Complementary and

Toddler Feeding
John Paul L. Oliveros, MD, DPPS, DPSPGHAN
Pediatric Gastroenterology
The First 1000 days of life

• The period between conception until the child’s 2nd

birthday

2016 Nutrition Month Talking Points: First 1000 days ni baby pahalagan para sa malusog na kinabukasan.
National Nutrition Council
The First two Years of Life

• the most sensitive period in child’s development with

regards physical and brain development
• “critical window” for the promotion of good growth, health,
and behavioral development
(UNICEF)
Complementary feeding
“the process of starting foods when breast milk alone is no
longer sufficient to meet the nutritional needs of a growing
infant”

“other foods and liquids are needed along with breastmilk”

Navarro, et. al., Fundamentals of Pediatrics: Competency-Based

The Concept of Complementary Feeding

W. H . O. TRADITIONAL
COMPLEMENTARY
FOOD
SOLID FOODS
Solid foods
Infant formula V.S.
MILK
BREASTMILK Breastmilk
Infant formula
Why?
Importance of Complementary
Feeding
• Fill the nutrient gap of breastmilk at 6mos
• Train infant on appropriate feeding skills necessary for healthy eating
habits later in life
Navarro, et. al., Fundamentals of Pediatrics: Competency-Based

• Enable transition from milk feeding to other table foods

• for nutritional and developmental reasons

Nelsons Textbook of Pediatrics 20th Edition

Nutrient Gap

WHO: Infant and Young Child Feeding. 2009

Nutrients and Infant brain
development
• “Early Brain Development is highly dependent on timed presence of
specific nutrients in sufficient quantities”
• “In the 6-24 month period, brain undergoes intense myelination and
synaptogenesis”
Gould, J., Complementary feeding, micronutrients and developmental outcomes in children.
NNI workshop. 2017
Nutrients and Infant brain
development

Goyal, et al., PNAS. 2015

Philippine Data

WHO.Indicators for assessing infant and young child feeding

practices: Part III : Country Profiles. 2008
Philippine Data (FNRI 2015)
Philippine Data (FNRI 2015)
Philippine Data (FNRI 2015)
WHO Guidelines on Complementary
Feeding
 GUIDELINES FOR COMPLEMENTARY
FEEDING

1. DURATION OF EXCLUSIVE BREASTFEEDING AND AGE OF INTRODUCTION OF COMPLEMENTARY FOODS

When
2. MAINTENANCE OF BREASTFEEDING

3. RESPONSIVE FEEDING
How/
4. SAFE PREPARATION AND STORAGE OF COMPLEMENTARY FOODS

5. AMOUNT OF COMPLEMENTARY FOOD NEEDED

Where
6. FOOD CONSISTENCY

7. MEAL FREQUENCY AND ENERGY DENSITY

What
8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS

9. USE OF VITAMIN-MINERAL SUPPLEMENTS OR FORTIFIED PRODUCTS FOR INFANT AND MOTHER

10. FEEDING DURING AND AFTER ILLNESS

When?
When
1. DURATION OF EXCLUSIVE BREASTFEEDING AND AGE OF
INTRODUCTION OF COMPLEMENTARY FOODS
• Practice exclusive breastfeeding from birth to 6 months of age
• Introduce complementary foods at 6 months of age (180 days)
while continuing breastfeeding

2. MAINTENANCE OF BREASTFEEDING
• Continue frequent, on-demand breastfeeding until 2 years of age
or beyond
Timing of complementary feeding
• Vary between countries and influenced by social and cultural factors
• Factors:
• Developmental readiness
• GI and renal functions: 4mos
• Neurodevelopmental skills: 4-6mos
• Nutritional requirements
• No apparent growth with EBF for 6months (Kramer)
• Iron deficiency anemia not significantly increased at 6mos EBF
• Health effects
• AGE lower in EBF for 6mos
• Increased risk of allergy if solids introduced before 3-4mos
• Increased risk of obesity if solids introduced before 3-4mos
Nutrition in Pediatrics. 5th edition. 2016
 Signs that the baby is ready for
complementary feeding

• Holds head straight when sitting down

• Opens mouth when others eat
• Is interested in foods when others eat
• Receives frequent breastfeeds but appears
hungry soon after
• Is not gaining weight adequately
 How
3. RESPONSIVE FEEDING
• feed infants directly and assist older children when they feed themselves
• feed slowly and patiently
• experiment with different food combinations, tastes, textures and methods of
encouragement
• minimize distractions during meals
• talk to children during feeding
• Repeated exposure to a certain food to facilitate acceptance
 How

4. SAFE PREPARATION AND STORAGE OF COMPLEMENTARY FOODS

• wash caregivers’ and children’s hands before food preparation and eating
• store foods safely and serve foods immediately after preparation
• use clean utensils to prepare and serve food
• use clean cups and bowls when feeding children
• avoid the use of feeding bottles which are difficult to keep clean
How

Five keys to safer food

Keep clean
Separate raw and cooked
Cook thoroughly
Keep food at safe temperatures
Use safe water and raw materials
What

5. AMOUNT OF COMPLEMENTARY FOOD NEEDED

• Start at 6 months of age with small amounts of food
• increase the quantity as the child gets older
• maintaining frequent breastfeeding
What
What
• 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 AMOUNT

DAY IN ADDITION TO
BREAST MILK
6-8 months 200 kcal/day Start with 2-3
tbsp. per feed,
increasing
gradually to ½ of
a 250 ml cup
9-11 300 kcal/day ½ of a 250 ml cup
What
6. FOOD CONSISTENCY
Gradually increase food consistency and variety as the infant gets
older
• 6 months: pureed, mashed and semi-solid foods
• 8 months: "finger foods"
• 12 months: “Table foods”
• Avoid foods that may cause choking
 What
• 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 AMOUNT TEXTURE
DAY IN ADDITION TO
BREAST MILK
6-8 months 200 kcal/day Start with 2-3 tbsp. per Start with thick
feed, increasing porridge, well mashed
gradually to ½ of a 250 foods
ml cup
Continue with mashed
family foods
9-11 300 kcal/day ½ of a 250 ml cup Finely chopped or
months mashed foods, and
foods that baby can
pick up
 What

7. MEAL FREQUENCY AND ENERGY DENSITY

Increase the number of times the child is fed complementary foods as he/she gets older

The number of meals that an infant or young child needs in a day depends on:
• how much energy the child needs to cover the energy gap
• the amount that a child can eat at one meal
• Stomach capacity: 30 ml/kg body weight
• the energy density of the food offered
• More than breastmilk: > 0.8 kcal/g
 What
AGE ENERGY NEEDED PER AMOUNT TEXTURE FREQUENCY
DAY IN ADDITION TO
BREAST MILK
6-8 months 200 kcal/day Start with 2-3 Start with thick 2-3 meals per day
tbsp. per feed, porridge, well
increasing mashed foods Depending on
gradually to ½ of child’s appetite, 1-
a 250 ml cup Continue with 2 snacks may be
mashed family offered
foods
9-11 300 kcal/day ½ of a 250 ml Finely chopped or 3-4 meals per day
months cup mashed foods, and
foods that baby can Depending on
pick up child’s appetite, 1-
2 snacks may be
offered
12-23 ¾ to full 250 ml cup 550 kcal/day Family foods, 3-4 meals per day
months chopped or mashed
if needed Depending on
What

8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS

• Feed a variety of foods to ensure that nutrient needs are met
• Meat, poultry, fish or eggs should be eaten daily
• Complementary foods should provide sufficient energy, protein and
micronutrients to cover a child’s energy and nutrient gap
What
 What
8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS
• Good complementary foods are :
Rich in energy, protein and micronutrients (particularly iron, zinc,
calcium, vit. A, vit. C and folate)
Not spicy or salty
Easy for the child to eat
Liked by the child
Locally available and affordable
 What
8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS
•A variety of other foods should be added every day to provide other nutrients.
•Animals or fish : sources of protein, iron and zinc
•Dairy products: sources of calcium, protein, energy and B vitamins
•Pulses: good sources of protein, and some iron
•Orange-coloured fruits and vegetables: rich in carotene and also vitamin C
•Fats and oils: concentrated sources of energy and essential fats
•Vegetarian diets: cannot meet nutrient needs at this age
•Avoid giving drinks with low nutrient value (e.g. tea, coffee and sugary drinks)
•Limit the amount of juice offered to avoid displacing more nutrient-rich foods
 Guidelines on complementary
feeding
9. USE OF VITAMIN-MINERAL SUPPLEMENTS OR FORTIFIED PRODUCTS FOR INFANT
AND MOTHER
• Use fortified complementary foods or vitamin-mineral supplements for the infant, as
needed
• Unfortified predominantly plant-based complementary foods: insufficient
amounts of key nutrients
• Inclusion of animal-source foods can meet the gap in some cases
• The amounts of animal-source foods that can feasibly be consumed by infants are
generally insufficient to meet the iron gap
• use of fortified products or supplements may be needed in places with little
animal food source
• breastfeeding mothers may also need vitamin mineral supplements or fortified
products
Guidelines in Complementary
feeding
10. FEEDING DURING AND AFTER ILLNESS
• Increase fluid intake during illness
• more frequent breastfeeding
• Encourage child to eat soft, varied, appetizing, favorite foods
• After illness, give food more often than usual and encourage the child
to eat more
 Complementary Feeding
Requirements

Frequency (F) Frequent feeding, from six months of age and while breastfeeding continues

Amount (A) Adequate amounts of food, sufficient to meet growing needs of the child, and
increasing with age
Texture (T) Appropriate consistency, energy dense, micronutrient rich
Variety (V) A variety of different foods
Active (A) Responsively fed
Hygiene (H) Hygienically prepared, fed with clean feeding implements-not using a bottle
Issues on Complementary Feeding
• CF and allergy
• CF and type 1 diabetes mellitus, obesity and cardiovascular
diseases
• Baby-Led Weaning
Complementary Feeding and
Allergies
• Increasing rates of allergic diseases
• despite advice to restrict or delay introduction of
potentially allergenic solid foods (e.g. Cow milk, fish, egg,
gluten, peanut)
? Immune tolerance
? certain factors (e.g. breastfeeding)
Complementary Feeding and
Allergies
• “Critical window” : between 4-6 months
• Some evidence of increased allergy risk when solids introduced
EARLY, before 3-4 months but evidence for delaying beyond 6 months
is weak
• Some evidence that DELAYED introduction of allergenic foods may
increase allergy risk

Prescott SL, et al. Pediatr Allergy and Immunol 2008; 19:375

Complementary Feeding and
Allergies
• introduction of solid food after 17 weeks (4 ½ months) of age is
associated with a lower risk of food allergy
• late introduction of foods (after 6 months of age) in an infant’s diet is
not useful to prevent allergies
Grimshaw KE, et al Pediatrics 2013;132
Complementary Feeding and
Allergies

Role of breast milk in the development of tolerance

• Introduction of CF while continuing breastfeeding might
reduce onset of allergies

Koplin JJ, Allen KJ. Clin Exp Allergy 2013; 43

Nwari BI, et al. Pediatrics 2010; 125
Grimshaw KE, et al. Pedaitrics 2013; 132
Complementary Feeding and
Allergies
• Current allergy prevention consensus: start CF at 4mos
• No reason to delay introduction of “more allergenic food” after
starting CF

Palmer, D. Update on timing and source of

allergenic food. NNI. 2017
 CF and Risk for type 1 DM, Obesity
and Cardiovascular Diseases

• No clear correlation between the timing of introduction of CF and risk of

obesity, type 2 diabetes and cardiovascular disease in later ages

Moorcroft KE, etal. Matern Child Nutr 2011;7

Fall CH, et al. Int J Epidemiol 2011;40

• Excessive protein intake (milk, meat, cheese) >15% total calories during
CF correlates with risk of overweight/obesity in later age, in parallel with
a decrease in fat intake
Agostoni C, et al. Int J Obes 2005; 29 (Suppl 2)
Rolland- Cachera MF, et al. Int J Obes 2006;30
CF and Risk for type 1 DM, Obesity
and Cardiovascular Diseases
• An excessive consumption of sweetened beverages before
1 year of age and a consequent increase in caloric intake
associated with obesity in childhood
Malik VS, et al Am J Clin Nutr 2009; 89

• No fruit juices for < 6mos old

Whole, pureed or homogenized fruits for 6-12 mos
AAP 2014
CF and Risk for type 1 DM, Obesity
and Cardiovascular Diseases
• It is inappropriate, during the first year of age, to add salt to food, due
to a possible increase in risk of hypertension in later age
Strazzullo P, et al. Nutr Metab Cardiovasc Dis 2012;22

• The introduction of LCPUFA from fish can have a beneficial effect on

arterial pressure in adulthood Damsgaard
CT, et al J Nutr 2006;136
Forsyth JS, et al. BMJ 2003;326
Alternative Complementary Feeding
Methods

• Baby-Led Weaning
• Method for introducing CF to infants whereby infants feed themselves with hand-
held foods instead of being spoon-fed with purees by parents
• Auto-weaning
• offering chopped and minced family meals to the infants
In both methods:
• infants should be milk-fed, ideally exclusively breastfed on demand
• should be offered complementary foods from 6 months of age
Alternative Complementary Feeding
Methods

• Advantages:
• improves relationships during shared family meals
• promotes infant’s autonomy
• saves time and money
• encourages healthier dietary intakes for parent
 Alternative Complementary Feeding
Methods

Concerns:
• Risk of inadequate iron intake
• generally offered steamed vegetables which are not good sources of absorbable iron
Carter RC, et al. Pediatrics 2010;126

• Risk of high salt intake

• Risk of insufficient energy intake
• A study comparing different feeding styles : increased incidence of underweight in a group of 92 baby-led infants and
an increased incidence of obesity in a group of 63 spoon-fed infants
Townsend E, Pitchford NJ. BMJ Open 2012;2

• Risk of choking
• oral motor function not yet well developed to safely ingest whole foods In 199 BLW infants, 30% had at least one
episode of choking with solid food ingestion (apple)
Townsend E, Pitchford NJ. BMJ Open 2012;2
What is the best method?
• No “De Cahon”
• Know the advantages and disadvantages of each method
• Factors to consider:
• Infection risk
• Allergy risk
• Neurodevelopmental capacity
• Availability of food and resources
 Optimizing complementary feeding
Not before 4 months but by 6 months
When Continue breastfeeding up to 2 years or more
Adequate sources of energy, macro- and micronutrients
What Appropriate proportion of nutrients
Appropriate frequency of feeding and texture of food
Repeated exposures to facilitate acceptance
How Responsive feeding
Make and Keep food safe to eat
Toddler Feeding
 AGE ENERGY AMOUNT TEXTURE FREQUENCY
NEEDED PER
DAY IN
ADDITION TO
BREAST MILK
6-8 months 200 kcal/day Start with 2-3 Start with thick 2-3 meals per
tbsp. per feed, porridge, well day
increasing mashed foods
gradually to ½ of Depending on
a 250 ml cup Continue with child’s appetite,
mashed family 1-2 snacks may
foods be offered
9-11 months 300 kcal/day ½ of a 250 ml Finely chopped 3-4 meals per
cup or mashed foods, day
and foods that
baby can pick up Depending on
child’s appetite,
1-2 snacks may
be offered
12-23 months ¾ to full 250 ml 550 kcal/day Family foods, 3-4 meals per
cup chopped or day
mashed if
You are what you eat,
what would you like to
be?
Julie Murphy: Nutrition Across a Lifetime