This guideline, Complementary feeding of infants and young children 6–23 months of age, supersedes the Guiding Principles for Complementary Feeding of the Breastfed Child (1) and Guiding principles for feeding non-breastfed children 6–24 months of age (2).
Background
Complementary feeding, defined as the process of providing foods in addition to milk when breast milk or milk formula alone are no longer adequate to meet nutritional requirements, generally starts at age 6 months and continues until 23 months of age, although breastfeeding may continue beyond this period (4). This is a developmental period when it is critical for children to learn to accept healthy foods and beverages and establish long-term dietary patterns (5). It also coincides with the peak period for risk of growth faltering and nutrient deficiencies (6).
The immediate consequences of malnutrition during these formative years – as well as in utero and the first 6 months of life – include impaired growth, significant morbidity and mortality, and delayed motor, cognitive, and socio-emotional development. It can later lead to increased risk of noncommunicable diseases (NCDs). In the long term, undernutrition in early childhood leads to reduced work capacity and earnings and, among girls, reduced reproductive capacity (6). Inappropriate complementary feeding can result in overweight, type 2 diabetes and disability in adulthood (7). The first two years of life are also a critical period for brain development, the acquisition of language and sensory pathways for vision and hearing, and the development of higher cognitive functions (8).
Purpose of the guideline
This guideline provides evidence-based recommendations on complementary feeding of infants and young children 6–23 months of age living in low, middle-and high-income countries. It considers the needs of both breastfed and non-breastfed children. These are public health recommendations, recognizing that children should be managed individually so that inadequate growth, overweight, or other adverse outcomes are identified, and appropriate action taken. This guideline does not address the needs of pre-term and low-birthweight infants, children with or recovering from acute malnutrition and serious illness, children living in emergencies, or children who are disabled. Except for children with disabilities, the needs of these other groups of children are addressed in other WHO guidelines.
Guideline development and methodology
The recommendations in this guideline were developed using the procedures outlined in the WHO handbook for Guideline Development (3). The steps included: identification of priority questions and critical outcomes; retrieval of the evidence; assessment and synthesis of the evidence; and formulation of recommendations, including research priorities. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was followed, to prepare evidence profiles related to preselected topics, based on up-to-date systematic reviews (9).
The available evidence on the benefits and harms of various feeding practices was evaluated using quantitative and qualitative systematic reviews, some that were commissioned by WHO and others that were recently published. In addition, dietary modelling was conducted to analyse how changes in dietary practices as considered in the guidelines would affect nutrient intakes, either creating or alleviating nutrient deficiencies.
The Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice based on Evidence (DECIDE) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability, and feasibility criteria, was used to guide the formulation of the recommendations by the guideline development group (10).
Recommendations
Recommendation 1
Continued breastfeeding
Breastfeeding should continue up to 2 years or beyond (strong, very low certainty evidence).
Remarks
To carry out this recommendation, all breastfeeding women will require an enabling environment and supportive services (11). For example:
Women who work outside the home need services such as onsite daycare, workplace breastfeeding rooms, and flexible work schedules.
All women need access to breastfeeding counselling services to address questions and challenges that arise when breastfeeding.
Pregnant women, mothers, families, and health care workers need to be protected from exploitative marketing from manufacturers and distributors of breast-milk substitutes.
Health care providers must be knowledgeable and skilled in supporting breastfeeding mothers with evidence-based care.
Recommendation 2
Milks 6–11 months: for infants 6–11 months of age who are fed milks other than breast milk, either milk formula or animal milk can be fed (conditional, low certainty evidence).
Milks 12–23 months: for young children 12–23 months of age who are fed milks other than breast milk, animal milk should be fed. Follow-up formulas are not recommended (conditional, low certainty evidence)
1.
Remarks
Dairy products, including liquid animal milks are part of a diverse diet and can contribute to nutritional adequacy (see also
Recommendation 4a). They are particularly important for non-breastfed children when other animal source foods (ASFs) are not available.
Types of animal milks that could be used include pasteurized animal milk, reconstituted evaporated (but not condensed) milk, fermented milk, or yogurt.
Flavoured or sweetened milks should not be used.
If infants 6–11 months of age are fed animal milks, full fat milk should be used.
Safe storage and handling practices of animal milks should be followed.
- 1
The GDG decided there was insufficient evidence for children 12–23 months on full fat vs low-fat milk and on animal vs. plant milk and, therefore, decided not to make a recommendation on these questions. Because sweetened milks include added sugars, they are not appropriate for infants and young children 6–23 months of age.
Recommendation 3
Age of introduction of complementary foods
Infants should be introduced to complementary foods at 6 months (180 days) while continuing to breastfeed (strong, low certainty evidence).
Remarks
The recommendation is a public health recommendation and recognizes that some infants may benefit from earlier introduction of complementary foods.
Mothers concerned about the adequacy of breast milk might benefit from lactation support.
Iron in breast milk is highly bioavailable, but some infants may be at risk of iron deficiency (ID), especially if they were preterm or low birthweight. Early introduction of complementary foods, even if iron-fortified, does not adequately prevent iron deficiency anaemia in high-risk populations.
Recommendation 4
Dietary diversity
Infants and young children 6–23 months of age should consume a diverse diet.
Animal source foods, including meat, fish, or eggs, should be consumed daily (strong, low certainty evidence).
Fruits and vegetables should be consumed daily (strong, low certainty evidence).
Pulses, nuts and seeds should be consumed frequently, particularly when meat, fish, or eggs and vegetables are limited in the diet (conditional, very low certainty evidence).
Remarks
Animal-source foods, fruits and vegetables, and nuts, pulses and seeds should be key components of energy intake because of their overall higher nutrient density compared to cereal grains.
Starchy staple foods should be minimized. They commonly comprise a large component of complementary feeding diets, particularly in low resource settings, and do not provide proteins of the same quality as those found in animal source foods and are not good sources of critical nutrients such as iron, zinc and Vitamin B12. Many also include anti-nutrients that reduce nutrient absorption.
When cereal grains are used, whole cereal grains should be prioritized, and refined ones minimized.
Care should be taken to ensure that pulses, nuts and seeds are given in a form that does not pose a risk of choking.
Recommendation 5
Unhealthy foods and beverages
Foods high in sugar, salt and trans fats should not be consumed (strong, low certainty evidence).
Sugar-sweetened beverages should not be consumed (strong, low certainty evidence).
Non-sugar sweeteners should not be consumed (strong, very low certainty evidence).
Consumption of 100% fruit juice should be limited (conditional, low certainty evidence).
Remarks
Broad policy actions will be needed to support the implementation of these recommendations, including, but not limited to agricultural policies that take into consideration the nutritional requirements of young children, policies regarding front-of-package labelling and marketing practices, among others.
Counselling caregivers about the short- and long-term harms of foods high in sugar, salt and trans fats, sugar sweetened beverages (SSBs), and non-sugar sweeteners is needed.
Recommendation 6
Nutrient supplements and fortified food products
In some contexts where nutrient requirements cannot be met with unfortified foods alone, children 6–23 months of age may benefit from nutrient supplements or fortified food products.
Multiple micronutrient powders (MNPs) can provide additional amounts of selected vitamins and minerals without displacing other foods in the diet (context-specific, moderate certainty evidence).
For populations already consuming commercial cereal grain-based complementary foods and blended flours, fortification of these cereals can improve micronutrient intake, although consumption should not be encouraged (context-specific, moderate certainty evidence).
Small-quantity lipid-based nutrient supplements (SQ-LNS) may be useful in food insecure populations facing significant nutritional deficiencies (context-specific, high- certainty evidence).
Remarks
WHO guidelines for micronutrient supplementation provide recommendations about the contexts when such supplements are recommended (
12).
None of the three products should ever be distributed as standalone interventions, rather they should always be accompanied by messaging and complementary support to reinforce optimal infant and young child feeding practices.
None of the products are a substitute for a diverse diet consisting of healthy and minimally processed foods.
Recommendation 7
Responsive feeding
Children 6–23 months of age should be responsively fed, defined as “feeding practices that encourage the child to eat autonomously and in response to physiological and developmental needs, which may encourage self-regulation in eating and support cognitive, emotional and social development” (13) (strong, low certainty evidence).
Remarks
Delivering the intervention of responsive feeding will require health care workers and others charged with delivering the intervention to have the capacity to provide the necessary guidance to caregivers and families.
Implementation of the recommendation will require caregivers to have time to be present while the young child eats or self-feeds and have resources so that food loss during self-feeding does not present a problem.
Research gaps
The GDG highlighted the very limited evidence for many of the recommendations. More studies using similar research protocols (age groups, outcomes, measurement techniques, etc.) across different regions, countries, population groups (by income levels, educational levels, cultural and ethnic backgrounds etc.) and contexts are required. Most topics, except for those related to nutrient supplements and fortified food products, lacked robust or sometimes any randomized controlled trials to guide decision making.
