The World Health Organization (WHO) released new / updated guidelines regarding complementary foods for ages 6-24 months old..
& at a quick glance, they are a little confusing...
Between 6 and 24 months, babies start trying different foods alongside breastmilk or formula. This stage, called complementary feeding, is super important for their growth and health. It's all about introducing them to lots of nutritious foods in different textures, colors, and nutrients. This helps them develop their taste buds, motor skills, and a good relationship with food. Caregivers should offer a mix of fruits, veggies, grains, proteins, and healthy fats, while being mindful of allergen introduction and ensuring meals are prepared safely. With patience and creativity, this feeding journey sets the foundation for healthy eating habits that can last a lifetime.
First, What is Complementary Feeding?
Complementary feeding, defined as the process of providing foods in addition to milk when breast milk or milk formula alone are no longer adequate to meet nutritional requirements. This generally begins around 6 months of age and continues until baby is ~24 months old,
NOTE: **This guideline does not address the needs of pre-term and low-birthweight infants, children with or recovering from acute malnutrition and serious illness, children living in emergencies, or children who are disabled. Except for children with disabilities, the needs of these other groups of children are addressed in other WHO guidelines."
To help you along, here are a few quick things to know! + I've color coded a few things!
There are 7 recommendations / areas of topic in total
I do encourage reading about how these recommendations came to be and what the scale used was...
For every recommendation, I've shared some key background, information on evidence, a summary of the evidence, and key takeaways
The summary of evidence provides more practical look in real talk <3
Some topics also include a Rationale (essentially a summary of thinking), Resource Implications, and additional items of importance noted as well
Information in this color or listed below a headline in this color is a fact, derived directly from the guidelines publication. This includes some of the guidelines presented.
Information in this color or under headlines with this color indicate personal opinions, thoughts, and advice on the topic
Information in this color is the science & evidence in detail! I did include some of the specific findings and significance of these findings, which may or may not interest everyone
So why do I feel like the guidelines are a bit misleading in certain ways?
THIS is how the recommendations came to be. If at least 70% of the GDG agreed, then it could be a recommendation. From there, recommendations were evaluated on a further level about how certain the results and findings are... and, for most of the recommendations presented.. the results and evidence are pretty weak..
An evidence-to decision tool – the Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence (DECIDE) framework – was used to promote deliberations and consensus decision-making (10). This tool includes the following considerations:
the certainty of the evidence across outcomes critical to decision-making
the balance of benefits and harms; values and preferences related to the recommended intervention in different settings and for different stakeholders, including the populations at risk;
the acceptability of the intervention among key stakeholders;
resource implications for programme managers;
equity;
the feasibility of implementation of the intervention.
The GDG discussed the findings of the systematic reviews and supplemental evidence, such as mathematical modelling. Following this discussion, the GDG reached consensus on the direction, strength, and wording of the recommendation. Where GDG members did not fully concur with the summary judgements for each of these considerations, multiple judgements were recorded. The GDG decided that70% of members would need to vote for the direction and/or strength of the recommendation to be accepted. All decisions were made by consensus, with the exception for recommendations on nutrient supplements and fortified food products, which were agreed by over 70% of members. Interventions in these guidelines are listed as recommended, not recommended, or recommended under certain conditions (context-specific). All recommendations are accompanied by a description of the certainty of the body of evidence (very low, low, moderate or high). Strength of the recommendation was classified as “strong” or “conditional”. According to the WHO handbook for guideline development, strong recommendations indicate that the GDG was confident that the desirable effects of adherence to the recommendation outweigh any undesirable consequences. If an intervention is not recommended, the reverse is true. Conditional recommendations indicate that the GDG was less confident or certain about the balance between benefits and harms of the recommendation. Context specific recommendations indicate that the GDG was certain that the desirable effects of the recommendation outweighed any undesirable consequences; however, not all populations needed the intervention. The GDG also provided additional remarks for further understanding of the recommendation. For further information about the basis for each recommendation users of this guideline should refer to these remarks, as well as to the judgement summary tables presented in Annex 4. Most topics (except for those related to MNPs, fortified cereal-grain complementary foods, fortified milks, and SQ-LNS) lacked robust studies or sometimes even a single randomized controlled trial (RCT) to guide decision making. Except for the recommendations for these supplements or food products, almost all the evidence for the other recommendations was rated as low to very low certainty.
Recommendation 1
Continued Breastfeeding
Breastfeeding should continue up to 2 years or beyond (strong, very low certainty evidence).
WHO and UNICEF have long recommended continued breastfeeding, along with complementary foods, for 2 years or beyond (17). Most national recommendations in LMICs are aligned with the WHO and UNICEF recommendation. For example, the Ministries of Health of Brazil and Kenya both recommend that children be breastfed for 2 years or more (64, 65). The American Academy of Pediatrics, which previously called for 12 months of breastfeeding, now supports continued breastfeeding “as long as mutually desired” for 2 years or beyond (66).
Breast milk contributes to macro- and micronutrient needs through the second year of life, particularly with respect to energy, protein and essential fatty acids, as well as vitamin A, calcium, and riboflavin. A recent systematic review reported that, on average, breastfed children 6–8 months, 12 WHO Guideline for complementary feeding of infants and young children 6–23 months of age 9–11 months, and 12–23 months of age received 77%, 63%, and 44% of their energy from breast milk, respectively (52)
Compared to breastfeeding in the second year versus no breastfeeding during this period, the systematic review found no evidence of any reduced or increased risk of developmental delay (OR = 1.15 [0.54, 2.43]), mean intelligence quotient (IQ) scores (SMD = -0.01 [-0.06, 0.08]), or highest school grade achieved (MD = 0.02 [-0.19, 0.23]). The evidence was graded as very low certainty for all outcomes. Compared to breastfeeding in the second year versus no breastfeeding during this period, very low certainty evidence found higher cumulative odds of underweight (OR = 1.25 [1.08, 1.46]) and wasting (OR = 2.16 [1.18, 3.98]), although the review noted that this association may be the result of confounding, whereby children’s poor growth leads to longer breastfeeding. Although not statistically significant, continued breastfeeding in the second year compared to no breastfeeding was suggestive of increased odds of stunting (OR = 1.87 [0.95, 3.68]) though not of overweight and obesity (OR = 0.94 [0.79, 1.12]). However, body mass index (BMI) was slightly lower in children and adolescents who breastfed into the second year of life (MD = -0.10 [-0.17, -0.03]). Among children 12–23 months of age, dietary modelling found that all 13 target nutrient intakes could be met for both breastfed and non-breastfed children. Although not modelled as a target nutrient, the intake of vitamin D was considerably higher among breastfed children; carbohydrate intake was comparable for both groups. Non-breastfed children, 12–23 months of age, needed to consume a more varied diet – including more types of starchy foods, fruits, dairy, and fats/oils – in order to meet nutrient needs
Summary of the evidence
In young children, continued breastfeeding in the second year compared to no breastfeeding during this period was associated with:
a reduced risk of acute gastroenteritis and respiratory tract infections. It was associated with
increased risk of underweight and wasting, though the authors note that this may be the result of confounding, whereby children’s poor growth leads to longer breastfeeding.
There was no association with stunting, overweight, or obesity. However, continued breastfeeding was associated with slightly lower BMI in children and adolescents.
The review found no evidence for developmental outcomes or mortality.
With respect to maternal health, there was no association of continued breastfeeding with breast, ovarian, uterine, or cervical cancer, type 2 diabetes, maternal hypertension stroke, cardiovascular mortality, concentrations of cholesterol, low-density lipoprotein, or high-density lipoprotein.
Duration of breastfeeding was associated with a lower risk of obesity but not with diabetes or cardiovascular health. It was, however, associated with increased risk of osteoporosis.
Dietary modelling showed that, compared to those not breastfed, children breastfed into the second year of life had higher levels of vitamin D and that non-breastfed children needed to consume a more varied diet to meet nutrient needs.
3.1.5 Values and preferences: The GDG noted that the value women place on continued breastfeeding is highly dependent on context. While some women may prefer to breastfeed for shorter durations, the high prevalence of breastfeeding into the second year in some countries shows that it is valued in many cultural settings and in other settings when programmes and policies support continued breastfeeding. The duration of breastfeeding has been declining in some countries and increasing in others. Maternal employment conditions and an enabling environment for breastfeeding help to shape preferences.
3.1.6 Resource implications
While no direct evidence was identified, the GDG considered that the costs of continued breastfeeding were likely lower than the costs of purchasing alternative milks. However, it was also acknowledged that there are opportunity costs incurred by many breastfeeding women in terms of time and ability to engage in remunerative activities where supportive policies and programmes are not in place.
There actually IS data available on the cost of breastfeeding.. Yale released a publication last year (2023), indicating that on average, a breastfeeding family can spend up to $11,000~
The study found that the costs of breastfeeding for a year can range from around $7940 to $10,585.
Personal thoughts: Yes, breastfeeding for 2 years! The Guidelines do address some major concerns regarding breastfeeding, such as maternal support, legal aid, etc. that must be handled in order for these recommendations to truly benefit.
In the grand scheme, this recommendation probably has the strongest data to back it
I am fairly bothered by the cost-analysis statement. It is clear that finances do impact feeding around the world, however this statement appears very poorly researched and seems more of an "assumption"..
Recommendation 2
Milks for ages 6-23 months
Milks 6–11 months: for infants 6–11 months of age who are fed milks other than breast milk, either milk formula or animal milk can be fed (conditional, low certainty evidence).
Milks 12–23 months: for young children 12–23 months of age who are fed milks other than breast milk, animal milk should be fed. Follow-up formulas are not recommended (conditional, low certainty evidence)
Okay, this is one of my LEAST favorite recommendations... mostly due to how confusing the wording is!!...
According to the 2016 Lancet Breastfeeding series, 37% of children aged 6–23 months in Lower Middle Class home's (LMIC's) do not receive breast milk, with variation in rates of 18% in low-income countries, 34% in the LMICs, and 55% in high-income countries (67). Although breast milk is always preferable, in such situations another milk, such as milk formula, animal milk, or another source of dairy is needed to address the unique nutritional needs of this age group.
Milks for infants 6–11 months of age
For infants in this group fed milks other than breast milk, Animal milks are an important source of key nutrients, including protein, calcium, riboflavin, potassium, phosphorus, magnesium, and zinc (68) . Milk protein stimulates insulin-like growth factor-1, important for bone mass acquisition and growth (69). Most milk formulas are derived from cow’s milk, though some are also plant-based. They have been continually altered to be as similar as nutritionally possible to breast milk, though lack its immunological properties and do not include all nutrients present in breast milk. Because milk formulas have been aggressively marketed and are associated with child morbidity and mortality, an International Code of Marketing of Breastmilk Substitutes was nearly unanimously approved by the World Health Assembly in 1981 (70). The use of cow’s milk in infancy has been associated with both gastrointestinal blood loss and iron deficiency anaemia (IDA) (43) , although it is not clear how long this association lasts. During this period, it is also associated with increased solute load for kidneys. Despite these outcomes, there continues to be differing opinions on nutrition and health outcomes related to feeding cow’s milk between 6 and 11 months of age (71).
The WHO Guiding Principles for Feeding Nonbreastfed Children 6–24 Months of Age states that feeding animal milk and appropriate complementary foods is a safe choice since the occult blood losses in infants 6–11 months of age are very minor and not likely to affect iron status (2). Furthermore, iron deficiency can be avoided by using iron supplements or complementary foods with adequate bioavailability of iron. The WHO Guideline for HIV and Infant Feeding recommends that for infants older than 6 months, commercial infant formula or animal milk (boiled for infants under 12 months) are acceptable alternatives to breastfeeding (72). However, milk formula is recommended when specific home conditions are met, including safe water and sanitation in the household, sufficient infant milk formula is available to support the normal growth and development, and the mother or caregiver can prepare it cleanly and frequently enough so that it carries a low risk of diarrhoea and malnutrition, among other adverse outcomes.
3.2.3 Evidence
Milks for infants 6–11 months of age fed milks other than breast milk: The systematic review identified a total of nine studies of which four were RCTs and five were observational cohort studies. All studies, except one, were from high-income countries. Meta-analyses of the two RCTs and two observational cohort studies found that consumption of cow’s milk compared to infant formula increased the risk of anaemia (RR = 4.03 [1.68, 9.65]) and (RR = 2.26 [1.15, 4.43]), respectively. Evidence from both sets of studies was considered of low certainty. Two cohort studies found that consumption of animal milk compared to formula milk increased the risk of IDA (risk ratio = 2.26 [1.15, 4.43]) (low certainty evidence)
Milks for young children 12–23 months of age fed milks other than breast milk: The systematic review identified five studies (796 children) that compared animal milk (full-fat or lower-fat) to follow-up formula. Only one study for the comparison of full fat versus lower fat milk and one study on the comparison of animal milk (full or lower fat) to plant milk was found. Animal milk compared to follow-up formula A meta-analysis of three studies found that among children 12–23 months, consumption of animal milk compared to follow-up formula fortified with iron. With respect to vitamin D status (assessed as serum 25-hydroxyvitamin D), two RCTS found children consuming animal milk had lower concentrations of vitamin D (nmol/L) (MD = -16.27 [-21.23, -11.31]) and higher risk of vitamin D deficiency (risk ratio = 2.64 [1.57, 4.45]). The evidence was rated as low certainty for both outcomes.
Summary of the evidence
The systematic review on milks for infants 6–11 months of age found that cow’s milk compared to milk formula may increase the risk of anaemia and IDA, and result in lower serum ferritin concentrations. The results were mixed for Hgb concentrations. There were no differences between milks for the anthropometric or developmental outcomes assessed, gastrointestinal blood loss or diarrhoea. The certainty of evidence for all outcomes was graded as very low or low certainty.
Summary of the evidence
With respect to milks for children 12–23 months, there was no difference in anthropometric indicators between children who consumed animal milk versus follow-up formula. Children consuming animal milk were more likely to have lower concentrations of vitamin D and have vitamin D deficiency. Indicators of iron status were also generally poorer among children consuming animal milk compared to follow-up formula. There were no differences on child development indicators. The only study that was available to study the effect of full fat compared to lower-fat
3.2.4 Balance of benefits and harms
The GDG was of the opinion that there was uncertainty in the balance of benefits and harms of animal milk compared to milk formula for infants 6–11 months of age and follow-up formula for young children 12–23 months of age, as it would vary widely by context. However, there was some agreement that there were probably some benefits for infants 6–11 months of age consuming milk formula rather than animal milk.
3.2.6 Resource implications
Based on the high cost of milk formula compared to animal milk, the resource implications for recommending such milks instead of animal milks are significant, especially in low-resource settings. Although there was uncertainty, the GDG was of the opinion that consideration of resource implications would favour consumption of animal milks.
It should be acknowledged that some of the concerns acknowledged such as lower Iron and Vitamin D status can also cause significant implications..
Again, it seems concerning not to see some hard numbers on these costs...
3.2.8 Rationale
The different recommendations for 6–11-month-old infants compared to 12–23-month-old children reflect the different nutritional needs of the two groups as well as the quantities of food each group is able to consume. The evidence showed that for infants 6–11 months of age, milk formula has some benefits over animal milk with respect to indicators of iron and vitamin D status. While milk formula provides supplemental sources of iron and other nutrients, there are also other ways to improve iron status, including through ASFs, iron supplementation, MNPs or fortified food products. No differences in growth were found between animal milk and infant formula or between animal milk and follow-up formula in developmental outcomes. Therefore, the GDG decided to recommend that either animal milk or milk formula could be consumed in later infancy (6–11 months). In contrast, children 12–23 months consume more food and therefore can derive more of their nutrient needs from food, including dairy foods and other ASFs. Animal milk is generally a suitable alternative to follow-up formula for this age group.
Personal Thoughts:
What this guideline is actually saying:
If you live in an area with safe, clean water + ability to prepare infant formula properly to reduce risks, it is best for infants (6-11 months) to drink breastmilk or infant milk formula in addition to the complementary foods.
If you live in an area that may have contaminated water or may not be able to prepare the formula in a clean/safe space, you may consider cow's milk as a dairy source rather than formula (6-11 months). If this route is chosen, it is essential to provide complementary foods that fill nutrient gaps such as iron, Vitamin D, etc.
Animal Milk's are appropriate in meeting the nutrient needs of 12-24 month olds. This is currently the recommendation anyways- transition to animal milk ~1 year old.
Toddler formula's / Follow Up formula's are not necessary unless truly medically needed.
I personally know ~2 kids who actually need to use these formulas, so it's somewhat 'rare' to ACTUALLY need a follow up formula.
Yet again, very weak data and even consensus for most of the recommendation..
Recommendation 3
Age of introduction of complementary foods
Infants should be introduced to complementary foods at 6 months (180 days) while continuing to breastfeed (strong, low certainty evidence).
The age of introduction of complementary feeding, when foods are introduced to complement a milk-based diet, is of critical importance to the nutrition and health of the growing infant. Various reviews have been conducted and most conclude that, while there were harms related to the introduction of complementary foods prior to 4 months, there were generally no harms of introducing complementary foods at around 6 months (79, 80)
Concerns about introduction of complementary foods before 6 months of age have primarily focused on four overall potential risks:
increased morbidity because of gastrointestinal diseases (such as diarrhoeal diseases) in settings where food and water hygiene is a concern,
inferior nutritional quality of complementary foods compared to breast milk in low-resource settings,
inadequate developmental readiness to consume foods
risk of obesity (4).
Concern about late introduction of complementary foods has primarily focused on:
the inadequacy in breast milk of key nutrients, particularly iron, needed for continued growth and development
potential increased risk of some food allergies (4).
There are also concerns that delaying the introduction of complementary foods could affect the acceptance of new flavours and textures.
In addition, accumulating evidence suggests that delaying the introduction of some nuts, such as peanuts, may promote rather than prevent food allergies (81). This may also be the case for other allergenic foods, such as milk.
Iron is of particular concern for exclusively breastfed infants, especially for those weighing < 3 kg at birth, whose mothers were iron deficient during pregnancy, or who did not receive their full endowment of placental blood because of early umbilical cord clamping (82, 83). Iron deficiency in breastfed infants can be prevented more effectively by targeted iron supplementation than by introducing complementary foods. WHO recommends enteral iron supplementation for human milk-fed preterm or low-birth-weight infants who are not receiving iron from another source (40).
Delayed cord clamping for all newborns is also recommended (39)
With respect to developmental readiness to begin consuming foods, the ability to sit without support is considered an important factor as it is associated with other aspects of physiological development, including gastrointestinal, renal, and immunological system maturation (84).
Globally, early introduction of complementary foods is common, Recommendations 21 occurring among 29% of infants < 6 months of age in LMICs (85). The highest percentages were in East Asia and the Pacific and Latin America, where about 47% and 48% of infants < 6 months of age were fed complementary foods, respectively.
Summary of the evidence
Evidence from RCTs suggests that early introduction of complementary foods, defined as ≤ 4 months, compared to at 6 months has no effect on stunting, underweight, wasting, measures of overweight/obesity, anaemia, or severe anaemia. When early introduction was defined as < 6 months compared to ≥ 6 months, observational studies suggest no association with stunting, underweight, wasting, HAZ, WAZ, length/height, or weight. Early introduction was associated with higher BMI. Results for indicators of iron status were mixed, with two studies showing no association with anaemia and one study showing an association with increased IDA among children who received complementary foods before 6 months compared to at or after 6 months. No associations were found with any of the other outcomes studied. Observational studies found that late introduction (> 6 months) compared to earlier introduction at ≥ 6 months was not associated with stunting, underweight, wasting, or weight. However, late introduction was associated with lower length/height. Late introduction was associated with lower BMI, though not with overweight or obesity. There was no association between the groups with anaemia, atopic dermatitis, lower respiratory tract infection, asthma, wheeze, or eczema.
3.3.5 Values and preferences: The GDG noted that values and preferences related to the age of introduction of complementary foods likely vary depending on culture
Personal Statement / Advice here:
Base starting those complementary foods more on Milestones and Skill Level rather than age. In order to start solid foods, baby should be able to:
Hold head up for extended time
Sit (ideally unassisted) for extended time while supporting head
Shows an interest in foods (grabs or eyes mom & dad's plates, reaches for foods, etc.)
As noted above: .With respect to developmental readiness to begin consuming foods, the ability to sit without support is considered an important factor as it is associated with other aspects of physiological development, including gastrointestinal, renal, and immunological system maturation (84).
Don't be scared of those common food allergens! <3
Recommendation 4
Dietary diversity
Infants and young children 6–23 months of age should consume a diverse diet.
Animal source foods, including meat, fish, or eggs, should be consumed daily (strong, low certainty evidence).
Fruits and vegetables should be consumed daily (strong, low certainty evidence),
Pulses, nuts and seeds should be consumed frequently, particularly when meat, fish, or eggs and vegetables are limited in the diet (conditional, very low certainty evidence).
Infants and young children need to consume a variety of foods to ensure their nutritional needs are met and to support healthy growth and development (4). A diet lacking in diversity increases the risk of nutrient deficiencies
WHO and UNICEF have defined eight key food groups for children, which include:
breast milk
flesh foods (meat, fish, poultry, and liver/organ meats;
dairy (milk, yogurts, cheese);
eggs;
legumes and nuts;
vitamin-A rich fruits and vegetables;
other fruits and vegetables;
grains, roots, and tubers (86).
They have defined minimum dietary diversity (MDD) as consumption of five out of the eight groups (86)3. According to a recent UNICEF report, globally only 28% of children 6–23 months of age met the indicator for MDD (88).
Infants, age 6–11 months have the lowest diversity compared to children in the older age groups.
lol thank you for clarifying that, WHO...
Both the Guiding Principles for Complementary Feeding of the Breastfed Child and Guiding Principles for Feeding the Non-Breastfed Child 6–24 Months of Age recommend that infants and young children should be fed a variety of foods to ensure dietary needs are met (1, 2).
Summary of the evidence
Evidence suggests that consumption of ASFs (animal source foods) improved growth outcomes, reduced the risk of anaemia and increased Hgb concentrations. Children who consumed eggs of chickens fed with DHA-enriched feed also had improved DHA status. The modelling study found that when meat, poultry, fish, and eggs were excluded from the diet for 6–8-month-old children, the diet could not fulfil nutrient needs for iron, zinc, and vitamin B12. For 9–11-monthold children, the gap in meeting iron requirements increased. All best-case diets included beef, lamb, game, liver, or small fish. The authors of the systematic review reported that the certainty of evidence was very mixed and rated the overall certainty as low, largely because for all but one food/outcome pair, only one study was identified making it impossible to conduct meta-analyses.
Summary of the evidence: The systematic review found that the frequency of legume consumption was not associated with anthropometric outcomes, though only one study was identified. Also, consumption of beans (daily versus less than daily) was not associated with anaemia. Dietary modelling showed that when legumes, nuts, and seeds were excluded from the diet other nutrient dense foods could fill any resulting nutrient gaps.
Summary of the evidence More versus less frequent consumption of fruit and vegetables had mixed results with respect to anthropometric outcomes. The evidence was also mixed for anaemia, though there is some indication that fruit consumption may be related to reduced anaemia. Overall fruit and vegetable consumption at 18 months was positively associated with later consumption of both food groups. Dietary modelling indicated that when fruits were excluded from the diet, no changes in nutrient intake for any age/feeding groups occurred. However, vegetables did help improve intake for some nutrients, especially among 6–8-month-old infants. Vegetables helped improve iron intake in all three age groups.
Personal Thoughts:
Yes, yes, yes! One of the few that I can say, yes! Provide a wide range of foods, flavors, textures to baby! Have some fun with it!
One of the only foods that baby CANNOT have during that first year? = Honey
Everything else -> have fun!
Recommendation 5
Unhealthy foods and beverages
okay, I just gotta start this one by asking, WTF qualifies as an "unhealthy" food or beverage?
Foods high in sugar, salt and trans fats should not be consumed (strong, low certainty evidence).
Sugar-sweetened beverages should not be consumed (strong, low certainty evidence).
Non-sugar sweeteners should not be consumed (strong, very low certainty evidence).
Consumption of 100% fruit juice should be limited (conditional, low certainty evidence).
Infants and young children are consuming increasing amounts of unhealthy foods and beverages, often referred to as highly processed or ultra-processed, that contain high amounts of free sugars, salt, and unhealthy fats such as saturated fats and trans fats (101–104). They are also generally high in energy and low in nutrients (57). Accumulating evidence shows that unhealthy snack foods and beverages may have negative effects on young child health, displace healthier foods, and may be associated with undernutrition, overweight, and adverse cardiometabolic outcomes (101, 102).
Among young children in Nepal, unhealthy snack foods and beverage consumption contributed 47% of total energy intake among the highest third of consumers compared to only 5% of total energy intake among the lowest third, corresponding to 279 kcal and 33 kcal, respectively (106).
Both the Guiding Principles for Complementary Feeding of the Breastfed Child and Guiding Principles for Complementary Feeding of Non-Breastfed Children 6 -24 Months of Age recommend avoiding drinks with low nutrient value, such as tea, coffee, and sugary drinks such as soda. They also state that juice consumption should be limited. The WHO Guideline for sugars intake for adults and children recommends a reduced intake of free sugars throughout the life course and reducing the intake of free sugars to less than 10% of total energy intake throughout the life course, and if possible, a further reduction to below 5% of total energy intake (20).
3.5.3 Evidence
.In the systematic review, the authors noted that there was no single classification system or criteria for unhealthy foods that covered all relevant exposures. Therefore, they used four measures to classify foods and beverages as unhealthy.
Four measures to classify foods and beverages as "unhealthy":
the NOVA classification (107)
the WHO/UNICEF indicator to define unhealthy food consumption (86).
The third and fourth categories were based on the nutrient content of foods and beverages and included foods high in free sugars, artificial sweeteners, saturated or trans fats, or salt and ‘fast foods’, ‘convenience foods’, and ‘extra foods’ as defined by the authors.
I'll share more about these classification systems in the future. For now, let's just all acknowledge the wide range of what is considered "healthy" versus "unhealthy"
Summary of evidence Overall, the review presented mixed evidence with respect to the association of unhealthy foods and beverages on the outcomes studied. Several studies found that consumption of SSBs and unhealthy foods might increase BMI, BMIZ, percentage body fat, dental caries and odds of overweight or obesity. Only one of five studies found that consumption of beverages with non-sugar sweeteners had an adverse outcome (higher BMI). Consumption of sweet foods in infancy may be positively associated with WHZ later in life and there may be adverse anthropometric outcomes among children 2– < 5 years of age and among children 5– ≤ 10 years. Consumption of 100% fruit juice was not associated with any of the outcomes evaluated. Among breastfed infants 6–11 months of age, dietary modelling showed that inclusion of sentinel unhealthy food items increased nutrient gaps for iron and zinc as well as several other nutrients and this was also true for iron among breastfed infants 9–11 months. There were few impacts on nutrient intakes for non-breastfed children 12–23 months of age.
3.5.8 Rationale: Unhealthy foods, often highly processed, contain high amounts of free sugars, salt, trans fats, and saturated fats. Sugar sweetened beverages contain high concentrations of free sugars in the form of added sugars. They are high in energy, while providing little in the way of nutrients. Both displace healthy foods, making it difficult to meet nutrient needs when they are consumed. Accumulating evidence shows they are associated with both undernutrition and overweight. The consumption of non-sugar sweeteners early in life may create a later preference for foods that are high in sugars. Although 100% fruit juice contains free sugars as the whole fruit has been concentrated, unlike SSBs, they provide some nutrients and do not appear to affect adiposity in children. The recommendation to not consume SSBs and limit consumptions of 100% fruit juice is consistent with the aims expressed in the WHO Guideline on sugars intake for adults and children (20), the WHO Manual on sugar-sweetened beverage taxation policies to promote healthy diets (36), and the Nutrient and promotion profile model: supporting appropriate promotion of food products for infants and young children 6–36 months in the WHO European Region (41), all of which aim to reduce sugar consumption.
Personal Thoughts and Takeaways:
Surface level, yes this is a lovely recommendation and useful. I'd prefer a different term rather than "unhealthy" give the unclear guidelines of what "healthy" versus "unhealthy" is.
It likely is appropriate to monitor the specific foods and beverages mentioned here! It just also leaves a window of uncertainty open..
Juice truly is one item that seems to be misunderstood by the public through my experiences as an RD..
I will definitely be diving deeper into this one in the future
Recommendation 6
Nutrient supplements and fortified food products
In some scenarios where nutrient requirements cannot be met with unfortified foods alone, children 6–23 months of age may benefit from nutrient supplements or fortified food products.
Multiple micronutrient powders (MNPs) can provide additional amounts of selected vitamins and minerals without displacing other foods in the diet (context-specific, moderate certainty evidence).
For populations already consuming commercial cereal grain-based complementary foods and blended flours, fortification of these cereals can improve micronutrient intake, although consumption should not be encouraged (context-specific, moderate certainty evidence).
Small-quantity lipid-based nutrient supplements (SQ-LNS) may be useful in food insecure populations facing significant nutritional deficiencies (context-specific, high- certainty evidence).
Consumption of a diverse diet of locally available nutrient-rich complementary foods should always be the first priority to satisfy the young child’s needs for growth and development. However, in settings where such foods are not regularly available or affordable, nutrient supplements and fortified food products may help fill nutrient gaps (109).
Four types of fortified products, designed to fill nutrient gaps during the complementary feeding period, were reviewed as part of this guideline:
MNPs
Multiple micronutrient powders (MNPs) MNPs are single-dose packets or sachets that contain multiple vitamins and minerals in powdered form.
purchased by third parties as part of nutrition programmes and distributed to recipients without charge
considered home fortificants in that they are intended to be mixed with a child’s typical complementary food in home.
Summary of the evidence: MNPs improved indicators of iron status, but did not affect zinc status, vitamin A status, child growth, diarrhoea, upper respiratory infections, or receptive or expressive language. Dietary modelling showed that the addition of MNPs to simulated real-world diets reduced and/ or eliminated nutrient gaps for several key nutrients, including iron, B vitamins and zinc.
fortified cereal grain-based complementary foods
Cereal grain-based complementary foods Fortified cereal grain-based complementary foods have been marketed commercially since 1928 and are widely distributed globally in food aid programmes (4).
commercially available throughout the world,
often based on wheat, corn or rice and blended with soy and fortified with micronutrients
Summary of the evidence: Consumption of a fortified cereal grainbased complementary food to children aged 6–23 months compared to no consumption improved indicators of iron status, though not zinc, vitamin A or growth outcomes. Children consuming a fortified cereal-based complementary food had better mental skill development scores and motor development scores, but not fine and gross motor scores when assessed separately. Dietary modelling found that when SCP was added to the diet daily, intakes of some nutrients were improved, though deficits remained, especially in iron.
fortified milks
commercially available throughout the world,
"A wide variety of fortified milks are commercially available and marketed globally as a way to fill nutrient gaps in the diets of young children (111)."
Summary of the evidence: Children consuming unfortified milk compared to fortified milk were more likely to be anaemic and have IDA, but not ID. There was no difference between the two milks on weight, stunting or wasting. However, children consuming unfortified milk compared to fortified milk had lower WAZ, WHZ, height velocity, and weight velocity. There was no effect of fortified milk compared to unfortified milk on oral health or respiratory infections. Children consuming fortified milk had fewer episodes of diarrhoea.
SQ-LNS.
Small quantity lipid-based nutrient supplements (SQ-LNS) SQ-LNS are a food-based product designed to prevent malnutrition in vulnerable populations by providing multiple micronutrients, protein, and essential fatty acids. Typical formulations provide about 100 to 120 kcals/per day
purchased by third parties as part of nutrition programmes and distributed to recipients without charge
considered home fortificants in that they are intended to be mixed with a child’s typical complementary food in home.
Summary of the evidence:: Evidence from RCTs shows that compared to controls, children consuming SQ-LNS have reduced mortality, are less likely to be stunted, wasted, underweight, have small head size, or severe undernutrition. Supplemented children had higher developmental scores. SQ-LNS also reduced anaemia, ID and IDA. Indicators of vitamin A status were also higher among children supplemented with SQ-LNS compared to controls. There was no difference in diarrhoeal or malarial morbidity. There were also no long-term preferences for unhealthy foods or beverages. Dietary modelling found that daily supplementation of SQ-LNS reduced, but did not eliminate, the iron gap for infants 6–8 months of age. However, it also introduced gaps in potassium and choline. For 9–11-month-olds, daily supplementation of SQ-LNS reduced the iron gap. In simulated real-world patterns in Bangladesh, Malawi and Mexico, daily supplementation of 6–23-month-olds with SQ-LNS eliminated gaps for the B vitamins, except for 1-year-olds in Bangladesh and reduced or eliminated calcium gaps. Potassium gaps were reduced for most groups. Certainty of the evidence The evidence was considered of high certainty because of the large number of RCTs, standardized outcomes across studies allowing for meta-analysis, and the fact that they were conducted in a variety of LMICs throughout Africa, Asia, and Latin America and the Caribbean.
3.6.4 Balance of benefits and harms The GDG believed the balance of benefits and harms of MNPs, fortified cereal grainbased complementary foods, fortified milks and SQ-LNS probably favoured their consumption, although there was uncertainty for MNPs and fortified milks. The benefits for all products were deemed to be moderate although there was variability or uncertainty depending on the product. The harms were judged to be none or uncertain.
3.6.8 Rationale: Young children have large nutrient needs that must be met with a relatively small amount of food. Therefore, children, especially those living in low-resource settings where staple foods provide the large part of energy needs, are at risk of nutrient deficiencies. Nutrient supplements and fortified food products can fill some nutrient gaps during the complementary feeding period. The robust evidence of effectiveness from the large number of RCTs for many of the supplements and food products also contributed to the decision-making.
The Guiding principles for complementary feeding of the breastfed child and Guiding principles for feeding non-breastfed children 6–24 months of age recommend the use of fortified complementary foods or vitamin/mineral supplements as needed.
Key Takeaways and Personal Thoughts:
If a nutritional supplement or fortified food is of true benefit, then it is of true benefit!! If it is recommended by your child's healthcare team to utilize fortified foods and/or supplements, please do so accordingly!
Malnutrition, undernutrition, and vitamin/mineral deficiencies can lead to irreversible growth stunting, cognitive impairment, and even death. The use of fortified foods and supplements as noted above is clearly a benefit when needed and used appropriately.
If this intervention is not recommended by your child's healthcare team, do not use or add these products to your feeding plan.
Recommendation 7
Responsive feeding
Children 6–23 months of age should be responsively fed, defined as “feeding practices that encourage the child to eat autonomously and in response to physiological and developmental needs, which may encourage self-regulation in eating and support cognitive, emotional and social development” (114) (strong, low certainty evidence).
Responsive feeding involves reciprocity between the child and caregiver during the feeding process.
Responsive feeding is grounded on the following three steps:
the child signals hunger and satiety through motor actions, facial expressions, or vocalizations;
the caregiver recognizes the cues and responds promptly in a manner that is emotionally supportive, contingent on the signal, and developmentally appropriate
the child experiences a predictable response to signals (115). Responsive feeding has been shown to promote healthy growth and development and to encourage children’s self-regulation, which is important to prevent both under- and overfeeding (116). It is considered as a core element of nurturing care (38, 117).
It is increasingly recognized that, in addition to what a child eats, how a child is fed is an important component of infant and young child feeding. Responsive feeding involves reciprocity between the child and caregiver during the feeding process. Responsive feeding is grounded on the following three steps: the child signals hunger and satiety through motor actions, facial expressions, or vocalizations; the caregiver recognizes the cues and responds promptly in a manner that is emotionally supportive, contingent on the signal, and developmentally appropriate; and, the child experiences a predictable response to signals (115). Responsive feeding has been shown to promote healthy growth and development and to encourage children’s self-regulation, which is important to prevent both under- and overfeeding (116). It is considered as a core element of nurturing care (38, 117).
Summary of the evidence: Summarizing the results of the systematic review is challenging in that the components of the interventions differed, as did the method of delivery across the studies. The few trials that examined the effect of an intervention that focused on only one component of responsive feeding found that repeated exposure to vegetables increased their consumption, though had no effect on fruit consumption. Interventions aimed at preventing undernutrition that included seven or more components of responsive feeding and developmental stimulation likely increased self-feeding and reduced child food refusals, and increased dietary diversity, frequency of consumption of some healthy foods, energy, and nutrient intakes. However, there were no effects on the consumption of sweet snacks and sugar dense foods.
3.7.8 Rationale Although the results of the systematic review were mixed, the GDG considered responsive feeding to be an important component of complementary feeding. Practiced appropriately, it may prevent undernutrition, by ensuring the child consumes enough food, as well as overweight and obesity, by ensuring that a child does not eat too much food. It encourages child self-regulation of energy intake and promotes child development.
Both the Guiding principles for complementary feeding of the breastfed child and Guiding principles for feeding the non-breastfed child 6–24 Months of age recommend responsive feeding. It is also recommended in the WHO Guideline on improving early childhood development (25).
Personal Thoughts:
We've heard tons about 'Paced Feeding' over the years, but this technically is not actually backed by the science!
I mean, I know I personally don't like when someone withholds food from me when I am hungry..!
You can be responsive while 'pacing' baby!
By no means should we allow baby to CHUG a bottle- respond to how your baby is eating appropriately! If you need to take a few moments to 'slow' baby down, do it! But if baby is hungry, baby is hungry! Please respond accordingly <3
Yes yes yes to responsive feeding!!
When talking to parents about "building that bond" with baby, THIS is a very simple and efficient way!
Alright, that was A LOT of info..
I will definitely take a closer look at these recommendations in the upcoming weeks
& provide more information for each one as needed.
For now, I hope you know that you are doing a fantastic job!!
& if you live in the United States, like I do, animal milk is NOT the most appropriate option for infants 6-11 months!
Please, PLEASE, Please continue to use breastmilk and/or infant formula until baby is the age of 12+ months!!
If you are interested in looking at the 'World Health Organization (WHO) Guideline for complementary feeding of infants and young children 6–23 months of age' for yourself, you can access it at the link below! Warning, this is a 96 page document lol
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Jessica Enderle, R.D., L.D.
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