16 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS 2.12 Breastfeeding pattern References To ensure adequate milk production and flow for 6 1.WHO.Infant feeding:the physiological basis. months of exclusive breastfeeding,a baby needs to Bulletin of the World Health Organization,1989, feed as often and for as long as he or she wants,both 67(Suppl..)l-107. day and night (28).This is called demand feeding, 2.Lawrence RA and Lawrence RM.Breastfeeding:a unrestricted feeding,or baby-led feeding. guide for the medical profession.6th Edition.Lon- Babies feed with different frequencies,and take dif- don,Mosby,2005. ferent amounts of milk at each feed.The 24-hour 3.Schanler R(Guest ed).Preface.The Pediatric Clin- intake of milk varies between mother-infant pairs ics of North America,2001,48(1):xix-xx. from 440-1220 ml,averaging about 800 ml per day throughout the first 6 months (29).Infants who are 4.Riordan J.The biological specificity of breast feeding on demand according to their appetite obtain milk.In:Breastfeeding and human lactation.Bos- what they need for satisfactory growth.They do not ton,USA,Jones and Bartlett,2004. empty the breast,but remove only 63-72%of avail- 5.Butte N,Lopez-Alarcon MG,Garza C.Nutrient able milk.More milk can always be removed,show- adequacy of exclusive breastfeeding for the term ing that the infant stops feeding because of satiety,not infant during the first six months of life.Geneva, because the breast is empty.However,breasts seem World Health Organization,2002. to vary in their capacity for storing milk.Infants of women with low storage capacity may need to feed 6.Cernadas JMC,Carroli G,Lardizabal J.Effect more often to remove the milk and ensure adequate of timing of cord clamping on neonatal venous daily intake and production(30). hematocrit values and clinical outcome at term:a randomized,controlled trial:In reply.Pediatrics, It is thus important not to restrict the duration or the 2006,118:1318-1319. frequency of feeds-provided the baby is well attached to the breast.Nipple damage is caused by poor attach- 7.Chaparro CM et al.Effect of timing of umbilical ment and not by prolonged feeds.The mother learns cord clamping on iron status in Mexican infants: to respond to her baby's cues of hunger and readiness a randomised controlled trial.Lancet,2006,367: to feed,such as restlessness,rooting(searching)with 1997-2004. his mouth,or sucking hands,before the baby starts to 8.Hanson LA.Immunobiology of human milk:how cry.The baby should be allowed to continue suckling breastfeeding protects babies.Texas,USA,Phar- on the breast until he or she spontaneously releases masoft Publishing,2004. the nipple.After a short rest,the baby can be offered the other side,which he or she may or may not want. 9.Hamosh M.Digestion in the newborn.Clinics in Perinatology:Neonatal Gastroenterology,1996, If a baby stays on the breast for a very long time(more 23(2):191-208. than one halfhour for every feed)or if he or she wants to feed very often(more often than every 1-1 hours 10.Sheard N.The role of breast milk in the devel- each time)then the baby's attachment needs to be opment of the gastrointestinal tract.Nutrition checked and improved.Prolonged,frequent feeds can Reviews,1988,48(1):l-8. be a sign of ineffective suckling and inefficient trans- 11.Innis SM.Human milk:maternal dietary lipids fer of milk to the baby.This is usually due to poor and infant development.The Proceedings of the attachment,which may also lead to sore nipples.If Nutrition Society,2007,66(3):397-404. the attachment is improved,transfer of milk becomes 12.Casey Cet al.Nutrient intake by breastfed infants more efficient,and the feeds may become shorter during the first five days after birth.American Jour- or less frequent.At the same time,the risk of nipple nal of Diseases of Childhood,1986,140:933-936. damage is reduced. 13.WHO.Home-modified animal milk for replacement feeding:is it feasible and safe?Discussion paper pre- pared for "HIV and infant feeding Technical Con- sultation",25-27 October 2006.Geneva,World Health Organization,2006 (http://www.who.int/
16 Infant and Young Child Feeding – Model Chapter for textbooks 2.12 Breastfeeding pattern To ensure adequate milk production and flow for 6 months of exclusive breastfeeding, a baby needs to feed as often and for as long as he or she wants, both day and night (28). This is called demand feeding, unrestricted feeding, or baby-led feeding. Babies feed with different frequencies, and take different amounts of milk at each feed. The 24-hour intake of milk varies between mother-infant pairs from 440–1220 ml, averaging about 800 ml per day throughout the first 6 months (29). Infants who are feeding on demand according to their appetite obtain what they need for satisfactory growth. They do not empty the breast, but remove only 63–72% of available milk. More milk can always be removed, showing that the infant stops feeding because of satiety, not because the breast is empty. However, breasts seem to vary in their capacity for storing milk. Infants of women with low storage capacity may need to feed more often to remove the milk and ensure adequate daily intake and production (30). It is thus important not to restrict the duration or the frequency of feeds – provided the baby is well attached to the breast. Nipple damage is caused by poor attachment and not by prolonged feeds. The mother learns to respond to her baby’s cues of hunger and readiness to feed, such as restlessness, rooting (searching) with his mouth, or sucking hands, before the baby starts to cry. The baby should be allowed to continue suckling on the breast until he or she spontaneously releases the nipple. After a short rest, the baby can be offered the other side, which he or she may or may not want. If a baby stays on the breast for a very long time (more than one half hour for every feed) or if he or she wants to feed very often (more often than every 1–1½ hours each time) then the baby’s attachment needs to be checked and improved. Prolonged, frequent feeds can be a sign of ineffective suckling and inefficient transfer of milk to the baby. This is usually due to poor attachment, which may also lead to sore nipples. If the attachment is improved, transfer of milk becomes more efficient, and the feeds may become shorter or less frequent. At the same time, the risk of nipple damage is reduced. References 1. WHO. Infant feeding: the physiological basis. Bulletin of the World Health Organization, 1989, 67(Suppl.):1–107. 2. Lawrence RA and Lawrence RM. Breastfeeding: a guide for the medical profession. 6th Edition. London, Mosby, 2005. 3. Schanler R (Guest ed). Preface. The Pediatric Clinics of North America, 2001, 48(1):xix–xx. 4. Riordan J. The biological specificity of breast milk. In: Breastfeeding and human lactation. Boston, USA, Jones and Bartlett, 2004. 5. Butte N, Lopez-Alarcon MG, Garza C. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva, World Health Organization, 2002. 6. Cernadas JMC, Carroli G, Lardizábal J. Effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial: In reply. Pediatrics, 2006, 118:1318–1319. 7. Chaparro CM et al. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet, 2006, 367: 1997–2004. 8. Hanson LA. Immunobiology of human milk: how breastfeeding protects babies. Texas, USA, Pharmasoft Publishing, 2004. 9. Hamosh M. Digestion in the newborn. Clinics in Perinatology: Neonatal Gastroenterology, 1996, 23(2):191–208. 10. Sheard N. The role of breast milk in the development of the gastrointestinal tract. Nutrition Reviews, 1988, 48(1):1–8. 11. Innis SM. Human milk: maternal dietary lipids and infant development. The Proceedings of the Nutrition Society, 2007, 66(3):397–404. 12. Casey Cet al. Nutrient intake by breastfed infants during the first five days after birth. American Journal of Diseases of Childhood, 1986, 140: 933–936. 13. WHO. Home-modified animal milk for replacement feeding: is it feasible and safe? Discussion paper prepared for “HIV and infant feeding Technical Consultation”, 25–27 October 2006. Geneva, World Health Organization, 2006 (http://www.who.int/
2.THE PHYSIOLOGICAL BASIS OF BREASTFEEDING 17 child_adolescent_health/documents/a91064/en/, 22.Uvnas Moberg K.The neuroendocrinology of the accessed 5 November 2008) mother-child interaction.Trends in Endocrinology 14.WHO.Guiding principles for feeding non-breastfed and Metabolism,1996,7:126-131. children 6-24 months of age.Geneva,World Health 23.Klaus M.Mother and infant:early emotional ties. Organization,2005. Pediatrics,.1998,102(5):l244-46. 15.Forsythe S.Enterobacter sakasakii and other bac- 24.Moore ER,Anderson GC,Bergman N.Early skin- teria in powdered infant milk formula.Maternal to-skin contact for mothers and their healthy and Child Nutrition,2005,1:44-50. newborn infants.Cochrane Database of Systematic 16.Setchell K et al.Exposure to phyto-oestrogens Reviews,2007,Issue 2. from soy-based formula.Lancet,1997,350:23-27. 25.Wilde CJ,Prentice A,Peaker M.Breastfeeding: 17.WHO.Breastfeeding counselling:a training course. matching supply and demand in human lacta- Trainer's guide (Session 3:How breastfeeding tion.Proceedings of the Nutrition Society,1995, 54:401-406. works);and Overhead figures(Figure 3/1).Gene- va,World Health Organization,1993 (WHO/ 26.Nyqvist KH,Sjoden PO,Ewald U.The develop- CDR/93.4 and WHO/CDR/93.6). ment of preterm infants'breastfeeding behaviour. 18.Edgar A.Anatomy of a working breast.New Early Human Development,1999,55:247-264. Beginnings [La Leche League International],2005 27.Woolridge MW.The 'anatomy'of infant sucking. March-April. Midwifery,1986,2:164-171. 19.Hartmann PE et al.Breast development and the 28.Kent J et al.Volume and frequency of breastfeed- control of milk synthesis.Food and Nutrition Bul- ing and fat content of breastmilk throughout the letin,1996,17(4):292-302 day.Pediatrics,2006,117(3):e387-392 20.Glasier A,McNeilly AS,Howie PW.The prolactin 29.Dewey K,Lonnerdal B.Milk and nutrient intake response to suckling.Clinical Endocrinology,1984, of breastfed infants from 1-6 months:relation to 21:109-116. growth and fatness.Journal of Pediatric Gastroen- 21.Ramsay DT et al.Ultrasound imaging of milk terology and Nutrition,1983,2:497-506. ejection in the breast of lactating women.Pediat- 30.Daly Hartmann PE et al.Breast development and rics,2004,113:361-367. the control of milk synthesis.Food and Nutrition Bulletin,.1996,17:292-302
17 child_adolescent_health/documents/a91064/en/, accessed 5 November 2008). 14. WHO. Guiding principles for feeding non-breastfed children 6–24 months of age. Geneva, World Health Organization, 2005. 15. Forsythe S. Enterobacter sakasakii and other bacteria in powdered infant milk formula. Maternal and Child Nutrition, 2005, 1:44–50. 16. Setchell K et al. Exposure to phyto-oestrogens from soy-based formula. Lancet, 1997, 350: 23–27. 17. WHO. Breastfeeding counselling: a training course. Trainer’s guide (Session 3: How breastfeeding works); and Overhead figures (Figure 3/1). Geneva, World Health Organization, 1993 (WHO/ CDR/93.4 and WHO/CDR/93.6). 18. Edgar A. Anatomy of a working breast. New Beginnings [La Leche League International], 2005 March–April. 19. Hartmann PE et al. Breast development and the control of milk synthesis. Food and Nutrition Bulletin, 1996, 17(4):292–302. 20. Glasier A, McNeilly AS, Howie PW. The prolactin response to suckling. Clinical Endocrinology, 1984, 21:109–116. 21. Ramsay DT et al. Ultrasound imaging of milk ejection in the breast of lactating women. Pediatrics, 2004, 113:361–367. 2. The physiological basis of breastfeeding 22. Uvnas Moberg K. The neuroendocrinology of the mother-child interaction. Trends in Endocrinology and Metabolism, 1996, 7:126–131. 23. Klaus M. Mother and infant: early emotional ties. Pediatrics, 1998, 102(5):1244–46. 24. Moore ER, Anderson GC, Bergman N. Early skinto-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, 2007, Issue 2. 25. Wilde CJ, Prentice A, Peaker M. Breastfeeding: matching supply and demand in human lactation. Proceedings of the Nutrition Society, 1995, 54:401–406. 26. Nyqvist KH, Sjoden PO, Ewald U. The development of preterm infants’ breastfeeding behaviour. Early Human Development, 1999, 55:247–264. 27. Woolridge MW. The ‘anatomy’ of infant sucking. Midwifery, 1986, 2:164–171. 28. Kent J et al. Volume and frequency of breastfeeding and fat content of breastmilk throughout the day. Pediatrics, 2006, 117(3): e387–392. 29. Dewey K, Lonnerdal B. Milk and nutrient intake of breastfed infants from 1–6 months: relation to growth and fatness. Journal of Pediatric Gastroenterology and Nutrition, 1983, 2:497–506. 30. Daly Hartmann PE et al. Breast development and the control of milk synthesis. Food and Nutrition Bulletin, 1996, 17:292–302
Complementary feeding 3.1 Guiding Principles for BOX1 Complementary Feeding Guiding principles for complementary feeding After 6 months of age,it becomes increasingly diffi- of the breastfed child cult for breastfed infants to meet their nutrient needs from human milk alone.Furthermore most infants 1.Practise exclusive breastfeeding from birth to 6 months of are developmentally ready for other foods at about 6 age,and introduce complementary foods at6months of months.In settings where environmental sanitation age(180days)whilening to breastfeed. is very poor,waiting until even later than 6 months to 2.Continue frequent,on-demand breastfeeding until2years introduce complementary foods might reduce expo- of age or beyond. sure to food-borne diseases.However,because infants are beginning to actively explore their environment at 3.Practise responsive feeding,applying the principles of this age,they will be exposed to microbial contami- psychosocal care. nants through soil and objects even if they are not 4.Practise good hygiene and proper food handling. given complementary foods.Thus,6 months is the recommended appropriate age at which to introduce 5.Start at 6 months of age with small amounts of food complementary foods(1). and increase the quantity as the child gets older,while maintaining frequent breastfeeding. During the period of complementary feeding,chil- 6.Gradually increase food consistency and variety as the dren are at high risk of undernutrition(2).Comple- infant grows older,adapting to the infant's requirements mentary foods are often of inadequate nutritional quality,or they are given too early or too late,in too and abilities。 small amounts,or not frequently enough.Premature 7.Increase the number of times that the child is fed cessation or low frequency of breastfeeding also con- complementary foods as the child gets older. tributes to insufficient nutrient and energy intake in 8.Feed a variety of nutrient-rich foods to ensure that all infants beyond 6 months of age. nutrient needs are met. The Guiding principles for complementary feeding of 9.Use fortified complementary foods or vitamin-mineral the breastfed child,summarized in Box 1,set standards supplements for the infant,as needed for developing locally appropriate feeding recom- mendations(3).They provide guidance on desired 10.Increase fluid intake during illness,including more feeding behaviours as well as on the amount,consist- frequent breastfeeding,and encourage the child to eat ency,frequency,energy density and nutrient content soft,favourite foods.After illness,give food more often of foods.The Guiding principles are explained in more than usual and encourage the child to eat more. detail in the paragraphs below. GUIDING PRINCIPLE 1.Practise exclusive breastfeeding but also in industrialized countries.According to the from birth to 6 months of age and introduce WHO growth standards,children who are exclusively complementary foods at6 months of age(180 days) breastfed grow better in the first 6 months than other while continuing to breastfeed infants (4). Exclusive breastfeeding for 6 months confers several By the age of 6 months,a baby has usually at least benefits to the infant and the mother.Chief among doubled his or her birth weight,and is becoming these is the protective effect against gastrointestinal more active.Exclusive breastfeeding is no longer suf- infections,which is observed not only in developing ficient to meet all energy and nutrient needs by itself
Complementary feeding 3.1 Guiding Principles for Complementary Feeding After 6 months of age, it becomes increasingly difficult for breastfed infants to meet their nutrient needs from human milk alone. Furthermore most infants are developmentally ready for other foods at about 6 months. In settings where environmental sanitation is very poor, waiting until even later than 6 months to introduce complementary foods might reduce exposure to food-borne diseases. However, because infants are beginning to actively explore their environment at this age, they will be exposed to microbial contaminants through soil and objects even if they are not given complementary foods. Thus, 6 months is the recommended appropriate age at which to introduce complementary foods (1). During the period of complementary feeding, children are at high risk of undernutrition (2). Complementary foods are often of inadequate nutritional quality, or they are given too early or too late, in too small amounts, or not frequently enough. Premature cessation or low frequency of breastfeeding also contributes to insufficient nutrient and energy intake in infants beyond 6 months of age. The Guiding principles for complementary feeding of the breastfed child, summarized in Box 1, set standards for developing locally appropriate feeding recommendations (3). They provide guidance on desired feeding behaviours as well as on the amount, consistency, frequency, energy density and nutrient content of foods. The Guiding principles are explained in more detail in the paragraphs below. A Guiding Principle 1. Practise exclusive breastfeeding from birth to 6 months of age and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed Exclusive breastfeeding for 6 months confers several benefits to the infant and the mother. Chief among these is the protective effect against gastrointestinal infections, which is observed not only in developing Box 1 Guiding principles for complementary feeding of the breastfed child 1. Practise exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed. 2. Continue frequent, on-demand breastfeeding until 2 years of age or beyond. 3. Practise responsive feeding, applying the principles of psychosocial care. 4. Practise good hygiene and proper food handling. 5. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding. 6. Gradually increase food consistency and variety as the infant grows older, adapting to the infant’s requirements and abilities. 7. Increase the number of times that the child is fed complementary foods as the child gets older. 8. Feed a variety of nutrient-rich foods to ensure that all nutrient needs are met. 9. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed 10. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, favourite foods. After illness, give food more often than usual and encourage the child to eat more. but also in industrialized countries. According to the WHO growth standards, children who are exclusively breastfed grow better in the first 6 months than other infants (4). By the age of 6 months, a baby has usually at least doubled his or her birth weight, and is becoming more active. Exclusive breastfeeding is no longer sufficient to meet all energy and nutrient needs by itself, Session 3
20 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS and complementary foods should be introduced to have revealed that a casual style of feeding predomi- make up the difference.At about 6 months of age,an nates in some populations.Young children are left to infant is also developmentally ready for other foods feed themselves,and encouragement to eat is rarely (5).The digestive system is mature enough to digest observed.In such settings,a more active style of feed- the starch,protein and fat in a non-milk diet.Very ing can improve dietary intake.The term"responsive young infants push foods out with their tongue,but feeding"(see Box 2)is used to describe caregiving that by between 6 and 9 months infants can receive and applies the principles of psychosocial care. hold semi-solid food in their mouths more easily. A child should have his or her own plate or bowl so GUIDING PRINCIPLE 2.Continue frequent on-demand that the caregiver knows if the child is getting enough breastfeeding until 2 years of age or beyond food.A utensil such as a spoon,or just a clean hand, may be used to feed a child,depending on the culture. Breastfeeding should continue with complementary The utensil needs to be appropriate for the child's age. feeding up to 2 years of age or beyond,and it should Many communities use a small spoon when a child be on demand,as often as the child wants. starts taking solids.Later a larger spoon or a fork may Breast milk can provide one half or more of a child's be used. energy needs between 6 and 12 months of age,and Whether breastfeeds or complementary foods are giv- one third of energy needs and other high quality en first at any meal has not been shown to matter.A nutrients between 12 and 24 months(6).Breast milk mother can decide according to her convenience,and continues to provide higher quality nutrients than the child's demands complementary foods,and also protective factors. Breast milk is a critical source of energy and nutrients GUIDING PRINCIPLE 4.Practise good hygiene and during illness(7),and reduces mortality among chil- proper food handling dren who are malnourished(8,9).In addition,as dis- Microbial contamination of complementary foods is cussed in Session 1,breastfeeding reduces the risk of a a major cause of diarrhoeal disease,which is partic- number of acute and chronic diseases.Children tend ularly common in children 6 to 12 months old (12). to breastfeed less often when complementary foods are introduced,so breastfeeding needs to be actively Safe preparation and storage of complementary foods can prevent contamination and reduce the risk of encouraged to sustain breast-milk intake. diarrhoea.The use of bottles with teats to feed liquids GUIDING PRINCIPLE 3.Practise responsive feeding is more likely to result in transmission of infection applying the principles of psychosocial care than the use of cups,and should be avoided(13). Optimal complementary feeding depends not only All utensils,such as cups,bowls and spoons,used on what is fed but also on how,when,where and for an infant or young child's food should be washed by whom a child is fed(10,11).Behavioural studies thoroughly.Eating by hand is common in many cul- tures,and children may be given solid pieces of food BOX2 to hold and chew on,sometimes called "finger foods". It is important for both the caregiver's and the child's Responsive feeding hands to be washed thoroughly before eating. Feed infants directly and assist older children when they Bacteria multiply rapidly in hot weather,and more feed themselves.Feed slowly and patiently,and encourage slowly if food is refrigerated.Larger numbers of bacte- children to eat,but do not force them. ria produced in hot weather increase the risk of illness If children refuse many foods,experiment with different (14).When food cannot be refrigerated it should be food combinations,tastes,textures and methods of eaten soon after it has been prepared(no more than 2 encouragement. hours),before bacteria have time to multiply. Minimize distractions during meals if the child loses Basic recommendations for the preparation of safe interest easily. foods(15)are summarized in Box 3. Remember that feeding times are periods of learning and love-talk to children during feeding,with eye-to-eye contact
20 Infant and Young Child Feeding – Model Chapter for textbooks and complementary foods should be introduced to make up the difference. At about 6 months of age, an infant is also developmentally ready for other foods (5). The digestive system is mature enough to digest the starch, protein and fat in a non-milk diet. Very young infants push foods out with their tongue, but by between 6 and 9 months infants can receive and hold semi-solid food in their mouths more easily. A Guiding Principle 2. Continue frequent on-demand breastfeeding until 2 years of age or beyond Breastfeeding should continue with complementary feeding up to 2 years of age or beyond, and it should be on demand, as often as the child wants. Breast milk can provide one half or more of a child’s energy needs between 6 and 12 months of age, and one third of energy needs and other high quality nutrients between 12 and 24 months (6). Breast milk continues to provide higher quality nutrients than complementary foods, and also protective factors. Breast milk is a critical source of energy and nutrients during illness (7), and reduces mortality among children who are malnourished (8, 9). In addition, as discussed in Session 1, breastfeeding reduces the risk of a number of acute and chronic diseases. Children tend to breastfeed less often when complementary foods are introduced, so breastfeeding needs to be actively encouraged to sustain breast-milk intake. A Guiding Principle 3. Practise responsive feeding applying the principles of psychosocial care Optimal complementary feeding depends not only on what is fed but also on how, when, where and by whom a child is fed (10,11). Behavioural studies have revealed that a casual style of feeding predominates in some populations. Young children are left to feed themselves, and encouragement to eat is rarely observed. In such settings, a more active style of feeding can improve dietary intake. The term “responsive feeding” (see Box 2) is used to describe caregiving that applies the principles of psychosocial care. A child should have his or her own plate or bowl so that the caregiver knows if the child is getting enough food. A utensil such as a spoon, or just a clean hand, may be used to feed a child, depending on the culture. The utensil needs to be appropriate for the child’s age. Many communities use a small spoon when a child starts taking solids. Later a larger spoon or a fork may be used. Whether breastfeeds or complementary foods are given first at any meal has not been shown to matter. A mother can decide according to her convenience, and the child’s demands. A Guiding Principle 4. Practise good hygiene and proper food handling Microbial contamination of complementary foods is a major cause of diarrhoeal disease, which is particularly common in children 6 to 12 months old (12). Safe preparation and storage of complementary foods can prevent contamination and reduce the risk of diarrhoea. The use of bottles with teats to feed liquids is more likely to result in transmission of infection than the use of cups, and should be avoided (13). All utensils, such as cups, bowls and spoons, used for an infant or young child’s food should be washed thoroughly. Eating by hand is common in many cultures, and children may be given solid pieces of food to hold and chew on, sometimes called “finger foods”. It is important for both the caregiver’s and the child’s hands to be washed thoroughly before eating. Bacteria multiply rapidly in hot weather, and more slowly if food is refrigerated. Larger numbers of bacteria produced in hot weather increase the risk of illness (14). When food cannot be refrigerated it should be eaten soon after it has been prepared (no more than 2 hours), before bacteria have time to multiply. Basic recommendations for the preparation of safe foods (15) are summarized in Box 3. Box 2 Responsive feeding K Feed infants directly and assist older children when they feed themselves. Feed slowly and patiently, and encourage children to eat, but do not force them. K If children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement. K Minimize distractions during meals if the child loses interest easily. K Remember that feeding times are periods of learning and love – talk to children during feeding, with eye-to-eye contact
3.COMPLEMENTARY FEEDING 21 BOX3 Table 1 summarizes the amount of food required at different ages,'the average number ofkilocalories that Five keys to safer food a breastfed infant or young child needs from com- ■Keepcean plementary foods at different ages,and the approxi- mate quantity of food that will provide this amount Separate raw and cooked of energy per day.The quantity increases gradually ■Cook thoroughly month by month,as the child grows and develops, Keep food at safe temperatures and the table shows the average for each age range. Use safe water and raw materials The actual amount (weight or volume)of food required depends on the energy density of the food offered.This means the number of kilocalories per ml,or per gram.Breast milk contains about 0.7 kcal GUIDING PRINCIPLE 5.Start at 6 months of age with per ml.Complementary foods are more variable,and small amounts of food and increase the quantity usually contain between 0.6 and 1.0 kcal per gram as the child gets older,while maintaining frequent Foods that are watery and dilute may contain only breastfeeding about 0.3 kcal per gram.For complementary foods The overall quantity of food is usually measured for to have 1.0 kcal per gram,it is necessary for them to convenience according to the amount ofenergy-that be quite thick and to contain fat or oil,which are the is,the number of kilocalories (kcal)-that a child most energy-rich foods. needs.Other nutrients are equally important,and are Complementary foods should have a greater energy either part of,or must be added to,the staple food. density than breast milk,that is,at least 0.8 kcal per Figure 10 shows the energy needs of infants and young gram.The quantities of food recommended in Table children up to 2 years of age,and how much can be 1 assume that the complementary food will contain provided by breast milk.It shows that breast milk 0.8-1.0 kcal per gram.If a complementary food is covers all needs up to 6 months,but after 6 months more energy dense,then a smaller amount is needed there is an energy gap that needs to be covered by to cover the energy gap.A complementary food that complementary foods.The energy needed in addition is more energy-dilute needs a larger volume to cover to breast milk is about 200 kcal per day in infants 6-8 the energy gap. months,300 kcal per day in infants 9-11 months,and When complementary food is introduced,a child 550 kcal per day in children 12-23 months ofage.The tends to breastfeed less often,and his or her intake amount of food required to cover the gap increases as of breast milk decreases (17),so the food effectively the child gets older,and as the intake of breast milk displaces breast milk.If complementary food is more decreases(16). energy diluted than breast milk,the child's total energy intake may be less than it was with exclusive FIGURE 10 breastfeeding,an important cause of malnutrition. Energy required by age and the amount from breast milk A young child's appetite usually serves as a guide to the amount of food that should be offered.However, 1200 Energy from breastmilk Energy gap illness and malnutrition reduce appetite,so that a 100 sick child may take less than he or she needs.A child recovering from illness or malnutrition may require 800 extra assistance with feeding to ensure adequate 600 intake.If the child's appetite increases with recovery, then extra food should be offered. 35m 6-8m 9-11m 12-23m Age(months) The age ranges should be interpreted as follows:a child 6-8 months is 6 months or older 180 days)but is not yet9 months old (270 days)
3. Complementary feeding 21 A Guiding Principle 5. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding The overall quantity of food is usually measured for convenience according to the amount of energy – that is, the number of kilocalories (kcal) – that a child needs. Other nutrients are equally important, and are either part of, or must be added to, the staple food. Figure 10 shows the energy needs of infants and young children up to 2 years of age, and how much can be provided by breast milk. It shows that breast milk covers all needs up to 6 months, but after 6 months there is an energy gap that needs to be covered by complementary foods. The energy needed in addition to breast milk is about 200 kcal per day in infants 6–8 months, 300 kcal per day in infants 9–11 months, and 550 kcal per day in children 12–23 months of age. The amount of food required to cover the gap increases as the child gets older, and as the intake of breast milk decreases (16). Table 1 summarizes the amount of food required at different ages,1 the average number of kilocalories that a breastfed infant or young child needs from complementary foods at different ages, and the approximate quantity of food that will provide this amount of energy per day. The quantity increases gradually month by month, as the child grows and develops, and the table shows the average for each age range. The actual amount (weight or volume) of food required depends on the energy density of the food offered. This means the number of kilocalories per ml, or per gram. Breast milk contains about 0.7 kcal per ml. Complementary foods are more variable, and usually contain between 0.6 and 1.0 kcal per gram. Foods that are watery and dilute may contain only about 0.3 kcal per gram. For complementary foods to have 1.0 kcal per gram, it is necessary for them to be quite thick and to contain fat or oil, which are the most energy-rich foods. Complementary foods should have a greater energy density than breast milk, that is, at least 0.8 kcal per gram. The quantities of food recommended in Table 1 assume that the complementary food will contain 0.8–1.0 kcal per gram. If a complementary food is more energy dense, then a smaller amount is needed to cover the energy gap. A complementary food that is more energy-dilute needs a larger volume to cover the energy gap. When complementary food is introduced, a child tends to breastfeed less often, and his or her intake of breast milk decreases (17), so the food effectively displaces breast milk. If complementary food is more energy diluted than breast milk, the child’s total energy intake may be less than it was with exclusive breastfeeding, an important cause of malnutrition. A young child’s appetite usually serves as a guide to the amount of food that should be offered. However, illness and malnutrition reduce appetite, so that a sick child may take less than he or she needs. A child recovering from illness or malnutrition may require extra assistance with feeding to ensure adequate intake. If the child’s appetite increases with recovery, then extra food should be offered. Box 3 Five keys to safer food K Keep clean K Separate raw and cooked K Cook thoroughly K Keep food at safe temperatures K Use safe water and raw materials Figure 10 Energy required by age and the amount from breast milk Energy from breastmilk Energy gap 0–2 m 3–5 m 6–8 m 9–11 m 12–23 m Age (months) 1200 1000 800 600 400 200 0 Energy (Kcal/day) 1 The age ranges should be interpreted as follows: a child 6–8 months is 6 months or older (≥ 180 days) but is not yet 9 months old (< 270 days)