BOX 13 · COMPLEMENTARY FEEDING
Complementary feeding means giving other foods in addition to breastmilk (or breastmilk substitutes).
Previously, the term weaning was used, but there was some confusion about its meaning. Some people thought that weaning meant stopping breastfeeding; others thought it meant the period during which the child changed from having only breastmilk to only family foods. Weaning foods could mean foods given when the child stopped breastfeeding or during the change from breastmilk to family foods.
Always using the term complementary feeding (also when translated into a local language), should avoid this confusion and ensure that the recommended feeding for children aged over six months is: continued breastfeeding plus complementary foods.
Start complementary foods when a baby is six months old
Topic 6 explains why most babies need only breastmilk for the first six months of life. Most babies should start complementary foods when they are six months old because at this age:
breastmilk alone cannot supply all the nutrients needed for growth;
children are able to eat and digest other foods.
Most children should breastfeed for two years and, if possible, beyond
Topic 7 discusses what foods to give children aged over six months. Breastfeeding on demand should continue until a child is 2 years old or beyond (unless the mother is HIV+: see below and Topic 6). As children grow, increasing amounts of complementary foods are needed to fill the gap between the nutrients supplied by breastmilk and childrens nutrient needs.
Advise parents to start by giving 1-2 teaspoons of semisolid food, for example porridge or mashed potato, and to add other foods to make good complementary meals (see below). By the age of eight months, babies also like finger foods, foods they can hold themselves, such as a chapati or banana. By the age of 1 year, most children can eat suitable family meals and snacks.
Prepare complementary foods hygienically - Keep clean
Good complementary foods:
are rich in energy, protein and micronutrients, especially iron, and are not watery (i.e. thick not thin porridges);
are easy to eat and digest;
are hygienically prepared and fed (see Topic 4);
contain no bones or hard pieces that might cause choking;
are not too spicy or salty. Too much salt is bad for children.
Use a variety of foods for childrens meals
Advise parents to prepare meals that provide:
a variety of foods (see Topic 3);
some fat-rich foods to increase the energy content;
fresh fruits and vegetables, especially ones rich in vitamins A and C;
eggs, milk foods and iron-rich animal foods (meat, offal, poultry, fish, as appropriate) daily or as often as possible.
Young children also need snacks. Here are examples of good snacks for young children.
Circle the snacks used locally and add others to the list.
SNACKS FOR YOUNG CHILDREN
FRUITS SUCH AS MANGO, PAWPAW, BANANA, AVOCADO
BOILED, PASTEURIZED OR SOURED ANIMAL MILK
CHAPATI OR BREAD WITH GROUNDNUT PASTE/PEANUT BUTTER OR MARGARINE
OR DIPPED IN MILK
SMALL PIECES OF BOILED OR FRIED CASSAVA, PLANTAIN OR YAM
SWEET POTATOES (ORANGE COLOURED)
Porridges made with germinated or fermented flours. Young children need foods rich in energy and nutrients because their stomachs are small and they cannot eat large amounts at each meal. Porridge is the most common food for young children, but its energy and nutrient content is often too low to meet their needs fully. This is due to the high starch content of staple foods, such as maize, millet, sorghum, cassava and yams. During cooking, these flours absorb much water, which makes them bulky and thick. If water is added to make the porridge less thick and easier for young children to eat, its energy and nutrient content is further decreased. Children would need to eat large quantities of such diluted porridge in order to meet their energy and nutrient needs, but because of their small stomachs it is difficult for young children to consume large quantities.
Ways to make porridges more energy and nutrient-rich, and easy to eat are by:
adding energy-rich (e.g. oil, butter/ghee) and nutrient-rich foods (such as flours of groundnut and other legumes, or sunflower seed) to the porridge;
making porridges with germinated or fermented cereal flours (see Box 14, page 64).
Porridges made with germinated or fermented cereal flours do not thicken as much as ordinary porridges. They can be made with less water and so contain more energy and nutrients in a smaller volume. Other advantages of these flours are the following:
the iron is better absorbed than from plain (non-germinated and non-fermented) flours;
porridge made from fermented flour is easier to digest and safer because germs cannot grow easily in fermented porridge.
BOX 14 · MAKING GERMINATED FLOUR AND PORRIDGES WITH GERMINATED OR FERMENTED CEREAL FLOURS
How to make germinated flour
How to make fermented porridge
There are many ways to make this. One way is to:
Sometimes flours from starchy roots (e.g. cassava) are made into fermented porridges.
Recipes for good porridges
You can use germinated or fermented flours to make good porridges. The recipes below suggest porridges that are energy and nutrient-rich.
They have been adapted from the following source: FAO. 2001. Improving nutrition through home gardening. A training package for preparing field workers in Africa, and WHO. 2000. Complementary feeding: family foods for breastfed children.
Millet and bean porridge (serves 4)
Sort the cowpea leaves, boil for about 5 minutes, dry and pound. Mix the pigeon pea and millet flours, add cold water and mix into a smooth paste. Add hot water to the paste and cook, stirring constantly, until the porridge is ready. Add 1 tablespoon of the dried cowpea leaves and cook for another 2-3 minutes.
To prepare a smaller amount of the same porridge (for one childs portion), use:
Mix maize and bean flour and cook to make a thick porridge. Add the spinach and vegetable oil and cook for another 2 minutes.
Cereal, groundnut, egg and spinach porridge
Add the groundnuts to the porridge. Add the raw egg and spinach and cook for a few minutes.
Legume flours are useful for enriching cereal and root or tuber flours used to prepare infant feeds. Box 15 shows the step-by-step stages in the processing of cowpea, pigeon pea and soybean flours.
BOX 15 · MAKING LEGUME FLOURS
To prepare the legume flours, the legumes are cleaned and any rotten grains or unwanted materials are sorted out. The legumes are then roasted and milled or ground. The flour is sieved to remove any remaining large pieces.
How to make cowpea flour
How to make pigeon pea flour
How to make soybean flour
Feed young children frequently
The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding. Young children have small stomachs, so they should eat often, with an increasing number of times as he/she grows older. For the average healthy and frequently breastfed child, complementary foods should be given as follows:
2-3 meals a day at ages 6-8 months;
3-4 meals a day at ages 9-24 months;
with additional 1-2 good snacks (see page 63) offered each day as desired after the age of six months.
Encourage young children to eat
Young children are often slow and messy eaters who are easily distracted. They eat more when their parents supervise mealtimes and actively and lovingly encourage them to eat (see Figure 10, page 68). This is especially important when children start complementary foods and until they are at least 3 years old.
Suggest that mothers, or the main caregivers:
sit with children and encourage them to eat by talking with them and telling them how good the food is;
make mealtimes happy times;
feed young children with the rest of the family but give them their own plates and spoons to make sure they get, and eat, their share;
give foods that children can hold if they want to feed themselves and tell them not to worry about messy eating - but make sure that all the food eventually gets into a childs mouth;
mix foods together if a child picks out and eats only favourite foods;
do not hurry children. A child may eat a bit, play a bit, and then eat again;
make sure the child is not thirsty because thirsty children eat less, but do not fill up the childs stomach with too much drink before or during the meal;
try to feed children as soon as they are hungry; do not wait for them to start crying for food;
do not feed when children are tired or sleepy;
make mealtimes interesting learning times; for example, teach the names of foods.
Sometimes even healthy children are fussy eaters. Check that the child is not sick, undernourished or unhappy and then advise families to:
give more attention when the child eats well and less when the child is trying to gain attention by refusing food;
play games to persuade a reluctant child to eat more;
avoid force-feeding because this increases stress and decreases appetite even more.
For more information on complementary feeding see: WHO. 2000. Complementary feeding: family foods for breastfed children (listed in Appendix 3).
Figure 10. Actively encouraging a young child to eat
(also see Topic 6, page 55)
The risk of passing HIV through breastmilk increases if a child has other foods as well as breastmilk. Therefore an HIV+, breastfeeding woman should exclusively breastfeed for a few months. When she wants to stop, she should:
do this over a much shorter period than usual (see Box 12, page 57);
give suitable replacement feeds. When the child is more than six months old, these feeds can be nutritious family foods, including as much food from animals as possible (i.e. milk and foods made from milk, eggs, meat, offal, poultry and fish).
By the age of 3 years, most children can feed themselves. But families should continue to watch and encourage children at mealtimes, especially if they are sick. Give family meals that contain a variety of different foods (see Topic 3) and are not too spicy, sugary or salty.Give three meals and 1-2 snacks a day.Where families eat from the same pot, it is a good idea to give young children their own plate or bowl so they receive their fair share of food.
SHARING THIS INFORMATION
Before sharing this information with families, you may need to:
1. Find out. When children usually start complementary foods.What foods are given at different ages. How foods are prepared (hygiene and consistency). How often children of different ages are fed. Who feeds the child, where and how. When and how HIV+ mothers start replacement feeding. What the blocks to the better feeding of young children are (there are likely to be several related to what children eat and how they are fed). Which blocks are the most important. Which should you try to remove first. What families say their problems are in feeding young children (e.g. mothers time constraints).
2. Prioritize. Decide which information is most important to share with groups or individual families.
3. Decide whom to reach. For example: mothers and caregivers of young children; other relatives who feed children, influence feeding practices (e.g. fathers) or can help mothers; staff of child care centres and nurseries.
4. Choose communication methods. For example: discussions with womens groups and at young child clinics; demonstrations of complementary meals and snacks, and how to feed them.
Examples of questions to start a discussion
(choose only a few questions that deal with the information families need most)
When should most children start to eat foods in addition to breastmilk?
Which are good foods for children aged 6-8 months?
How often should we feed complementary meals to children aged 6-8 months? 9-11 months?
Do we give young children snacks? What do we give? Are there other local snacks that are good for young children?
Do you use germinated or fermented flours to make porridge? Why are porridges that are made with germinated or fermented flours good foods for young children?
Do we actively encourage young children to eat? Discuss who feeds a child, where the child is fed and what utensils are used. Demonstrate how to feed a young child.