22 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS TABLE1 Practical guidance on the quality,frequency and amount of food to offer children 6-23 months of age who are breastfed on demand AGE ENERGY NEEDED PER DAY IN TEXTURE FREQUENCY AMOUNT OF FOOD AN AVERAGE ADDITION TO BREAST MILK CHILD WILL USUALLY EAT AT EACH MEAL' 6-8 months 200 kcal per day Start with thick porridge, 2-3 meals per day Start with 2-3 tablespoonfuls well mashed foods per feed,increasing gradually Depending on the child's appetite, to of a 250 ml cup Continue with mashed 1-2 snacks may be offered family foods 9-11 months 300 kcal per day Finely chopped or mashed 3-4 meals per day 2 of a 250 ml cup/bowl foods,and foods that baby can pick up Depending on the child's appetite, 1-2 snacks may be offered 12-23 months 550 kcal per day Family foods,chopped or 3-4 meals per day %to full 250 ml cup/bowl mashed if necessary Depending on the child's appetite 1-2 snacks may be offered Further information The amounts of food induded in the table are recommended when the energy density of the meals is about 0.8 to 1.0 kcal/g. example: for 6 to8 months,increase gradually to two thirds cup for9to 11 months,give three quarters cup for 12to23 months,give a full cup. The table should be adapted based on the energy content of local complementary foods. The mother or caregiver should feed the child using the principles of responsive feeding,recognizing the signs ofhunger and satiety.These signs should guide the amount of food given at each meal and the need for snacks. If baby is not breastfed,give in addition:1-2 cups of milk per day,and 1-2 extra meals per day(18). GUIDING PRINCIPLE 6.Gradually increase food to give more kcal and to include a variety of nutri- consistency and variety as the infant grows older, ent-rich ingredients including animal-source foods. adapting to the infant's requirements and abilities There is evidence of a critical window for introducing 'lumpy'foods:if these are delayed beyond 10 months The most suitable consistency for an infant's or young child's food depends on age and neuromus- of age,it may increase the risk of feeding difficulties cular development(19).Beginning at 6 months,an later on.Although it may save time to continue feed- infant can eat pureed,mashed or semi-solid foods.By ing semi-solid foods,for optimal child development it 8 months most infants can also eat finger foods.By is important to gradually increase the solidity of food 12 months,most children can eat the same types of with age. foods as consumed by the rest of the family.However, GUIDING PRINCIPLE 7.Increase the number of times they need nutrient-rich food,as explained in Guiding that the child is fed complementary foods as the child principle 8,and foods that can cause choking,such as gets older whole peanuts,should be avoided. As a child gets older and needs a larger total quantity A complementary food should be thick enough so of food each day,the food needs to be divided into a that it stays on a spoon and does not drip off.Gen- larger number of meals. erally,foods that are thicker or more solid are more energy-and nutrient-dense than thin,watery or soft The number of meals that an infant or young child foods.When a child eats thick,solid foods,it is easier needs in a day depends on:
22 Infant and Young Child Feeding – Model Chapter for textbooks A Guiding Principle 6. Gradually increase food consistency and variety as the infant grows older, adapting to the infant’s requirements and abilities The most suitable consistency for an infant’s or young child’s food depends on age and neuromuscular development (19). Beginning at 6 months, an infant can eat pureed, mashed or semi-solid foods. By 8 months most infants can also eat finger foods. By 12 months, most children can eat the same types of foods as consumed by the rest of the family. However, they need nutrient-rich food, as explained in Guiding principle 8, and foods that can cause choking, such as whole peanuts, should be avoided. A complementary food should be thick enough so that it stays on a spoon and does not drip off. Generally, foods that are thicker or more solid are more energy- and nutrient-dense than thin, watery or soft foods. When a child eats thick, solid foods, it is easier Table 1 Practical guidance on the quality, frequency and amount of food to offer children 6–23 months of age who are breastfed on demand Age Energy needed per dayin Texture Frequency Amount offood an average addition to breast milk child will usually eat at each meala 6–8 months 200 kcal per day Start with thick porridge, 2–3 meals per day Start with 2–3 tablespoonfuls well mashed foods per feed, increasing gradually Depending on the child’s appetite, to ½ of a 250 ml cup Continue with mashed 1–2 snacks may be offered family foods 9–11 months 300 kcal per day Finely chopped or mashed 3–4 meals per day ½ of a 250 ml cup/bowl foods, and foods that baby can pick up Depending on the child’s appetite, 1–2 snacks may be offered 12–23 months 550 kcal per day Family foods, chopped or 3–4 meals per day ¾ to full 250 ml cup/bowl mashed if necessary Depending on the child’s appetite, 1–2 snacks may be offered Further information The amounts of food included in the table are recommended when the energy density of the meals is about 0.8 to 1.0 kcal/g. If the energy density of the meals is about 0.6 kcal/g, the mother should increase the energy density of the meal (adding special foods) or increase the amount of food per meal. For example: — for 6 to 8 months, increase gradually to two thirds cup — for 9 to 11 months, give three quarters cup — for 12 to 23 months, give a full cup. The table should be adapted based on the energy content of local complementary foods. The mother or caregiver should feed the child using the principles of responsive feeding, recognizing the signs of hunger and satiety. These signs should guide the amount of food given at each meal and the need for snacks. a If baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day (18). to give more kcal and to include a variety of nutrient-rich ingredients including animal-source foods. There is evidence of a critical window for introducing ‘lumpy’ foods: if these are delayed beyond 10 months of age, it may increase the risk of feeding difficulties later on. Although it may save time to continue feeding semi-solid foods, for optimal child development it is important to gradually increase the solidity of food with age. A Guiding Principle 7. Increase the number of times that the child is fed complementary foods as the child gets older As a child gets older and needs a larger total quantity of food each day, the food needs to be divided into a larger number of meals. The number of meals that an infant or young child needs in a day depends on:
3.COMPLEMENTARY FEEDING 23 how much energy the child needs to cover the ener- FIGURE 11 gy gap.The more food a child needs each day,the Gaps to be filled by complementary foods for a breastfed more meals are needed to ensure that he or she gets child 12-23 months enough. 100 Gap the amount that a child can eat at one meal.This depends on the capacity or size of the child's stom- S breast milk ach,which is usually 30 ml per kg of the child's body weight.A child who weighs 8 kg will have a stomach capacity of 240 ml,about one large cup- 25 ful,and cannot be expected to eat more than that at one meal. Energy Vitamin A the energy density of the food offered.The energy Nutrient density of complementary foods should be more than breast milk,that is,at least 0.8 kcal per gram. If the energy density of food is lower,a larger vol- The largest gap is for iron,so it is especially impor- ume of food is needed to fill the gap,which may tant that complementary foods contain iron,if pos- need to be divided into more meals. sible from animal-source foods such as meat,organs, As shown in Table 1,a breastfed infant 6-8 months old poultry or fish.Pulses(peas,beans,lentils,nuts)fed needs 2-3 meals a day,and a breastfed infant 9-23 with vitamin C-rich foods to aid absorption provide months needs 3-4 meals a day.Depending on the an alternative,but they cannot replace animal-source child's appetite,1-2 nutritious snacks may be offered. foods completely. Snacks are defined as foods eaten between meals, Box 4 summarizes characteristics of good complemen- often self-fed finger foods,which are convenient and tary foods. easy to prepare.If they are fried,they may have a high energy density.The transition from 2 to 3 meals, and from smaller to larger meals,happens gradually BOX4 between those ages,depending on the child's appetite and how he or she is developing. Good complementary foods are: If a child eats too few meals,then he or she will not Rich in energy,protein and micronutrients(particularly receive enough food to cover energy needs.If a child iron,zinc,calcium,vitamin A,vitamin Cand folate); eats too many meals,he or she may breastfeed less, ■Not spicy or salty: or may even stop breastfeeding altogether.In the first Easy for the child to eat; year of life,displacement of breast milk may reduce the quality and amount of the child's total nutrient ■Liked by the child; intake. Locally available and affordable. GUIDING PRINCIPLE 8.Feed a variety of nutrient-rich foods to ensure that all nutrient needs are met The basic ingredient of complementary foods is usu- Complementary foods should provide sufficient ally the local staple.Staples are cereals,roots and energy,protein and micronutrients to cover a child's starchy fruits that consist mainly of carbohydrate energy and nutrient gaps,so that together with breast and provide energy.Cereals also contain some pro- milk,they meet all his or her needs. tein;but roots such as cassava and sweet potato,and Figure 11 shows the energy,protein,iron and vitamin A starchy fruits such as banana and breadfruit,contain gaps that need to be filled by complementary foods for very little protein. a breastfed child 12-23 months of age.The light part A variety of other foods should be added to the staple of each bar shows the percentage of the child's daily every day to provide other nutrients.These include: needs that can be provided by an average intake of 550 ml of breast milk.The dark part of the bar shows the Foods from animals or fish are good sources of pro- gap that needs to be filled by complementary foods. tein,iron and zinc.Liver also provides vitamin A and folate.Egg yolk is a good source of protein and
3. Complementary feeding 23 K how much energy the child needs to cover the energy gap. The more food a child needs each day, the more meals are needed to ensure that he or she gets enough. K the amount that a child can eat at one meal. This depends on the capacity or size of the child’s stomach, which is usually 30 ml per kg of the child’s body weight. A child who weighs 8 kg will have a stomach capacity of 240 ml, about one large cupful, and cannot be expected to eat more than that at one meal. K the energy density of the food offered. The energy density of complementary foods should be more than breast milk, that is, at least 0.8 kcal per gram. If the energy density of food is lower, a larger volume of food is needed to fill the gap, which may need to be divided into more meals. As shown in Table 1, a breastfed infant 6-8 months old needs 2–3 meals a day, and a breastfed infant 9–23 months needs 3–4 meals a day. Depending on the child’s appetite, 1–2 nutritious snacks may be offered. Snacks are defined as foods eaten between meals, often self-fed finger foods, which are convenient and easy to prepare. If they are fried, they may have a high energy density. The transition from 2 to 3 meals, and from smaller to larger meals, happens gradually between those ages, depending on the child’s appetite and how he or she is developing. If a child eats too few meals, then he or she will not receive enough food to cover energy needs. If a child eats too many meals, he or she may breastfeed less, or may even stop breastfeeding altogether. In the first year of life, displacement of breast milk may reduce the quality and amount of the child’s total nutrient intake. A Guiding Principle 8. Feed a variety of nutrient-rich foods to ensure that all nutrient needs are met Complementary foods should provide sufficient energy, protein and micronutrients to cover a child’s energy and nutrient gaps, so that together with breast milk, they meet all his or her needs. Figure 11 shows the energy, protein, iron and vitamin A gaps that need to be filled by complementary foods for a breastfed child 12–23 months of age. The light part of each bar shows the percentage of the child’s daily needs that can be provided by an average intake of 550 ml of breast milk. The dark part of the bar shows the gap that needs to be filled by complementary foods. Figure 11 Gaps to be filled by complementary foods for a breastfed child 12–23 months Energy Protein Iron Vitamin A Nutrient Gap Provided by 550 ml breast milk 100 75 50 25 0 Percentage of daily needs (%) The largest gap is for iron, so it is especially important that complementary foods contain iron, if possible from animal-source foods such as meat, organs, poultry or fish. Pulses (peas, beans, lentils, nuts) fed with vitamin C-rich foods to aid absorption provide an alternative, but they cannot replace animal-source foods completely. Box 4 summarizes characteristics of good complementary foods. Box 4 Good complementary foods are: K Rich in energy, protein and micronutrients (particularly iron, zinc, calcium, vitamin A, vitamin C and folate); K Not spicy or salty; K Easy for the child to eat; K Liked by the child; K Locally available and affordable. The basic ingredient of complementary foods is usually the local staple. Staples are cereals, roots and starchy fruits that consist mainly of carbohydrate and provide energy. Cereals also contain some protein; but roots such as cassava and sweet potato, and starchy fruits such as banana and breadfruit, contain very little protein. A variety of other foods should be added to the staple every day to provide other nutrients. These include: K Foods from animals or fish are good sources of protein, iron and zinc. Liver also provides vitamin A and folate. Egg yolk is a good source of protein and
24 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS vitamin A,but not of iron.A child needs the solid young children can consume a variety of foods from part of these foods,not just the watery sauce the age of six months,including cow milk,eggs,pea- nuts,fish and shellfish (18) Dairy products,such as milk,cheese and yoghurt, are useful sources of calcium,protein,energy and GUIDING PRINCIPLE 9.Use fortified complementary B vitamins. foods or vitamin-mineral supplements for the infant as Pulses-peas,beans,lentils,peanuts,and soybeans needed are good sources of protein,and some iron.Eat- ing sources of vitamin C(for example,tomatoes, Unfortified complementary foods that are predomi- citrus and other fruits,and green leafy vegetables) nantly plant-based generally provide insufficient amounts of certain key nutrients (particularly iron, at the same time helps iron absorption. zinc and vitamin B6)to meet recommended nutrient Orange-coloured fruits and vegetables such as car- intakes during complementary feeding.Inclusion of rot,pumpkin,mango and papaya,and dark-green animal-source foods can meet the gap in some cases, leaves such as spinach,are rich in carotene,from but this increases cost and may not be practical for which vitamin A is made,and also vitamin C. the lowest-income groups.Furthermore,the amounts of animal-source foods that can feasibly be consumed Fats and oils are concentrated sources of energy, and of certain essential fats that children need to by infants (e.g.at 6-12 months)are generally insuf- ficient to meet the gap in iron.The difficulty in meet- grow. ing the needs for these nutrients is not unique to Vegetarian(plant-based)complementary foods do not developing countries.Average iron intakes in infants by themselves provide enough iron and zinc to meet in industrialized countries would fall well short of all the needs of an infant or young child aged 6-23 recommended intake if iron-fortified products were months.Animal-source foods that contain enough not widely available.Therefore,in settings where lit- iron and zinc are needed in addition.Alternatively, tle or no animal-source foods are available to many fortified foods or micronutrient supplements can fill families,iron-fortified complementary foods or foods some of the critical nutrient gaps. fortified at the point of consumption with a multinu- Fats,including oils,are important because they trient powder or lipid-based nutrient supplement may increase the energy density of foods,and make them be necessary. taste better.Fat also helps the absorption of vitamin A and other fat-soluble vitamins.Some fats,espe- GUIDING PRINCIPLE 10.Increase fluid intake during illness,including more frequent breastfeeding,and cially soy and rapeseed oil,also provide essential fatty acids.Fat should comprise 30-45%of the total ener- encourage the child to eat soft,favourite foods.After gy provided by breast milk and complementary foods illness,give food more often than usual and encourage together.Fat should not provide more than this pro- the child to eat more portion,or the child will not eat enough of the foods During an illness,the need for fluid often increases, that contain protein and other important nutrients, so a child should be offered and encouraged to take such as iron and zinc. more,and breastfeeding on demand should continue. Sugar is a concentrated source of energy,but it has A child's appetite for food often decreases,while the no other nutrients.It can damage children's teeth, desire to breastfeed increases,and breast milk may become the main source of both fluid and nutrients and lead to overweight and obesity.Sugar and sug- ary drinks,such as soda,should be avoided because A child should also be encouraged to eat some com- they decrease the child's appetite for more nutritious plementary food to maintain nutrient intake and foods.Tea and coffee contain compounds that can enhance recovery (20).Intake is usually better if the interfere with iron absorption and are not recom- child is offered his or her favourite foods,and if the mended for young children. foods are soft and appetizing.The amount eaten at Concerns about potential allergic effects are a com- any one time is likely to be less than usual,so the mon reason for families to restrict certain foods in caregiver may need to give more frequent,smaller the diets of infants and young children.However, meals. there are no controlled studies that show that restric- When the infant or young child is recovering,and his tive diets have an allergy-preventing effect.Therefore, or her appetite improves,the caregiver should offer
24 Infant and Young Child Feeding – Model Chapter for textbooks vitamin A, but not of iron. A child needs the solid part of these foods, not just the watery sauce. K Dairy products, such as milk, cheese and yoghurt, are useful sources of calcium, protein, energy and B vitamins. K Pulses – peas, beans, lentils, peanuts, and soybeans are good sources of protein, and some iron. Eating sources of vitamin C (for example, tomatoes, citrus and other fruits, and green leafy vegetables) at the same time helps iron absorption. K Orange-coloured fruits and vegetables such as carrot, pumpkin, mango and papaya, and dark-green leaves such as spinach, are rich in carotene, from which vitamin A is made, and also vitamin C. K Fats and oils are concentrated sources of energy, and of certain essential fats that children need to grow. Vegetarian (plant-based) complementary foods do not by themselves provide enough iron and zinc to meet all the needs of an infant or young child aged 6–23 months. Animal-source foods that contain enough iron and zinc are needed in addition. Alternatively, fortified foods or micronutrient supplements can fill some of the critical nutrient gaps. Fats, including oils, are important because they increase the energy density of foods, and make them taste better. Fat also helps the absorption of vitamin A and other fat-soluble vitamins. Some fats, especially soy and rapeseed oil, also provide essential fatty acids. Fat should comprise 30–45% of the total energy provided by breast milk and complementary foods together. Fat should not provide more than this proportion, or the child will not eat enough of the foods that contain protein and other important nutrients, such as iron and zinc. Sugar is a concentrated source of energy, but it has no other nutrients. It can damage children’s teeth, and lead to overweight and obesity. Sugar and sugary drinks, such as soda, should be avoided because they decrease the child’s appetite for more nutritious foods. Tea and coffee contain compounds that can interfere with iron absorption and are not recommended for young children. Concerns about potential allergic effects are a common reason for families to restrict certain foods in the diets of infants and young children. However, there are no controlled studies that show that restrictive diets have an allergy-preventing effect. Therefore, young children can consume a variety of foods from the age of six months, including cow milk, eggs, peanuts, fish and shellfish (18). A Guiding Principle 9. Use fortified complementary foods or vitamin-mineral supplements for the infant as needed Unfortified complementary foods that are predominantly plant-based generally provide insufficient amounts of certain key nutrients (particularly iron, zinc and vitamin B6) to meet recommended nutrient intakes during complementary feeding. Inclusion of animal-source foods can meet the gap in some cases, but this increases cost and may not be practical for the lowest-income groups. Furthermore, the amounts of animal-source foods that can feasibly be consumed by infants (e.g. at 6–12 months) are generally insufficient to meet the gap in iron. The difficulty in meeting the needs for these nutrients is not unique to developing countries. Average iron intakes in infants in industrialized countries would fall well short of recommended intake if iron-fortified products were not widely available. Therefore, in settings where little or no animal-source foods are available to many families, iron-fortified complementary foods or foods fortified at the point of consumption with a multinutrient powder or lipid-based nutrient supplement may be necessary. A Guiding Principle 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 During an illness, the need for fluid often increases, so a child should be offered and encouraged to take more, and breastfeeding on demand should continue. A child’s appetite for food often decreases, while the desire to breastfeed increases, and breast milk may become the main source of both fluid and nutrients. A child should also be encouraged to eat some complementary food to maintain nutrient intake and enhance recovery (20). Intake is usually better if the child is offered his or her favourite foods, and if the foods are soft and appetizing. The amount eaten at any one time is likely to be less than usual, so the caregiver may need to give more frequent, smaller meals. When the infant or young child is recovering, and his or her appetite improves, the caregiver should offer
3.COMPLEMENTARY FEEDING 25 an extra portion at each meal or add an extra meal or lodine snack each day. In 1994,WHO and UNICEF recommended universal salt iodization (USI)as a safe,cost-effective and sus- 3.2 Recommendations for micronutrient tainable strategy to ensure sufficient intake of iodine supplementation by all individuals.However,in areas with severe Micronutrients are essential for growth,develop- iodine deficiency,vulnerable groups-pregnant and ment and prevention of illness in young children.As lactating women and children less than 2 years discussed earlier in Guiding principle 9,micronutrient may not be adequately covered when USI is not fully supplementation can be an effective intervention in implemented,and iodine supplementation may be some situations.Recommendations are summarized necessary.The WHO/UNICEF Joint Statement on below. reaching optimal iodine nutrition in pregnant and lactating women and young children provides guid- Vitamin A ance for the categorization of countries and subse- WHO and UNICEF recommend universal supple- quent planning of an adequate response(24). mentation with vitamin A as a priority in children aged 6-59 months in countries with a high risk of Zinc deficiency (Table 2).In these countries,a high dose Zinc supplementation is recommended as adjunct of vitamin A should also be given to children with therapy in the management ofdiarrhoea.Zinc(20 mg/ measles,diarrhoea,respiratory disease,chickenpox, day)should be given to all children with diarrhoea for other severe infections or severe protein-energy mal- 10-14 days.In infants below 6 months of age,the dose nutrition,or who live in the vicinity of children with of zinc should be 10 mg/day(25). vitamin A deficiency(21). 3.3 Local adaptation of complementary feeding recommendations TABLE 2 High-dose universal distribution schedule for prevention Table3 lists types of foods,the principle nutrients they of vitamin A deficiency contain,and how they can be fed to children for good complementary feeding.To develop specific feeding Infants 6-12 months of age 100 000 IU orally,every 4-6 months recommendations that respond to the Guiding prin- Children 12 months of age 200000 IU orally,every 4-6 months ciples and that are locally acceptable and affordable,a process of adaptation is needed.It is useful to involve caregivers and families in the process of adaptation, Iron and of deciding what is culturally appropriate (26). As a rule,fortified foods should be preferred to iron The following steps are usually required: supplements for children during the complementary Review existing national or local feeding guide- feeding period.Caution should be exercised with iron lines. supplementation in settings where the prevalence of malaria and other infectious diseases is high.In Develop a list of locally available foods. malaria-endemic areas,universal iron supplemen- Find out the nutrient content of the local foods tation is not recommended.If iron supplements are from food tables(27). used,they should not be given to children who have Calculate the amount of various foods that would sufficient iron stores as the risks of severe adverse events appear to be greater in those children.Pre- provide a child with his or her daily needs of the vention and management of anaemia in such areas various nutrients-linear programming tech- niques can be used for this (28) requires a screening system to identify iron-deficient children,and the availability of and accessibility to Assess which foods and quantities of foods caregiv- appropriate anti-malarial and other anti-infective ers and families accept as suitable for children,and treatments(22,23). identify their feeding practices and preferences. Arrange trials ofimproved practices,asking moth- ers or other caregivers to choose new,improved feeding practices and try them out themselves
25 an extra portion at each meal or add an extra meal or snack each day. 3.2 Recommendations for micronutrient supplementation Micronutrients are essential for growth, development and prevention of illness in young children. As discussed earlier in Guiding principle 9, micronutrient supplementation can be an effective intervention in some situations. Recommendations are summarized below. Vitamin A WHO and UNICEF recommend universal supplementation with vitamin A as a priority in children aged 6–59 months in countries with a high risk of deficiency (Table 2). In these countries, a high dose of vitamin A should also be given to children with measles, diarrhoea, respiratory disease, chickenpox, other severe infections or severe protein-energy malnutrition, or who live in the vicinity of children with vitamin A deficiency (21). Table 2 High-dose universal distribution schedule for prevention of vitamin A deficiency Infants 6–12 months of age 100 000 IU orally, every 4–6 months Children > 12 months of age 200 000 IU orally, every 4–6 months Iron As a rule, fortified foods should be preferred to iron supplements for children during the complementary feeding period. Caution should be exercised with iron supplementation in settings where the prevalence of malaria and other infectious diseases is high. In malaria-endemic areas, universal iron supplementation is not recommended. If iron supplements are used, they should not be given to children who have sufficient iron stores as the risks of severe adverse events appear to be greater in those children. Prevention and management of anaemia in such areas requires a screening system to identify iron-deficient children, and the availability of and accessibility to appropriate anti-malarial and other anti-infective treatments (22,23). Iodine In 1994, WHO and UNICEF recommended universal salt iodization (USI) as a safe, cost-effective and sustainable strategy to ensure sufficient intake of iodine by all individuals. However, in areas with severe iodine deficiency, vulnerable groups – pregnant and lactating women and children less than 2 years – may not be adequately covered when USI is not fully implemented, and iodine supplementation may be necessary. The WHO/UNICEF Joint Statement on reaching optimal iodine nutrition in pregnant and lactating women and young children provides guidance for the categorization of countries and subsequent planning of an adequate response (24). Zinc Zinc supplementation is recommended as adjunct therapy in the management of diarrhoea. Zinc (20 mg/ day) should be given to all children with diarrhoea for 10–14 days. In infants below 6 months of age, the dose of zinc should be 10 mg/day (25). 3.3 Local adaptation of complementary feeding recommendations Table 3 lists types of foods, the principle nutrients they contain, and how they can be fed to children for good complementary feeding. To develop specific feeding recommendations that respond to the Guiding principles and that are locally acceptable and affordable, a process of adaptation is needed. It is useful to involve caregivers and families in the process of adaptation, and of deciding what is culturally appropriate (26). The following steps are usually required: K Review existing national or local feeding guidelines. K Develop a list of locally available foods. K Find out the nutrient content of the local foods from food tables (27). K Calculate the amount of various foods that would provide a child with his or her daily needs of the various nutrients – linear programming techniques can be used for this (28). K Assess which foods and quantities of foods caregivers and families accept as suitable for children, and identify their feeding practices and preferences. K Arrange trials of improved practices, asking mothers or other caregivers to choose new, improved feeding practices and try them out themselves. 3. Complementary feeding
26 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS TABLE3 Appropriate foods for complementary feeding WHAT FOODS TO GIVE AND WHY HOW TO GIVE THE FOODS BREAST MILK:continues to provide energy and high quality nutrients Infants 6-11 months up to 23 months Continue breastfeeding STAPLE FOODS:provide energy,some protein(cereals only)and Give adequate servings of: vitamins Examples:cereals(rice,wheat,maize,millet,quinoa),roots -Thick porridge made out of maize,cassava,millet;add milk,soy,ground (cassava,yam and potatoes)and starchy fruits (plantain and nuts or sugar breadfruit) -Mixtures of pureed foods made out of matoke,potatoes,cassava,posho ANIMAL-SOURCE FOODS:provide high quality protein,haem iron,zinc (maize or millet)or rice:mix with fish,beans or pounded groundnuts; and vitamins add green vegetables Examples:liver,red meat,chicken,fish,eggs(not good source of iron) Give nutritious snacks:egg,banana,bread,papaya,avocado,mango,other fruits,yogurt,milk and puddings made with milk,biscuits or crackers,bread or MILK PRODUCTS:provide protein,energy,most vitamins(especially chapati with butter,margarine,groundnut paste or honey,bean cakes,cooked vitamin A and folate),calcium potatoes Examples:milk,cheese,yogurt and curds GREEN LEAFY AND ORANGE-COLOURED VEGETABLES:provide vitamins Children 12-23 months A,C,folate Continue breastfeeding Examples:spinach,broccoli,chard,carrots,pumpkins,sweet potatoes Give adequate servings of: PULSES:provide protein (of medium quality),energy,iron(not well -Mixtures of mashed or finely cut family foods made out of matoke absorbed) potatoes,cassava,posho (maize or millet)or rice;mix with fish or beans Examples:chickpeas,lentils,cowpeas,black-eyed peas,kidney or pounded groundnuts;add green vegetables beans,lima beans -Thick porridge made out of maize,cassava,millet;add milk,soy,ground OILSAND FATS:provideenergy and essentialfattyacids nuts or sugar Examples:oils(preferably soy or rapeseed oil),margarine,butter Give nutritious snacks:egg,banana,bread,papaya,avocado,mango,other orlard fruits,yogurt,milk and puddings made with milk,biscuits or crackers,bread or SEEDS:provide energy chapwith butter,margarine,roundnut pasteorhoney,bean cakes,cooked Examples:groundnut paste or other nut pastes,soaked or potatoes germinated seeds such as pumpkin,sunflower,melon,sesame REMINDER: Foods rich in iron Liver (any type),organ meat,flesh of animals(especially red meat),flesh of birds (especially dark meat),foods fortified with iron Foods rich in Vitamin A Liver(any type),red palm oil,egg yolk,orange coloured fruits and vegetables,dark green vegetables Foods rich in zinc Liver(any type)n meat,food prepared with blodflesh ofanimals,birds and fish,shell fish,ggyolk Foods rich in calcium Milk or milk products,small fish with bones Foods rich in Vitamin C Fresh fruits,tomatoes,peppers(green,red,yellow),green leaves and vegetables Obtain feedback on what works best in their circumstances. Whether or not vitamin-mineral supplements should be included in the recommendations depends on the micronutrient content of locally-available foods,and whether children can eat enough suitable foods
26 Infant and Young Child Feeding – Model Chapter for textbooks Obtain feedback on what works best in their circumstances. Whether or not vitamin-mineral supplements should be included in the recommendations depends on the micronutrient content of locally-available foods, and whether children can eat enough suitable foods. Infants 6–11 months K Continue breastfeeding K Give adequate servings of: — Thick porridge made out of maize, cassava, millet; add milk, soy, ground nuts or sugar — Mixtures of pureed foods made out of matoke, potatoes, cassava, posho (maize or millet) or rice: mix with fish, beans or pounded groundnuts; add green vegetables K Give nutritious snacks: egg, banana, bread, papaya, avocado, mango, other fruits, yogurt, milk and puddings made with milk, biscuits or crackers, bread or chapati with butter, margarine, groundnut paste or honey, bean cakes, cooked potatoes Children 12–23 months K Continue breastfeeding K Give adequate servings of: — Mixtures of mashed or finely cut family foods made out of matoke, potatoes, cassava, posho (maize or millet) or rice; mix with fish or beans or pounded groundnuts; add green vegetables — Thick porridge made out of maize, cassava, millet; add milk, soy, ground nuts or sugar K Give nutritious snacks: egg, banana, bread, papaya, avocado, mango, other fruits, yogurt, milk and puddings made with milk, biscuits or crackers, bread or chapati with butter, margarine, groundnut paste or honey, bean cakes, cooked potatoes Table 3 Appropriate foods for complementary feeding Whatfoodsto give and why Howto give the foods Breast milk: continues to provide energy and high quality nutrients up to 23 months Staple foods: provide energy, some protein (cereals only) and vitamins K Examples: cereals (rice, wheat, maize, millet, quinoa), roots (cassava, yam and potatoes) and starchy fruits (plantain and breadfruit) Animal-source foods: provide high quality protein, haem iron, zinc and vitamins K Examples: liver, red meat, chicken, fish, eggs (not good source of iron) Milk products: provide protein, energy, most vitamins (especially vitamin A and folate), calcium K Examples: milk, cheese, yogurt and curds Green leafy and orange-coloured vegetables: provide vitamins A, C, folate K Examples: spinach, broccoli, chard, carrots, pumpkins, sweet potatoes Pulses: provide protein (of medium quality), energy, iron (not well absorbed) K Examples: chickpeas, lentils, cowpeas, black-eyed peas, kidney beans, lima beans Oils and fats: provide energy and essential fatty acids K Examples: oils (preferably soy or rapeseed oil), margarine, butter or lard Seeds: provide energy K Examples: groundnut paste or other nut pastes, soaked or germinated seeds such as pumpkin, sunflower, melon, sesame Reminder: Foods rich in iron K Liver (any type), organ meat, flesh of animals (especially red meat), flesh of birds (especially dark meat), foods fortified with iron Foods rich in Vitamin A K Liver (any type), red palm oil, egg yolk, orange coloured fruits and vegetables, dark green vegetables Foods rich in zinc K Liver (any type), organ meat, food prepared with blood, flesh of animals, birds and fish, shell fish, egg yolk Foods rich in calcium K Milk or milk products, small fish with bones Foods rich in Vitamin C K Fresh fruits, tomatoes, peppers (green, red, yellow), green leaves and vegetables