recuperation.
• Use condoms, consistently and correctly, to prevent transmission of HIV.
  

References
Brown KH, Dewey KG, Allen LH. Complementary Feeding of Young Children in Developing Countries: A Review Of Current Scientific Knowledge. WHO/ UNICEF, 1998.

Dewey KG. Guiding Principles for Complementary Feeding of the Breastfed Child. PAHO/ WHO, 2003.

WHO. Complementary Feeding: Family Foods for Breastfed Children. Geneva: World Health Organization, 2000.

For more information, please visit our website at: www.linkagesproject.org

This issue of Facts for Feeding is a joint publication of LINKAGES (Breastfeeding, LAM, Related Complementary Feeding, and Maternal Nutrition Program) and the SARA (Support for Analysis and Research in Africa) Project. LINKAGES is supported by the Bureau for Global Health of the United States Agency for International Development (USAID) under Cooperative Agreement No. HRN-A-00-97-00007-00, and SARA is funded by USAID's Bureau for Africa, Office of Sustainable Development, under Contract No. AOT-C-00-99-00237-00. LINKAGES and SARA are both managed by the Academy for Educational Development. The opinions expressed herein are those of the author( s) and do not necessarily reflect the views of USAID or AED.

Updated April 2004