Weaning/Complementary foods for babies

What is it?

Exclusive breastfeeding (Feeding only breast milk) is adequate for baby till 6 months of life. After 6 months, breastfeeding alone is no longer enough for optimal growth and development of the child. Hence, along with breast milk, it is necessary to start complementary feeding (CF)/ Weaning i.e., the process of introduction of suitable semi-solid food at the right age. An infant of this age is also developmentally ready for other foods.

Problem statement:

Undernutrition is associated with 45% of child deaths. Less than a fourth of infants aged 6–23 months have age-appropriate dietary diversity. Globally, 144 million children under 5 yrs of age are too short for their age (stunted).

What happens when not given?

If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth may falter. 6 months is the ideal time or “sensitive period”. If CFs is delayed, then child may enter “critical period” after which the infant may always be a poor chewer and may be poor in eating solids later. 

How it should be given?

Caregivers should take active care in the feeding of infants by being responsive to the child’s clues for hunger and also encouraging the child to eat. 

• Timely – CFs are introduced when the need for energy and nutrients exceeds what can be provided through exclusive breastfeeding.
• Adequate – CFs provide sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs.
• Safe – CFs are hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats.
• Properly fed – CFs are given consistent with a child’s signals of appetite and satiety, and that meal frequency and feeding are suitable for age.

When to start?

Weaning must begin soon after completing 6 months of age as the biting movement of jaw appears around 5 months. Around 6–7 months, swallowing of solid foods occurs and the side-to-side movement of tongue develops by 8–12 months. The other reasons for complementary feeding at 6 months of age are: 

1. Child develops neck/head control and hand-to-mouth coordination. 
2. Child starts enjoying mouthing and biting. 
3. The intestines are mature and ready to digest pulses and cereals. 
4. Baby likes chewing and gumming semisolids as there is hardening of gums and eruption of teeth. 
5. Tendency to push solids out of mouth decreases.

Which foods should be used?

Prefer the regular family food that is locally available and culturally acceptable rather than cooking special foods. The recent concept is of “Baby-led Weaning”, i.e., feed as per baby’s choice shall be practiced. Food should be easily digestible and nourishing . Taste and palatability of food should be good for the infant. It should be

Appropriate to give:

• Combination of cereals and pulses (Khichdi, Dalrice, etc.), locally available staple foods such as idli, dosa, dhokla, ragi, chapati, roti, paratha with oil/ ghee, and some amount of sugar. 
• Mashed banana, other pulpy fruits (e.g., mango, papaya), sweet potato, and potato
• Sprouts, pulses, legumes, groundnuts, almonds, cashewnuts, raisins (Note: Any nut should be well grinded and mixed with food as solid pieces may cause choking in young children)

Avoidable:

• *Biscuits, breads, pastry, chocolates, cheese, softy, ice cream, doughnuts, cakes, etc. 
• # Tinned foods, packaged or stored foods, artificially cooked foods with preservatives or chemicals 
• *Commercial breakfast cereals {*These foods should not form the main bulk of complementary foods and may be offered only occasionally.}
• # Fruit juices and fruit drinks Milk-based cereals preparations 
• # Repeatedly fried foods containing trans-fatty acids (which predispose to obesity, diabetes, atherosclerosis, cardiac, and neurological problems in future) { #These foods should be avoided altogether in children below 2 years of age. }

What precautions are needed:

1. Follow proper hand washing with soap before preparing and eating the food. 
2. The foods shall be stored safely and served fresh after preparation. 
3. Use clean utensils for preparing and serving the food. 
4. Spoon, cups, and bowls used for feeding the children shall be clean. 
5. Avoid using feeding bottle as it is difficult to clean and maintain the hygiene. “Bottle feeding is injurious to health of the child.” Diarrhea, dehydration, and malnutrition are usually the results of unsafe bottle-feeding.

Quantity, frequency, and texture of complementary foods:

Principles to be followed for complementary feeding:

• Start complementary feeds after completion of 180 days. 
• Continue breastfeeding up to 2 years of age along with appropriate complementary feeding. 
• Give semi-solid food (Avoid watery food such as soups, fruit juices, and animal milk) 
• Prefer home-made food (clean, fresh, cheap, and easily available) 
• Prefer balanced food (Cereal + pulse + vegetables) using locally available ingredients preparations. 
• Introduce one food at one time; once child starts accepting it, introduce another preparation. 
• Addition of ghee, oil, oil-seed powder, fats adds to energy, and palatability of food (except in children who are overweight or obese) 
• Child’s choice and preferences shall be respected. Avoid force feeding. 
• Give as much as child consumes. Monitor weight of the child.

Things to be avoided for complementary feeding:

• Avoid delay in starting complementary feeding. 
• Avoid outside, artificial, packaged, and commercial and Junk foods. 
• Avoid foods with excess of sugar, salt, and trans-fatty acids. 
• Avoid ultra-processed and refined foods. 
• Bottle-feeding has only disadvantages; avoid it. 
• Avoid feeding while watching television or mobile. 
• Do not force to feed. Feeding should not be an unpleasant experience. 
• Avoid overfeeding. 
• Avoid foods that may cause choking. 

Feeding your baby: 6–8 months old:

From 6–8 months old, feed your baby half a cup of soft food two to three times a day. Your baby can eat anything except honey, which she shouldn't eat until she is a year old. You can start to add a healthy snack, like mashed fruit, between meals. As your baby gets increasing amounts of solid foods, she should continue to get the same amount of breastmilk. 

Begin to feed at 6 months :

Type of food: Soft porridge, well mashed food 

How often: 2 to 3 times each day 

How much: 2 to 3 tablespoons at each meal 

From 6 up to 9 months:

Type of food: Mashed food 

How often: 2 to 3 times each day and 1 to 2 snacks 

How much: 2 to 3 tablespoons up to one-half (1/2) cup at each meal

From 9–11 months old:

Now baby can take half a cup of food three to four times a day, plus a healthy snack. Now you can start to chop up soft food into small pieces instead of mashing it. Your baby may even start to eat food herself with her fingers. Continue to breastfeed whenever your baby is hungry.

If your baby refuses a new food or spits it out, don’t force it. Try again a few days later. You can also try mixing it with another food that your baby likes or squeezing a little breastmilk on top.

How often: 3 to 4 times each day and 1 to 2 snacks 

How much: At least one half (1/2) cup at each meal

From 12 up to 24 months:

Type of food: Family foods, chopped or mashed if necessary 

How often: 3 to 4 times each day and 1 to 2 snacks How much: Three-quarters (3/4) up to 1 full cup at each meal

* A snack is extra food between meals ** A cup is 250 ml 

Feeding non-breastfed babies:

If you're not breastfeeding your baby, she’ll need to eat more often. She'll also need to rely on other foods, including milk products, to get all the nutrition to her body needs.

• Start to give your baby solid foods at 6 months of age, just as a breastfed baby would need. 
• Begin with 2 to 3 spoonful of soft and mashed food 4 times a day, which will give her the nutrients she needs without breastmilk.
• From 6–8 months old, she’ll need half a cup of soft food 4 times a day, plus a healthy snack. 
• From 9–11 months old, she’ll need half a cup of food 4 to 5 times a day, plus 2 healthy snacks.

Living with HIV:

If you are living with HIV, introduce your baby to his first solid foods at 6 months and continue to breastfeed him while taking your ARV medicines and following your treatment plan.

First food for the baby:

• The staple cereal of the family should be used to make the first food for an infant. 
• Porridge can be made with suji (semolina), broken wheat, atta (wheat flour) ground rice, ragi, millet etc, by using a little water or milk, if available. 
• Roasted flour of any cereal can be mixed with boiled water, sugar and a little fat to make the first complementary food for the baby.
• Adding sugar or jaggery and ghee or oil is important as it increases the energy value of the food. 
• In the beginning the porridge could be made a little thinner but as the child grows older the consistency has to be thicker. 
• A thick porridge is more nutritious than a thin one. 
• In case a family can not prepare the porridge for the infant separately, pieces of half chapatti could be soaked in half a cup of milk or boiled water, mashed properly and fed to the baby after adding sugar and fat. 
• Soaked and mashed chapatti could be passed through a sieve so as to get a soft semi-solid food for the infant.
• Fruits like banana, papaya, chikoo, mango etc. could be given at this age in a mashed form. 

References:

1. https://www.who.int/health-topics/complementary-feeding#tab=tab_1
2. https://iapindia.org/pdf/Ch-040-IAP-Parental-Guideline-Complementary-Feeding.pdf
3. https://www.cdc.gov/nutrition/infantandtoddlernutrition/foods-and-drinks/index.html
4. https://www.unicef.org/parenting/food-nutrition/feeding-your-baby-6-12-months
5. https://motherchildnutrition.org/india/complementary-feeding-guidelines.html
6. https://www.unicef.org/parenting/food-nutrition/feeding-your-baby-when-to-start-solid-foods
7. https://www.unicef.org/parenting/food-and-nutrition/first-foods-for-baby
8. https://www.unicef.org/uganda/media/3416/file/UGDA%20children%20feeding%20flyer.pdf
9. https://www.unicef.org/media/108431/file/Brochure%20Feeding%20After%206%20Months.pdf
10. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/
11. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding
12. https://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/Guildelines_for_immunization/MCP_Guide_Book.pdf
13. https://nhm.assam.gov.in/sites/default/files/swf_utility_folder/departments/nhm_lipl_in_oid_6/menu/document/mcp_card_english.pdf
14. https://www.nhmmizoram.org/upload/mcpcard/MCP%20Card%20Revised.pdf