introduction

chapter 8

Complementary feeding
Timely introduction of appropriate complementary foods promotes good health,
nutritional status and growth of infants and young children during a period of
rapid growth, and should be a high priority for public health.

Throughout the period of complementary feeding, breast-milk should con-

tinue to be the main type of milk consumed by the infant.

Complementary foods should be introduced at about 6 months of age. Some

infants may need complementary foods earlier, but not before 4 months of age.

Unmodified cow’s milk should not be used as a drink before the age of 9 months,
but can be used in small quantities in the preparation of complementary foods
from 6–9 months of age. From 9–12 months, cow’s milk can be gradually
introduced into the infant’s diet as a drink.

Complementary foods with a low energy density can limit energy intake, and
the average energy density should not usually be less than 4.2 kJ (1 kcal)/g.
This energy density depends on meal frequency and can be lower if meals are
offered often. Low-fat milks should not be given before the age of about 2 years.

Complementary feeding should be a process of introducing foods with an

increasing variety of texture, flavour, aroma and appearance, while maintain-
ing breastfeeding.

Highly salted foods should not be given during the complementary feeding
period, nor should salt be added to food during this period.

WHAT IS COMPLEMENTARY FEEDING?

Complementary feeding is the provision of foods or fluids to infants in
addition to breast-milk. Complementary foods can be subdivided into:

• transitional foods, which are complementary foods specifically designed to

meet the particular nutritional or physiological needs of the infant; and

• family foods, which are complementary foods given to the young child
that are broadly the same as those consumed by the rest of the family.
170 chapter 8

During the period of transition from exclusive breastfeeding to the cessa-

tion of breastfeeding, infants gradually become accustomed to eating fam-
ily foods until they entirely replace breast-milk (see Fig. 1). Children are
physically capable of consuming family foods by 1 year of age, after which
they no longer need to be modified to meet the special needs of the infant.

The age during which transitional foods are introduced is a particularly

sensitive time in infant development. The diet undergoes its most radical
change, from a single food (breast-milk) with fat as the major energy source
to one in which an increasing variety of foods are required to meet nutri-
tional needs. This transition is associated not only with increasing and
changing nutrient requirements, but also with rapid growth, physiological
maturation and development of the infant.

Poor nutrition and less-than-optimum feeding practices during this critical

period may increase the risk of growth faltering (wasting and stunting) and
nutritional deficiencies, especially of iron, and may have longer-term ad-
verse effects on health and mental development. Thus, nutritional inter-
ventions and improved feeding practices targeted at infants are among the
most cost-effective that health professionals can promote.

PHYSIOLOGICAL DEVELOPMENT AND MATURATION

The ability to consume “solid” food requires maturation of the neuromus-
cular, digestive, renal and defence systems.

Neuromuscular coordination
Maturation of the neuromuscular system influences the timing of the
introduction of “solid” foods and the ability of infants to consume them.
Many of the feeding reflexes exhibited during the different stages of devel-
opment either facilitate or interfere with the introduction of different types
of food. At birth, for example, both the rooting reflex and the suck-and-
swallow mechanisms facilitate breastfeeding (1,2) but the gag reflex may
interfere with the introduction of solids.

Before 4 months, infants do not have the neuromuscular coordination to

form a food bolus, transfer it to the oropharynx and swallow it. Head
control and back support are immature and make it difficult for infants to
maintain a position for successful ingestion and swallowing of semisolid
foods. Infants start to bring objects to their mouth at about 5 months of
age, and development of the “munching reflex” at this time permits con-
sumption of some solid foods, regardless of whether or not teeth have
complementary feeding 171

appeared. By about 8 months, most infants can sit unsupported, their first
teeth have appeared, and they have sufficient tongue flexibility to enable
them to swallow thicker boluses of food. Soon after, infants have the
manual skills to feed themselves, drink from a cup using two hands, and eat
family foods. It is essential to encourage infants to develop eating skills,
such as chewing and bringing objects to the mouth, at the appropriate
stages. If these skills are not acquired early, behavioural and feeding prob-
lems may occur later on.

Some of these reflexes and age-related oral skills are listed in Table 42,
together with possible implications for the types of foods that can be safely
consumed. The foods mentioned in Table 42 are examples and are not the
only ones that can be introduced into the diet at the different stages de-
scribed. Moreover, there is no rigid relationship between food types and
neurodevelopment; the infant is merely physically more capable of han-
dling that particular food at that stage of development.

Digestion and absorption

The secretion of gastric, intestinal and pancreatic digestive enzymes is not
developed to adult levels in young infants. Nevertheless, the infant is able to
digest and absorb the nutrients in human milk fully and efficiently, and
breast-milk contains enzymes that contribute to the hydrolysis of fat, car-
bohydrate and protein in the gut. Similarly, during early infancy the secre-
tion of bile salts is only marginally adequate to permit micelle formation,
and the efficiency of fat absorption is lower than in childhood and adult-
hood. Bile-salt-stimulated lipase, present in breast-milk but absent from
commercial formulas, may in part compensate for this deficiency. By about
4 months, gastric acid assists gastric pepsin to digest protein fully.

Although pancreatic amylase begins to make an effective contribution to

the digestion of starches only at the end of the first year, most cooked
starches are digested and absorbed almost completely (4). Even during the
first months of life, the colon plays a vital role in the final digestion of those
nutrients that are not fully absorbed in the small intestine. The intracolonic
microflora changes with age and in relation to whether the infant is breastfed
or formula-fed. The microflora ferments undigested carbohydrates and
fermentable fibre to short-chain fatty acids, which are absorbed in the colon
to ensure maximum uptake of energy from carbohydrates. This process,
known as “colonic salvage”, may contribute up to 10% of absorbed energy.

By the time adapted family foods are introduced into the infant’s diet at
about 6 months, the digestive system is sufficiently mature to efficiently
172 chapter 8

Table 42. Neurological development of infants and young children and

implications for types of food that can be consumed at different ages

Age Reflexes/skills Types of food Examples of foods

(months) present that can be
consumeda

0–6 Suckling/sucking Liquids Breast-milk

and swallowing

4–7 Appearance of early Puréed foods Vegetable (e.g. carrot)

“munching” or fruit (e.g. banana)
Increased strength purées; mashed
of suck potato; gluten-free
Movement of gag cereals (e.g. rice); well
reflex from mid to cooked puréed liver
posterior third of and meat
tongue

7–12 Clearing spoon with Mashed or chopped Well cooked minced liver
lips foods and finger and meat; mashed
Biting and chewing foods cooked vegetables
Lateral movements and fruit; chopped raw
of tongue and fruit and vegetables
movement of food (e.g. banana, melon,
to teeth tomato); cereals
(e.g. wheat, oats) and
bread

12–24 Rotary chewing Family foods

movements
Jaw stability
a
This indicates the types of food that can be consumed and swallowed successfully; it does not
necessarily indicate when these foods should be offered.

Sources: Stevenson & Allaire (2); Milla (3).

digest starch, protein and fat in the non-milk diet. Nevertheless, infants
have a small gastric capacity (about 30 ml/kg body weight). Thus if foods
are too bulky and of low energy density, infants are sometimes unable to
consume enough to satisfy their energy and nutrient requirements. Com-
plementary foods therefore need to have a high energy and micronutrient
density, and should be offered as small, frequent meals.
complementary feeding 173

Renal function
Renal solute load refers to the sum of solutes that must be excreted by the
kidneys. It mainly comprises nonmetabolizable dietary components, pri-
marily the electrolytes sodium, chloride, potassium and phosphorus, which
have been ingested in excess of body needs, and metabolic end-products, of
which the nitrogenous compounds resulting from the digestion and me-
tabolism of protein are the most important.

Potential renal solute load refers to solutes of dietary and endogenous origin that
would have to be excreted in urine if none were diverted into the synthesis of
new tissue or lost through non-renal routes. It is defined as the sum of the four
electrolytes (sodium, chloride, potassium and phosphorus) plus the solutes
derived from the metabolism of protein, which usually contributes more than
50% of the potential renal solute load. Table 43 shows the considerable varia-
tion in the potential renal solute load of various milks and formulas.

The newborn baby has limited renal capacity to deal with a high solute load
and at the same time conserve fluids. The osmolarity of human milk is
appropriate for infants and anxiety about excess renal solute load is prima-
rily a concern for non-breastfed infants, especially those fed unmodified
cow’s milk. These concerns are particularly pertinent during illness. By
around 4 months, renal function has matured considerably and infants can
conserve water better and deal with higher solute concentrations. Thus,
recommendations on complementary feeding do not ordinarily need to be
modified to take account of the stage of renal development.

Defence system
The development and maintenance of an effective mucosal barrier in the
intestine is an essential defence mechanism. In the neonate the mucosal barrier is
immature, making it vulnerable to injury by enteropathic microorganisms and

Table 43. Potential renal solute load of various milks and formulas

Milk or formula Potential renal solute load

(mosmol/litre)

Mature human milk 93

Commercial infant formula 135
Evaporated milk formula 260
Whole cow’s milk 308
Source: Fomon (5).
174 chapter 8

sensitive to some antigenic food proteins. Human milk contains a wide

range of factors, absent from commercial infant formulas, that stimulate
the development of active defence mechanisms and help to prepare the
gastrointestinal tract for the ingestion of transitional foods. The
nonimmunological defence mechanisms that help protect the intestinal
surface against microorganisms, toxins and antigens include gastric acidity,
mucus, intestinal secretions and peristalsis.

The relatively poor defences of the young infant’s digestive tract, together
with reduced gastric acidity, contribute to the risk of injury to the mucosa
by foreign food and microbiological proteins, which can cause direct toxic
or immunologically mediated damage. Some foods contain proteins that
are potentially antigenic, such as soya protein, gluten (present in some
cereals), cow’s milk, egg and fish proteins, which have been associated with
an enteropathy. It is therefore prudent to avoid introducing these foods before
6 months of age, particularly where there is a family history of food allergy.

WHY ARE COMPLEMENTARY FOODS NEEDED?

As the baby grows and becomes more active, breast-milk alone is insuffi-
cient to meet the full nutritional and psychological needs of the infant.
Adapted family foods (transitional foods) are needed to fill the gap in
energy and iron and other essential nutrients, between what is provided by
exclusive breastfeeding and the total nutritional requirements of the infant
(see Fig. 1). This gap increases with age, demanding an increasing contribu-
tion of energy and nutrients, especially iron, from foods other than breast-
milk. Complementary foods also play an important part in the develop-
ment of neuromuscular coordination.

Infants do not have the physiological maturity to progress from exclusive

breastfeeding directly to family foods. Specially adapted family foods (tran-
sitional foods) are therefore necessary to bridge this gap, and are required
until about 1 year of age when the infant is sufficiently mature to consume
normal family foods. The introduction of transitional foods also exposes
the infant to a variety of textures and consistencies, thus encouraging the
development of vital motor abilities such as chewing.

WHEN SHOULD COMPLEMENTARY FOODS BE

INTRODUCED?
The optimal age at which to introduce transitional foods can be determined
by comparing the advantages and disadvantages of doing so at various ages.
complementary feeding 175

The adequacy of breast-milk to provide sufficient energy and nutrients to

maintain growth and prevent deficiencies should be assessed, together with
the risk of morbidity, especially of infectious and allergic disease from
contaminated foods and “foreign” food proteins. Other important consid-
erations include physiological development and maturity, and the various
developmental cues that indicate an infant’s eating readiness; and maternal
factors, such as nutritional status, the effect of reduced suckling on maternal
fertility and caring ability and practices (see Chapter 9).

Starting complementary feeding too soon has its dangers because:

• breast-milk can be displaced by complementary foods, leading to re-

duced production of breast-milk and thereby the risk of insufficient
energy and nutrient intake by the infant;

• infants are exposed to microbial pathogens present in foods and fluids,

which are potentially contaminated and thereby increase the risk of
diarrhoeal disease and consequently malnutrition;

• the risks of diarrhoeal disease and food allergies are increased because of
intestinal immaturity, and these increase the risk of malnutrition; and

• mothers become fertile more quickly, because decreased suckling re-

duces the period during which ovulation is suppressed.

There will also be problems if complementary foods are introduced too late
because:

• inadequate provision of energy and nutrients from breast-milk alone

may lead to growth faltering and malnutrition;

• micronutrient deficiencies, especially of iron and zinc, may develop

owing to the inability of breast-milk to meet requirements; and

• the optimal development of motor skills such as chewing, and the

infant’s acceptance of new tastes and textures, may not be ensured.

It is therefore necessary to introduce complementary foods at the appropri-

ate developmental stages.

There remains much debate on when precisely to start complementary

feeding. While there is agreement that the optimal age differs between
176 chapter 8

individual infants, whether the recommendation should be “between 4 and

6 months” or “about 6 months” is an open question. To clarify, “6 months”
is defined as the end of the first 6 months of life, when the infant is 26 weeks
old, as opposed to the start of the sixth month of life, that is at 21–22 weeks
of age. Likewise, “4 months” refers to the end and not the start of the fourth
month of life. There is almost universal agreement that complementary
feeding should not be started before the age of 4 months and should not be
delayed beyond the age of 6 months. Resolutions from the World Health
Assembly in 1990 and 1992 advise “4–6 months”, while a 1994 resolution
recommends “about 6 months”. In several more recent publications from
WHO and UNICEF, both expressions have been used. In a WHO review
by Lutter (6) it was concluded that the scientific basis for recommend-
ing 4–6 months is not adequately documented. In a recent WHO/UNICEF
report on complementary feeding in developing countries (7) the authors
recommend that full-term infants should be exclusively breastfed to about
6 months of age.

The 4–6-month range is used in many recommendations from industrial-

ized countries. In contrast, the recent official recommendations from the
Netherlands (8) state that for breastfed infants with adequate growth, it is
not necessary to offer any complementary food before the age of about
6 months, from a nutritional point of view. If parents decide to start earlier,
however, this is acceptable provided the infant is at least 4 months old.
Furthermore, a statement from the American Academy of Pediatrics (9)
recommends “about six months”, and various Member States in the WHO
European Region also adopted this when adapting and implementing the
Integrated Management of Childhood Illness (IMCI) training packages for
health professionals (see Annex 3).

When deciding if the recommendation should be 4–6 or about 6 months,

the way in which parents or health professionals interpret this should be
assessed. Health professionals may misinterpret the recommendation and
so encourage the introduction of complementary foods by 4 months, just
to be “on the safe side”. As a result, parents may believe that their children
should be eating complementary foods by the time they reach 4 months
and therefore introduce “tastes” of food before 4 months (7). National
authorities should therefore assess how their recommendations are inter-
preted by both parents and health professionals.

In countries in economic transition, there is evidence of an increased risk of

infectious disease when complementary foods are introduced before
6 months, and complementary feeding before this time does not appear to
complementary feeding 177

enhance the rate at which infants gain weight or length (10,11). Indeed,
exclusive breastfeeding for around the first 6 months confers a health ad-
vantage. In poor environmental conditions, even if energy intake increases
slightly with the introduction of complementary feeding, the energy cost
of reacting to the increased morbidity associated with the introduction of
foods and fluids other than breast-milk (especially likely to occur in unhy-
gienic environments) results in no net gain in terms of energy balance. For
nutrients, the potential gain from the introduction of complementary
foods is likely to be offset by the losses due to increased morbidity and the
reduced bioavailability of nutrients from breast-milk when additional foods
are given simultaneously with breast-milk. In settings where nutrient defi-
ciency in infants under 6 months of age is a concern, improved maternal
food intake may be a more effective and less risky way of preventing defi-
ciencies in both mother and infant. Optimum maternal nutrition during
pregnancy and lactation not only ensures good quality milk for the baby
but also maximizes a mother’s capacity to care for her infant.

For the WHO European Region, it is recommended that all infants should
be exclusively breastfed from birth to about 6 months of age, and at least for
the first 4 months of life. Some infants may need complementary foods
before 6 months of age, but these should not be introduced before 4 months.
Signs that complementary foods should be introduced before 6 months are
that the baby, in the absence of obvious disease, is not gaining weight
adequately (based on two or three sequential assessments) (see Chapter 10),
or appears hungry after unrestricted breastfeeding. Attention should be
paid to the use of appropriate growth reference charts, bearing in mind that
breastfed infants have growth rates that differ from those on which the US
National Center for Health Statistics references are based (12). Neverthe-
less, consideration should also be given to other factors, including birth
weight and the gestational age, clinical condition and overall growth and
nutritional status of the infant when starting complementary feeding be-
fore 6 months. A study in Honduras (13) found that the provision of free,
high-quality complementary foods from the age of 4 months to breastfed
infants with a birth weight between 1500 g and 2500 g did not confer a
growth advantage. These findings support the recommendation for exclu-
sive breastfeeding for about 6 months, even in low-birth-weight infants.

COMPOSITION OF COMPLEMENTARY FOODS

In Chapter 3, estimates of the average amounts of energy required from
complementary foods at different ages were defined. The effect was consid-
ered of different levels of breast-milk intake and varying energy density of
178 chapter 8

complementary foods on the meal frequency required to satisfy energy

requirements, taking into account the restrictions on volume dictated by
gastric capacity. In the following section, these issues are revisited and ex-
plored in more detail. The physical properties of starch are discussed in
relation to the thickness of the staple complementary food. Based on this,
possible modifications to the preparation of the staple are proposed, which
should help to produce a food that is neither too thick for the infant to
consume nor so thin that energy and nutrient density are reduced. Further-
more, ways in which the nutrient density of the staple food can be im-
proved through the addition of other complementary foods are considered,
as are other factors affecting the amount of food consumed (such as flavour
and aroma) and the amount of each nutrient actually absorbed (bioavailability
and nutrient density).

Energy density and viscosity

The main factors influencing the extent to which an infant can meet his or
her energy and nutrient requirements are the consistency and energy density
(energy per unit volume) of the complementary food and the frequency of
feeding. Starch often provides the principal source of energy, but when
heated with water starch granules gelatinize to produce a bulky, thick (vis-
cous) porridge. These physical properties make the porridge difficult for
infants to both ingest and digest. Furthermore, the low energy and nutrient
density means that large volumes of food have to be consumed to meet the
infant’s requirements. This is not usually possible, owing to the infant’s
limited gastric capacity and to the limited number of meals offered per day.
Dilution of thick porridges to make them easier to swallow will further
reduce their energy density. Complementary foods traditionally tend to be
of low energy density and protein content, and although their liquid con-
sistency makes them easy to consume, the volumes needed to meet infant
energy and nutrient requirements often exceed the maximum volume the
infant can ingest. The addition of some oil can make staples softer and easier
to eat even when cold. The addition of a lot of sugar or lard, however, while
improving energy density, will increase the viscosity (thickness) and there-
fore make the food too difficult for the infant to consume in large amounts.

Thus, complementary foods should be rich in energy, protein and

micronutrients, and have a consistency that allows easy consumption. In
some parts of the developing world this problem has been addressed through
the addition of amylase-rich flour to thick porridges, which reduces their
viscosity without reducing their energy and nutrient contents (14). Amylase-
rich flour is produced by the germination of cereal grain, which activates
amylase enzymes that then break down starch into sugars (maltose,
complementary feeding 179

maltodextrins and glucose). As starch is broken down, it loses its ability to

absorb water and swell, and therefore porridge made with germinated flour
rich in amylase has a high energy density while retaining a semi-liquid
consistency, but increased osmolarity. These flours are time-consuming
and tedious to prepare, but can be made in large quantities and added in
small amounts to liquify porridges as required (15). They can also be
produced commercially at low cost.

Starch-containing foods can also be improved by mixing with other foods,

although it is essential to be aware of the effects of such additions, not only
on the viscosity of the food but also on its protein and micronutrient
density. For example, while the addition of animal fats, oil or margarine
increases the energy content, it has a negative effect on protein and micro-
nutrient density. Therefore, starch-containing foods should be enriched
with foods that enhance their energy, protein and micronutrient contents.
This can be achieved by adding milk (breast-milk, commercial infant for-
mula or small amounts of cow’s milk or fermented milk products), which
improves protein quality and increases the density of essential nutrients.

Nutrient density and bioavailability

The quantity of nutrients available for infant growth and development
depends on both the amount in breast-milk and transitional foods and their
bioavailability. Bioavailability is defined as the absorbability of nutrients
and their availability for utilization for metabolic purposes, while nutrient
density is the amount of a nutrient per unit of energy, such as 100 kJ, or per
unit of weight, such as 100 g.

There are major differences between the nutrient density and bioavailability
of micronutrients in animal products and plant-derived foods. Per unit of
energy, animal products usually contain more of certain nutrients such as
vitamins A, D and E, riboflavin, vitamin B12, calcium and zinc. The iron
content of some animal products (such as liver, meat, fish, and poultry) is
high, whereas that of others (milk and dairy products) is low. In contrast,
the densities of thiamin, vitamin B6, folic acid and vitamin C are generally
higher in plants and some, such as legumes and maize, also contain substan-
tial amounts of iron. In general, however, the bioavailability of minerals
from plant products is poor compared with that from animal products.

Micronutrients that have poor bioavailability when consumed in plant

products include iron, zinc, calcium and β-carotene in leafy and some other
vegetables. In addition, the absorption of β-carotene, vitamin A and other
fat-soluble vitamins is impaired when diets are low in fat.
180 chapter 8

Diets with high nutrient bioavailability are diverse and contain generous
amounts of legumes and foods rich in vitamin C, combined with small
amounts of meat, fish and poultry. Diets with low nutrient bioavailability
consist mainly of cereals, legumes and roots with negligible quantities of
meat, fish or vitamin C-rich foods.

Variety, flavour and aroma

To ensure that the energy and nutrient needs of growing children are ful-
filled, they should be offered a wide variety of foods of high nutritional
value. Moreover, it is possible that offering children a more varied diet
improves their appetite. Although patterns of food consumption vary from
meal to meal, children adjust their energy intake at successive meals so that
overall daily energy intake is normally relatively constant. Nevertheless,
there is also some variation in energy intake from day to day. Despite having
preferences, when offered a range of foods children tend to select a variety,
including the preferred ones, to make a nutritionally complete diet.

A number of organoleptic features, such as flavour, aroma, appearance and

texture, may affect the infant’s intake of transitional foods. Taste buds
detect four primary taste qualities: sweet, bitter, salt and sour. Sensitivity to
taste helps protect against the ingestion of harmful substances and, in addi-
tion, can help regulate a child’s intake. While children do not need to learn
to like sweet or salty foods there is substantial evidence that children’s
preferences for the majority of other foods are strongly influenced by learn-
ing and experience (16). The only innate preference in humans is for the
sweet taste, and even newborn infants avidly consume sweet substances.
This can be a problem, because children develop a preference in relation
to the frequency of exposure to particular tastes. Rejection of all foods
except sweet ones will limit the variety of a child’s intake of food and
nutrients.

Children appear to consume more when they receive a varied diet compared
with a monotonous one. It is important that children, for whom all foods
are initially unfamiliar, have repeated exposure to new foods during the
complementary feeding period in order to establish a healthy food accept-
ance pattern. It has been suggested that a minimum of 8–10 exposures are
needed, with clear increases in food acceptance appearing after 12–15 expo-
sures (17). Parents should thus be reassured that refusal is normal. Foods
should be offered repeatedly, as those that are initially rejected are often
accepted later. If the child’s initial rejection is interpreted as unchangeable,
the food will probably not be offered to the child again and the opportunity
for exposure to new foods and tastes will be lost.
complementary feeding 181

The process of complementary feeding depends on the infant learning to

enjoy new foods. Breastfed infants may accept solid foods more rapidly
than those fed on commercial infant formula, as they have become used to
a range of flavours and odours transmitted via the mother’s milk (18).

PRACTICAL RECOMMENDATIONS FOR THE INTRODUCTION

OF COMPLEMENTARY FOODS
The main stages in the progression of an infant’s diet from breast-milk to
family foods are outlined below. They make up a continuum, and transi-
tion from one to the next is relatively fast and smooth. It is essential to
recognize the variations between infants in their developmental readiness
for complementary feeding, and therefore individual patterns in the rate of
introduction of different complementary foods. The following guidelines
should help to ensure that infants receive an adequate nutrient supply, that
bioavailability and nutrient density are maximized, and that appropriate
behavioural skills are stimulated and developed. Chapter 9 includes a dis-
cussion of the social and domestic issues and practices that underlie success-
ful complementary feeding.

Developmental stage 1
The aim at this initial stage is to accustom the infant to eat from a spoon.
Initially only a small amount (about one or two teaspoons) of food is
needed, and should be offered on the tip of a clean teaspoon or finger. It can
take a little time for the baby to learn how to use the lips to clear food off a
spoon, and how to move food to the back of the mouth ready for swallow-
ing. Some food may run down the chin, or be spat out. This is to be
expected at first and does not mean that the child does not like the food.
Fluids
Breastfeeding on demand should continue at the same frequency and inten-
sity as in the period of exclusive breastfeeding, and breast-milk should
remain the primary source of fluid, nutrients and energy. No other drinks
are necessary at this time.
Transitional foods
The first foods offered should be single-ingredient, puréed foods with a
smooth consistency, with no added sugar, salt or strong seasonings such as
curry powder or chilli pepper. Good examples include non-wheat cereals
such as puréed home-cooked rice, mashed potato, soft thick porridge made
from traditional cereal foods such as oats, and puréed vegetables or fruit.
Breast-milk (or infant formula) can be added to purées to help soften them.
182 chapter 8
Meal frequency
Small amounts of complementary foods once or twice a day will help the
baby to learn the skill of eating food and enjoying new tastes. Foods should
be offered after breastfeeding in order to avoid replacing breast-milk.

Developmental stage 2
Once the infant has accepted spoon feeding, new tastes and textures can be
added to increase the variety of the diet and to help the development of
motor skills (Table 42). Developmental cues that infants are ready for
thicker purées include their ability to sit without support and to transfer
objects from one hand to the other.
Fluids
Breastfeeding on demand should continue, and breast-milk should remain the
primary source of fluid, nutrients and energy. The infant may not maintain the
same frequency and intensity of breastfeeding as during exclusive breastfeeding.
Transitional foods
Well cooked puréed meat (especially liver), pulses, vegetables, fruit and
different cereals can be introduced. To encourage infants to accept new
foods, it is a good idea to introduce a new flavour, such as meat, with a
familiar favourite such as puréed fruit or vegetables. Similarly, when intro-
ducing lumpier foods, a familiar favourite of the infant’s should be mixed
with the new, coarser-textured food (such as carrots with small, noticeable
lumps). Savoury foods should be encouraged rather than sweet ones, and
desserts should be low in sugar.
Meal frequency
A few weeks into the complementary feeding period, infants should be having
between two and three small meals a day, selected from a wide variety of foods.

Developmental stage 3
As infants continue to develop, foods with a thicker consistency and a
lumpier texture can be introduced to help them learn to chew and manage
small pieces of food. With the development of fine motor skills and the
appearance of teeth, infants are able to pick up small pieces of food, transfer
them to the mouth and chew them; it is important to encourage these skills
by offering finger foods.
Fluids
Breastfeeding on demand should continue to ensure a constant energy
intake from breast-milk. As the infant grows, however, the energy and
complementary feeding 183

nutrients from transitional foods become increasingly important to ensure

that the infant’s growing nutrient requirements are met. Cow’s milk and
other milk products can be used in small amounts in the preparation of
foods, and after 9 months unmodified cow’s milk can be given as a drink to
infants who are no longer breastfed. Fluids other than breast-milk should
be given in a cup.
Transitional foods
Vegetables need to be cooked until soft, and meats should be minced and
then coarsely puréed. Meals should be varied and contain fruit and vegeta-
bles, legumes and small amounts of fish, kefir, meat, liver, egg or cheese. To
prevent the risk of salmonella poisoning, it is essential to cook eggs well;
dishes containing raw eggs should not be used (see Chapter 12). Finger
foods such as toasted bread, carrot and pear should be offered at each meal.
Moderate amounts of butter or margarine should be used on bread, while
foods with added sugar such as biscuits and cakes should be discouraged.
Meal frequency
Two or three main meals should be offered each day, and can be interspersed
with snacks such as yoghurt, small amounts of kefir, mashed raw or stewed
apple, and bread spread with butter or margarine or jam. Infants who are
not breastfed or formula-fed will need at least five meals a day by this stage.

Developmental stage 4
During the latter months of the complementary feeding period, feeding of
the infant should be combined with self-feeding. While infants and young
children practise their feeding skills, however, they cannot self-feed enough
to achieve adequate intake and caregivers still have an active role in feeding
(Chapter 9).
Fluids
Breast-milk continues to be an important part of the diet and should
preferably be the main fluid into the second year and beyond. The intake of
fresh cow’s milk and cow’s milk products can be gradually increased from
the age of 9 months.
Transitional foods
As the infant progresses to a more mature diet, foods should be chopped or
mashed, and meat should be minced. Finger foods, such as small cubes of
fruit, vegetables, potato, toast, cheese and soft meat, should be included at
each meal to encourage the infant to feed himself or herself. Feeds made up
of high-fat foods alone should be avoided.
184 chapter 8
Meal frequency
Infants should receive three main meals interspersed with about two snacks
per day.

By the age of about 1 year, children can share the normal family diet and do
not require specially prepared foods. Adding salt is still not recommended,
and its restriction will benefit the whole family. Children eat slowly, so
special considerations have to be made to allow for the extra time and
attention needed (Chapter 9). Infants and young children need encourage-
ment when learning to eat, and the adults who feed them need patience.
Helping and encouraging toddlers to eat, rather than leaving them to serve
themselves from the family dish, can greatly increase the amount of food
they consume. Infants and young children should always be supervised
during feeding (Chapter 9).

WHAT ARE THE BEST FOODS TO PREPARE FOR INFANTS?

The choice of foods used for complementary feeding differs considerably
between populations, owing to tradition and availability. The following
section discusses the use of different foods for complementary feeding. A
useful way of calculating the contribution of different foods to fill the
energy and nutrient gap left when breast-milk no longer meets the infant’s
growing needs is given in a new WHO report (19).

Foods of plant origin

Food contains combinations of other substances in addition to nutrients,
most of which are abundant in plants. No single food can supply every
nutrient (with the exception of breast-milk for young infants). For exam-
ple, potatoes provide vitamin C but do not provide iron, while bread and
dried beans provide iron but not vitamin C. To prevent disease and pro-
mote growth, a healthy diet must therefore contain a variety of foods.

Plant foods contain biologically active components or metabolites that

have been used for centuries in traditional cures and herbal medicines. The
isolation, identification and quantification of these plant metabolites is
related to their potential protective role, and interest in identifying them
has arisen because of the epidemiological evidence showing that some pro-
tect against cancer and cardiovascular disease in adults. It is plausible that
such components also have beneficial effects on young children, although
scientific evidence is lacking. Many plant metabolites are not nutrients in
the traditional sense and are sometimes called “non-nutrients”. They include
substances such as dietary fibre and related substances, phytosterols, lignans,
complementary feeding 185

flavonoids, glucosinolates, phenols, terpenes and allium compounds. These

are found in a variety of different plants, some of which are listed in Table 44.

To ensure an intake of all these protective substances, it is important to eat as

wide a variety of different plant foods as possible. Taking vitamin supple-
ments or extracted plant substances as a replacement for, or in addition to,
eating good wholesome food is unnecessary and is generally not recom-
mended on health grounds.
Cereals
Cereals form the staple foods of virtually all populations. Those that con-
tribute significantly to the diet in the WHO European Region are wheat,
buckwheat, barley, rye, oats and rice. In general, cereals contain 65–75% of
their total weight as carbohydrate, 6–12% as protein and 1–5% as fat. The
majority of the carbohydrate is present as starch, but cereals are also a major
source of fibre and contain some simple sugars. Most raw cereals contain
slowly digestible starch, which becomes rapidly digested when cooked.
Partially milled grains and seeds contain starch resistant to digestion.

Cereals are also a source of micronutrients. These are concentrated in the

outer bran layers of the cereal grain, which also contain phytates that can
have a negative effect on the absorption of several micronutrients. Thus the
high-extraction flours such as wholemeal flour, which contain more of the
outer layers of the grain, are richer in micronutrients but also contain a
higher proportion of phytates. Conversely the finer, whiter flours, which
have a smaller proportion of the original grain, have a lower phytate content
but are also lower in micronutrients.

Table 44. Examples of “non-nutrients” and their plant food sources

“Non-nutrient” Plant food source

Fibre and related substances Oats, wheat, rye, soyabean, most vegetables and
fruit
Phytosterols Maize, rape seed, sunflower seed, soya bean
Lignans Rye bran, berries, nuts
Flavonoids Onion, lettuce, tomato, peppers, citrus fruits, soya
products
Glucosinolates Broccoli, cabbage, brussels sprouts
Phenols Grapes, raspberries, strawberries
Terpenes Citrus fruits, cherries, herbs
Allium compounds Garlic, onion, leek
186 chapter 8
Potatoes
The potato is a stem tuber and a major constituent of the diet in many
European countries. Potatoes are rich in starch and because they can be
stored under simple conditions for quite long periods, together with cereals
they offer a staple supply of food energy throughout the year. Potatoes
contain relatively little protein, although the biological value of potato
protein is quite high. Potatoes contain significant amounts of vitamin C
and are also a good source of thiamin. The content of vitamin C in potatoes
varies with length of storage: approximately two thirds of the ascorbic acid
remains after 3 months and about one third remains after 6–7 months.
Freshly cooked potato is rapidly and easily digestible. If it is cooled after
cooking, however, its starch may become retrograded, forming so-called
“resistant starch” that is indigestible in the small intestine though fermentable
in the colon.
Vegetables and fruit
Vegetables and fruit provide vitamins, minerals, starch and fibre, together
with other non-nutrient substances such as antioxidants and phytosterols
(see above). They play a major protective role, helping to prevent micronu-
trient deficiency, and generally have a low fat content.

Vegetables and fruit make the most significant contribution to vitamin C

intake. Eating vegetables and fruit that contain vitamin C (for example
cabbage, broccoli, and the citrus fruits and their juices), along with iron rich
foods such as beans, lentils and whole-grain cereals, will improve the ab-
sorption of non-haem iron from plant foods (see Chapter 6). Other
micronutrients present in vegetables and fruits are the B vitamins, including
vitamin B6. Dark-green leaves and orange-coloured fruits and vegetables are
rich in carotenoids, which are converted to vitamin A, and dark-green leaves are
also rich in folate, with potassium and magnesium present in significant levels.

Vegetables and fruits contain different vitamins, minerals, non-nutrients

(such as antioxidants) and fibre, and it is therefore advisable to choose a
variety to meet daily nutrient recommendations. Some of the health ben-
efits associated with vegetables and fruits may come from non-nutrient
components. This is one reason why vitamins and minerals are best ob-
tained from vegetables and fruit rather than from tablets or supplements,
ensuring that other (perhaps as yet undiscovered) essential food constitu-
ents are also eaten.

The availability of fresh vegetables and fruit varies by season and region,
although frozen, dried and preserved vegetables and fruits can ensure a
complementary feeding 187

supply of these foods throughout the year. Wherever possible, locally grown
produce should be selected. If they are preserved, or if processed products
are used, they should contain the minimum possible amounts of added
fats, oils, sugars and salt.

Many green leafy vegetables are cooked before consumption. Cooking in

water can lead to leaching and thermal losses of vitamin C, especially when
the vegetables are left to stand before consumption. Using only a minimum
amount of water, or boiling for a very short time, reduces vitamin losses.
Legumes
Legumes, and particularly seed legumes (soya beans, peas, beans and len-
tils), are of major nutritional value, particularly when animal products are
scarce. They have a low water content when mature, store well, and in many
diets are an important source of nutrients when eaten alongside cereals. The
seed legumes have a high protein content and the protein is of good biologi-
cal value. The seeds are rich in complex carbohydrates, both starch and
dietary fibre, and they also provide significant quantities of vitamins and
minerals.

Some legumes, however, contain a range of toxic constituents including

lectins, which act as haemagglutinins and trypsin inhibitors. When mature,
a number of seeds (such as kidney bean) contain toxic concentrations of
these constituents, and it is therefore vital that they are prepared correctly,
with thorough soaking and cooking, to avoid any toxic effect.

Foods of animal origin

Animal products are rich sources of protein, vitamin A and easily absorb-
able iron and folate. Meat and fish are the best sources of zinc, while dairy
products are rich in calcium. Meat, fish and seafood all promote the absorp-
tion of non-haem iron, and meat (especially liver and other offal) also
provide well absorbed haem iron (Chapter 6). Epidemiological studies
have shown that meat consumption is associated with a lower prevalence of
iron deficiency. Animal products, however, are often expensive and eating
excess protein is uneconomic and inefficient as the extra protein will be
broken down into energy and stored as fat if the energy is not immediately
required. If it is energy that is needed, it is more efficient to obtain it from
energy-dense foods rich in micronutrients rather than from protein.
Meat
Nutrients are present in different concentrations in the fat and lean tissues
of meat, being more concentrated in the lean tissue. The ratio of fat to lean
188 chapter 8

tissue therefore determines the energy value and the concentration of nearly
all nutrients. In western Europe, current nutritional advice to the general
population is to reduce saturated fat intake, and leaner carcasses are now in
demand. In contrast, in central and eastern parts of the Region, the fat
content of most meats and meat products is still very high. Liver, however,
is naturally low in fat and has the additional benefit of being easily cooked
and puréed without becoming stringy, and is thus easier for infants and
young children to eat. Indeed, liver deserves a special mention as one of the
best transitional foods, since it is an excellent source of protein and of most
essential micronutrients.

Lean meat contains substantial amounts of protein of high biological value,

and is an important source of highly bioavailable minerals such as iron and
zinc. Young children may have difficulty eating meat because of its stringy
nature, and meat (preferably lean) used in complementary foods should be
minced, chopped or puréed.

Even though some meats are expensive, some (such as liver) are not, and
only small amounts can have nutritional benefits in infants and young
children. Small amounts of meat added to an otherwise vegetarian diet have
a positive effect on length gain (20,21), either through the better biological
value of the protein or because of the minerals provided.
Fish and seafood
Fish is an important source of good quality protein, weight-for-weight
providing the same quantities as lean meat. Moreover all fish, both fresh-
water and saltwater fish and shellfish, are rich sources of essential amino
acids. This protein is accompanied by very low amounts of fat in white fish
and shellfish, while the fat in other fish (such as salmon, tuna, sardines,
herring and mackerel) has a high proportion of n-3 long-chain polyunsatu-
rated fatty acids, which are important for neurodevelopment. Fish repre-
sents a good source of iron and zinc, which are found in slightly lower
concentrations than in meat with the exception of shellfish, which tend to
accumulate trace elements. Oysters, for example, are one of the richest
sources of zinc. Saltwater fish are also a key source of iodine, which is
accumulated from their marine environment. Care is needed because of the
potential risks of eating fish caught in water that is contaminated (see
Chapter 12).
Eggs
The eggs of a range of domesticated birds, including chickens, ducks and
geese, are important in the diet throughout the European Region. Eggs
complementary feeding 189

provide a versatile food of high biological value. Egg proteins contain

amino acids essential to growth and development, and the lipids in eggs are
rich in phospholipids with a high ratio of polyunsaturated to saturated fatty
acids. Eggs can be produced efficiently and relatively cheaply, and are a
valuable means of improving the intake of animal protein. Egg protein has
been associated with allergic reactions and should therefore not be in-
troduced before the age of 6 months. Eggs are a potential cause of
salmonella poisoning (see Chapter 12) and so should be thoroughly
cooked.

Eggs are often thought of as a good source of iron, and as a result are
introduced early into the complementary diet. Although their iron content
is relatively high, however, the iron is bound to phosphoprotein and albu-
min and is therefore not very bioavailable.
Milk and other dairy products
The nutritional composition of fresh cow’s milk makes it a source of many
nutrients for the growing child, but it should not be introduced before the
age of 9 months (Chapter 6) because:

• it may displace breast-milk intake;

• it has a low iron content;
• it may cause gastrointestinal bleeding, especially before the age of
6 months; and
• it has a high protein and sodium content, 3–4 times greater than that of
human milk.

To ensure that animal milks are microbiologically safe, it is important

that they are either pasteurized or boiled before consumption (Chap-
ter 12). Cow’s milk from which the fat has been partly (semi-skimmed
milk, usually 1.5–2% fat) or fully (skimmed milk, usually < 0.5% fat)
removed has a significantly lower energy and fat-soluble vitamin con-
tent than whole cow’s milk. Similarly, powdered milks made from
dried, skimmed milk have a low energy content. Furthermore, like
commercial infant formula, powdered milks may become contami-
nated if they are made up with unclean water. It is therefore essential to
prepare them under hygienic conditions, strictly following instructions
to ensure that the reconstituted milk is neither too concentrated nor too
dilute.

Lactose intolerance (due to loss of expression of intestinal lactase in children

in some nonpastoral populations) is rare in the European Region, and does
190 chapter 8

not represent a contraindication to the use of cow’s milk or the milk of

other mammals during complementary feeding.

Age of introduction of cow’s milk

Some mothers may be unable to provide sufficient breast-milk during late
infancy to satisfy their infant’s requirement. This can be for a variety of
reasons, including the need or choice to return to work. Some countries
recommend that cow’s milk is excluded from the infant’s diet until the age
of 12 months. Before 12 months, they recommend that infants are given
breast-milk only, or commercial infant formula, primarily for the reasons
listed above. Other countries recommend that cow’s milk can gradually be
introduced from the age of 9 or 10 months. There are no negative effects of
giving breast-milk or commercial infant formula up to the age of 12 months,
provided sufficient amounts are given and the iron content of complemen-
tary foods is adequate. In many countries in the Region, however, commer-
cial infant formula is much more expensive than cow’s milk, and therefore
giving commercial infant formula to 12 months of age may be economi-
cally prohibitive. Based on these arguments, it is prudent to make the
following recommendations for the optimal time of introduction of cow’s
milk.

Unmodified cow’s milk should not be used as a drink, and milk products
should not be given in large quantities, before the age of 9 months. They
can, however, be used in small quantities in the preparation of complemen-
tary foods from the age of 6 months. Between 9 and 12 months of age,
cow’s milk and other milk products given as a drink can be gradually
introduced into the infant’s diet, preferably in addition to breast-milk, if
breast-milk intake is not sufficient or if the family wants to change from
infant formula.

Amount of cow’s milk

It is recommended that breastfeeding should continue throughout the first
year of life and into the second year if possible. If the volume of breast-milk
is still high (more than about 500 ml per day) there is no reason to introduce
other milks. Nevertheless, many women in the Region stop breastfeeding
before their baby is 1 year of age, and if they continue to breastfeed during
the 9–12-month period the average milk intake is low. If the total milk
intake is very low or nil, there is a risk of deficiency of several nutrients, and
potentially a problem with protein quality if there are no other sources of
animal protein. During late infancy (from about 9 months) an excessive
intake of cow’s milk could limit diversification of the diet, which is impor-
tant in exposing the infant to new tastes and textures that promote the
complementary feeding 191

development of eating skills. Furthermore, because the content and

bioavailability of iron in cow’s milk is low, a large intake predisposes an
infant to iron deficiency. For example, if a 12-month-old infant consumes
one litre of cow’s milk or the equivalent in milk products, as much as two
thirds of his or her energy requirement are covered, leaving very little room
for a varied healthy diet.

Low-fat milks
In many countries, milk with a reduced fat content is recommended for
adults as part of a healthy diet. It is not recommended before the age of
1 year, however, and in some countries not before 2–3 years of age. In the
United Kingdom, for example, semi-skimmed milk is not normally rec-
ommended before the age of 2 years, and fully skimmed milk is not recom-
mended until the child is over 5 years old (17). The recommendation to
delay the introduction of fat-reduced milks is not only because of their low
energy density but also because protein constitutes a considerably higher
proportion of their energy. In skimmed milk, for example, protein
constitutes 35% of energy compared to 20% in full fat milk and only
5% in breast-milk. If a large proportion of the energy intake comes
from fat-reduced milks, this will increase the protein intake to levels
that may be harmful. On the other hand, fat-reduced milk is not harm-
ful if given in small to moderate amounts, and if additional fat is added
to the diet.

Thus it is prudent not to introduce fat-reduced milks before the age of

about 2 years. When introducing other milks, such as goat’s, sheep’s, cam-
el’s and mare’s milk, into the infant’s diet, the same basic guidelines should
be followed. Allowances should be made for the varying solute loads and
vitamin and mineral contents of different milks, and in all cases it is vital to
ensure that they are microbiologically safe.

Fermented milk products

Liquid milk has a short shelf life. Fermentation extends its shelf life and
thereby allows milk and its products to be stored and transported. Most
fermented milks are the product of fermentation with lactobacilli, which
leads to the generation of lactic and short-chain fatty acids from lactose, and
consequently a fall in pH that inhibits the growth of many pathogenic
microorganisms. Fermented milks are nutritionally similar to unfermented
milk, except that some of the lactose is broken down to glucose, galactose
and the products described above. These fermented milks represent an
excellent source of nutrients such as calcium, protein, phosphorus and
riboflavin.
192 chapter 8

A number of health benefits have traditionally been attributed to fermented

milk products, and they have been used to prevent a wide range of diseases
including atherosclerosis, allergies, gastrointestinal disorders and cancer (22).
Although empirical findings are yet to be supported by controlled studies,
initial results from investigations into the antibacterial, immunological,
antitumoral and hypocholesterolaemic effects of fermented milk consump-
tion suggest potential benefits. In young children there is increasing evi-
dence that certain strains of lactobacilli have a beneficial effect against the
occurrence and duration of acute diarrhoea (23). The potential health ef-
fects, also called probiotic effects, are caused by either the large amount of
live bacteria present in the product, or by short-chain fatty acids or other
substances produced during fermentation.

Fermented milk products are thought to enhance the absorption of non-

haem iron, as a result of their lower pH. The two most common fermented
milks available in the Region that contain probiotics are yoghurt and kefir.

Yoghurt is produced when milk (usually cow’s milk) is fermented with

Lactobacillus bulgaricus and Streptococcus thermophilus under defined con-
ditions of time and temperature.

Kefir is a fermented milk with a characteristic fizzy, acidic taste, which

originated in the Caucasus mountains and currently accounts for 70% of
the total amount of fermented milk consumed in the countries of the
former Soviet Union (24). It is produced when kefir grains (small clusters
of microorganisms held together in a polysaccharide matrix) or mother
cultures prepared from the grains are added to milk and cause its fermenta-
tion.

Cheese is also a fermented milk product, in which the unstable liquid is

converted into a concentrated food that can be stored. Hard cheeses are
approximately one third protein, one third fat and one third water, and are
also rich sources of calcium, sodium and vitamin A and, to a lesser extent,
the B vitamins. Soft cheeses such as cottage cheese contain more water than
hard cheese and are therefore less nutrient- and energy-dense. Cubed or
diced cheese can be introduced in small amounts into the complementary
feeding diet at around 6–9 months of age, but the intake of cheese spreads
should be limited before 9 months.

Fruit juices
In this publication, fruit juice refers to the juice produced by compressing
fruits. The term fruit juice or fruit drink is sometimes used to describe a
complementary feeding 193

drink made from jam or compote mixed with water. These usually
contain only water and sugar, with negligible vitamin C, and therefore
have none of the benefits of “real” fruit juice or the fruits from which
juice can be made.

Nutritionally, fruit juices produced from compressed fruit contain all

the nutrients present in fruits with the exception of the dietary fibre.
The major sources are citrus fruits such as orange, lemon and grapefruit.
Apple and grape juice are also common, and in Europe fruit nectars such
as those made from apricot, pear and peach are also popular. Fruit juices
are a good source of vitamin C, and if given as part of a meal will
improve the bioavailability of non-haem iron present in plant foods. It
is nevertheless important to limit the volume given to avoid interfering
with the intake of breast-milk and with the diversification of the diet.
Furthermore, fruit juices contain glucose, fructose, sucrose or other
sugars, which because of their acidity can cause dental caries and erosion
of the teeth.

In some populations there is a belief that fruit juice should not be given to
infants because it is too acid, and tea is given instead. While it is true that
some fruit juices have a very low pH, there is no logical reason to avoid
giving them to infants or to recommend tea in preference. The pH of the
stomach is close to 1 (very acidic) and acidic fruit juices have no adverse
effects. However, there are concerns raised by the extreme consumption of
so-called fruit juices containing artificial sweeteners and simple carbohy-
drates other than glucose, sucrose or fructose. Those containing sugar
alcohols, such as mannitol and sorbitol, have been blamed for diarrhoea in
some children (25,26).

Honey
Honey may contain the spores of Clostridium botulinum, the causal agent
of botulism. Since the gastrointestinal tract of infants contains insufficient
acid to kill these spores, honey should not be given to infants lest they
contract the disease.

Tea
Tea is a popular drink throughout the European Region but is not recom-
mended for infants and young children. Tea contains tannins and other
compounds that bind iron and other minerals, thereby reducing their
bioavailability. Furthermore, sugar is often added, which increases the risk
of dental caries. Also, sugar consumed in tea may blunt the appetite and
inhibit the consumption of more nutrient-dense foods.
194 chapter 8

Herbal teas
In many western European countries, there is a growing trend towards
the use of “natural” substances and alternative medicines, and this has
led to an increase in the use of herbal preparations for infants. Owing to
their small size and rapid growth rate, however, infants are potentially
more vulnerable than adults to the pharmacological effects of some of
the chemical substances present in herbal teas. Herbal teas such as camo-
mile tea may also have the same adverse effects on non-haem iron
absorption as other teas including green tea (27). There is moreover a
lack of scientific data on the safety of various herbs and herbal teas for
infants.

Vegetarian and vegan diets

Vegetarian diets exclude, to various degrees, animal products. The main area
of concern regarding vegetarian diets is the small but significant risk of
nutritional deficiencies. These include deficiencies of iron, zinc, riboflavin,
vitamin B12, vitamin D and calcium (especially in vegans) and inadequate
energy intake. These deficiencies are highest in those with increased require-
ments, such as infants, children and pregnant and lactating women.
Although the inclusion of animal products does not ensure the ad-
equacy of a diet, it is easier to select a balanced diet with animal products
than without them. Meat and fish are important sources of protein,
readily absorbed haem iron, zinc, thiamin, riboflavin, niacin and vita-
mins A and B12. In a vegetarian diet, these nutrients must come from
other sources.

Eggs, cheese and milk all provide high-quality protein and are also a good
source of the B group vitamins and calcium. Problems may occur as a result
of complementary diets containing no animal products (and thereby no
milk), particularly during late infancy and early childhood when the breast-
milk supply may be low. Such diets rely solely on plant proteins, and the
only plant protein approaching the quality of animal protein comes from
soya. If it is not prepared correctly, however, feeding soya during infancy has
potential negative effects because of its high content of phyto-estrogens and
antinutrients such as phytate. It may also evoke antigenic reactions, and can
cause an enteropathy similar to that of coeliac disease and cow’s milk pro-
tein intolerance. The protein of the vegan diet must be made up of a good
mix of plant proteins, such as legumes accompanied by wheat, or rice with
lentils. For adults, protein from two or more plant groups daily is likely to
be adequate. For children, however, and especially those aged 6–24 months,
each meal should contain wherever possible two complementary sources of
plant protein.
complementary feeding 195

Vegan diets (those with no source of animal protein and especially no milk)
may have serious adverse effects on infant development and should be
discouraged. Examples are very restrictive macrobiotic diets (a restrictive
vegetarian regimen coupled with adherence to natural and organic foods,
especially cereals), which carry a high risk of nutrient deficiencies and have
been associated with protein–energy malnutrition, rickets, growth retardation
and delayed psychomotor development in infants and children (28,29). Such
diets are not recommended during the complementary feeding period (30).

SOME PRACTICAL RECOMMENDATIONS FOR FOOD

PREPARATION
Family foods
Home-prepared foods usually provide a sound foundation for comple-
mentary feeding and their use is encouraged. A good start to complemen-
tary feeding is to use a mixture of family foods, with the staple food (such as
bread, potato, rice or buckwheat) as a base. A wide variety of household
foods can be used. Most need to be softened by cooking and then puréed,
mashed or chopped. A small amount of breast-milk or cooled boiled water
may need to be added when puréeing food, but not so that the food is too
dilute and no longer nutrient-dense. Transitional foods should be relatively
bland and not strongly seasoned with either salt or sugar. Only minimal
amounts of sugar should be added to sour fruits to improve their palatabil-
ity. Adding unnecessary extra sugar to infant foods and drinks may encour-
age a preference for sweet foods later in life, with adverse effects on dental
and general health (see Chapter 11).

Ideally, infants should share family meals. The foods they receive should be
prepared, as far as possible, without added sugar or salt. Very salty foods
such as pickled vegetables and salted meats should be avoided. A portion of
family food should be removed for the infant, and flavourings such as salt
or spices can then be added for the rest of the family.

As discussed above, some complementary foods have a low energy and

nutrient density or can be bulky and viscous, making them difficult for an
infant to consume. Conversely, gruels and soups that are easy for the infant
to eat cannot be consumed in the volumes necessary to meet the infant’s
nutritional requirements. To improve the nutritional quality and energy
density of porridges and other bulky foods, therefore, caregivers should:

• cook with less water and make a thicker porridge;

• replace most (or all) water with breast-milk or formula milk;
196 chapter 8

• enrich thick porridge by adding, for example, milk powder, oil or fat
(not more than one teaspoon per 100 g serving, to avoid excess) but
restrict the use of sugars, which are not so energy-dense as oils and fats;
• add fruit or vegetables rich in micronutrients; and
• add a little protein-rich food such as kefir, eggs, legumes, liver, meat or
fish.

Caregivers should choose suitable foods and cook them in a way that
maximizes their nutritional value. Feeding guidelines should be available to
all caregivers to help them know what and how to feed their children.
Education about infant feeding, as with breastfeeding, should begin at
school and should be included in antenatal classes and after the birth of
the baby, and be provided by primary health care staff including health
visitors.

Commercial baby foods

Commercial baby foods can be convenient but are often expensive and may
offer no nutritional advantages over properly prepared family foods, except
where there is a special need for micronutrient fortification. Even if caregivers
decide to feed commercially prepared infant foods, home-prepared foods
should also be given to accustom the infant to a greater range of flavours and
textures.

Policy-makers should refer to the recommendations of the Codex

Alimentarius Commission (31), a report jointly sponsored by WHO and
FAO that specifies compositional standards for commercial baby foods.
Many countries in economic transition represent a new market for baby
food companies, and some lack the means of regulating the marketing,
quality and composition of commercially produced infant feeds. Although
commercial baby foods are popular with parents because they are quick,
easy and convenient to prepare, these advantages need to be balanced against
the relative cost, which may be prohibitive for low-income families.

REFERENCES
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emerging chewing. Child development, 55: 831–843 (1984).
2. STEVENSON, R.D. & ALLAIRE, J.H. The development of normal feeding
and swallowing. Pediatric clinics of North America, 38: 1439–1453
(1991).
3. MILLA, P.J. Feeding, tasting, and sucking. In: Pediatric gastrointestinal
disease. Vol. 1. Philadelphia, B.C. Decker, 1991, pp. 217–223.
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