For Healthcare Professionals only

Complementary Feeding : Introducing Solid Foods - The Role Of Variety, Vegetables And Repeated Exposure
By - Prof Marion M Hetherington
School of Psychology, University of Leeds, UK

Question and Answers

The answers to all the questions have been provided by Dr. Bhaskar Raju.

Q1: As food allergies are increasing, what is the ideal time to start complementary feeding in the paediatric practice in particularly 5th, 6th and 7th months, when do you start?

There is some evidence that starting solids before 4m of age and after 7m of age, could exacerbate allergic tendencies. There is also some evidence that starting solids under cover of Breast Milk between 4 to 7m of age reduces the incidence, or at least postpones development of food allergy (esp. Gluten allergy). These facts notwithstanding, for a country like India, where optimal nutrition and safety from infections are a priority, WHO and the Infant and Young Child Feeding Guidelines of the Government of India recommend exclusive breast feeds till 180 days of life and start of clean nutritious solids at completion of 6m of age. The Honduran study and the Bylarus studies have conclusively proven.

  1. Addition of high quality solids at 4m of age along with same quantity of BM taken so far, did not result in any additional nutritional benefit to the infant, noticeable either as additional weight or length gain.(Honduras).
  2. Addition of nutritious clean solids under medical supervision at 4m of age, did result in slight but significant increase in rate of Respiratory and GI infections, besides slight increase in Atopy as well. (Bylarus)

So, WHO concluded there is no benefit to the baby in adding solids earlier than 180 days and it could increase incidence of infections, in spite of best efforts at hygiene and advised exclusive breast feeds till 180 days.

The data for formula fed babies is sketchy at present, in this regard. So, as a general rule whether formula fed or BM fed, solids at 180 days is strictly recommended.

References:-

  1. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality: Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2000;355:451–455.
  2. Kramer MS, Kakuma R: The Optimal Duration of Exclusive Breast Feeding: Cochrane database A Systematic Review. Geneva, World Health Organization, 2002
  3. Cohen RJ, Brown KH, Canahuati J, et al: Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomized intervention study in Honduras. Lancet 1994;343:288–293.
  4. Dewey KG, Cohen RJ, Brown KH, Rivera LL: Age of introduction of complementary foods and growth of term, low-birth-weight, breast-fed infants: a randomized intervention study in Honduras. Am J Clin Nutr 1999;69:679–686
  5. Kramer MS, Chalmers B, Hodnett ED, et al; PROBIT Study Group (Promotion of Breastfeeding Intervention Trial ): a randomized trial in the Republic of Belarus. JAMA 2001;285:413–420.

Q2: In India Complementary feeding is mainly cereal based. Rice is commonly used as complementary food. What do you think is the right cereal to initiate complementary feeding?

It is true, between Rice and Wheat, rice is slightly less allergenic. However, when combined with milk or other sources of proteins like pulses, both cereals are equally good and there is nothing to recommend one or the other. Rice allergy is rare, though reported. South India, Celiac disease is extremely rare in the native populations. In places where Celiac disease is common, the Physician will have to take a call on when to expose infants to Wheat. Late exposure does not prevent or mitigate severity of Celiac disease.

Q3: While we all agree that cereal based Complementary food is acceptable but to ensure a proper growth velocity, which are the fats and pulses that need to be added to the diet during complementary feeding? Is it vegetable oil or animal based fat which is acceptable in complementary feeding? Which pulses can be part of complementary foods?

All pulses used in India are acceptable sources of proteins for growing infants provided there is a balanced mix of cereals and pulses to take care of individual essential amino acids that may be missing in the pulses or cereal. It a cultural and maternal choice.
The recommendations as far as fats are concerned are:

  1. 25% of calories to be from Fat.
  2. Not more than 10% fat to be fully saturated fats. This recommendation might change in the future, given the growing evidence. Milk fat is good for the baby and vegetable fats are not necessarily healthier fats.
  3. DHA enrichment of diet with Fish would be beneficial esp in preterm and small for date babies born with low stores of DHA.
  4. Standard advise of 2 tsp of oil/ghee/butter with every 100gms of solid foods is good practical advice.

References:-

  1. Prentice AM, Paul AA: Fat and energy needs of children in developing countries. Am J Clin Nutr 2000;72(suppl):1253S–1265S.
  2. Michaelsen KF, Dyerberg J, Falk E, et al: Children, dietary fat and cardiovascular disease. A report from the Danish Nutrition Council (in Danish with summary in English).
  3. http://www.ernaeringsraadet.dk/pdf/kostrapport.pdf
  4. Shea S, Basch CE, Stein AD, et al: Is there a relationship between dietary fat and stature or growth in children three to five years of age? Pediatrics 1993;92:579–586.

Q4: In India babies are fed by hand at the age of 6 months however in the west spoon feeding is used. Which will have more positive effect on the growth and development of the child as mother’s hand feeding or spoon feeding?

Initiation of complementary feeds are best done with spoon, for the simple reason it is a lot easier to keep the spoon clean and sterile than hand. As soon as infant develops finger and hand control, finger foods need to encouraged. Feeding through spoons or hand beyond 8m of life in not recommended. Allowing the baby to pick up the food morsels by itself, off a tray or plate and put it into its mouth, not only enhances hand and arm coordination, but also satiety. The chances are overeating and obesity are less with infants eating themselves as soon as they are able to. Babies will make a mess initially, but will learn to eat to their satisfaction quite fast, if encouraged.

References:-

  1. Kenneth H. Brown Breastfeeding and Complementary Feeding of Children up to 2 Years of AgeAgostoni C, Brunser O (eds): Issues in Complementary Feeding. Nestlé Nutria Workshop Ser
  2. Pediatric Program, vol 60, pp 1–13, Nestec Ltd., Vevey/S. Karger AG, Basel, © 2007

Q5: Which according to you are better traditional foods or complementary well balanced commercial foods?

Commercially available complementary foods made by reputed brands are good. Nutritionally balanced (Except where it is recommended to be mixed with milk to become nutritionally balanced). In addition, they have Baby-acceptable taste and texture. So they are good starter foods for infants waiting to be initiated into solids, provided the family can afford the foods. Many local companies do make and sell powders of multiple cereals and pulses calling them Complementary foods. The physician has to very careful while recommending them. Many of these are made in make shift factories without adequate hygiene. They may not be nutritionally complete and inadequate in micronutrients. The physician has to satisfy himself of the quality of such locally made and sold products, before recommending them. Commercially available products are just “Bridge Foods”. You can use them to allow the infant to accept solids easily and learn to swallow them. Over 6 to 8 weeks, one has to rapidly shift to home available, nutritionally balanced, properly textured and culturally acceptable foods.

Q6: When to start animal protein in Complementary feeding? What is the right age to start animal protein on non-vegetarian food items?

At a chemical level, there is not much difference in animal and vegetable proteins, besides concentration of essential amino acids. After all Mother’s milk and Cow’s milk are animal proteins. Animal proteins can be started anytime post 6m, provided you can make it available for the baby in a form, taste and texture that is acceptable for the baby. Eggs are usually well accepted by the baby by 7m. Chicken and fish could also be tried by that time, but since they are very unfamiliar taste for the baby, it may be difficult to get them to accept it. Meat or fish pureed with rice and perhaps dhal may be better accepted than plain meat or fish initially. Generally, children from families that routinely take animal proteins daily, including during pregnancy, accept animal protein as complementary food more avidly, since they get primed to those flavours during gestation through the amniotic fluid that carries these flavours to the baby.

Q7: What amount of complementary feeding would be required at typically 8-9 months of age and how many times a day?

Studies have shown that average infant of about 8m (9Kgs) will have a stomach capacity of about 250-275ml. That means it can accept up to about 200-220ml of food. Ideal number of solid feeds at 8m of age would be 3. If 3 feeds of approximately 200ml are given, one could manage with foods of about 50kcals/100gms of food. That kind of energy density is easy to obtain with home available foods. If solid feeds are kept at 2/day, the required energy density jumps to >70kcals/100gms which is difficult to achieve with home available foods. If more than 3 solid feeds are given there is danger of eating into Breast milk intake and hence not recommended.

References:-

  1. Brown KH, Sanchez-Grinan M, Perez F, et al: Effects of dietary energy density and feeding frequency on total daily energy intakes by recovering malnourished children. Am J Clin Nutr ;199:62:13–18.