1. Complementary Feeding DR. PRADEEP DUBEY, MD(Ped) DCH. CONSULTANT DEV. & NEURO PEDIATRICS AADIGURU NEUROPEDIATRIC CENTRE NEAR PREM MANDIR, WRIGHT TOWN JABALPUR

2. Children Under 3 years Who are Underweight (NFHS-3, 2005-2006) Not a change over seven years Not a change over seven years 0-29 % 30-39 % 40-49 % 50 -100 %

3. Ranking by Children U-3 who are underweight (NFHS-3) RankStates % of Underweight 1 Madhya Pradesh 60.3 5Gujarat47.4 6 Uttar Pradesh 47.3 12Karnataka41.1 21Delhi33.1 26Punjab27.0 INDIA45.9

4. Under-5 deaths preventable through universal coverage with individual preventive interventions INDIA Source: Jones et al. LANCET 2003;362:65-71 0%2%4%6%8%10%12%14%16%18% Breastfeeding Complementary feeding Clean delivery Hib vaccine Clean water, sanitation, hygiene Zinc Vitamin A Antenatal steroids Newborn temperature management Tetanus toxoid Antibiotics for PRM Measles vaccine Nivirapine and replacement feeding Insecticide-treated materials Antimalarial IPT in pregnancy Intervention Percent

5. Complementary Feeding, 6-9 months (NFHS-3, 2005-2006) Shown good change in 7 years, national average almost doubled Shown good change in 7 years, national average almost doubled Reaching Greens is a challenge Reaching Greens is a challenge 0-59 % 60-79 % 80-94 % 95-100 %

6. Ranking by Complementary Feeding (NFHS-3) RankStates Complementary Feeding 1Kerala93.6 2Sikkim89.6 11Himachal66.0 15Delhi59.8 25Punjab50.0 27 Uttar Pradesh 45.5 INDIA55.8

7. Optimal Feeding Norms as per National Guidelines on Infant and Young Child Feeding Starting breastfeeding within one hour of birth Starting breastfeeding within one hour of birth Exclusive breastfeeding for the first six months Exclusive breastfeeding for the first six months Introducing appropriate and adequate complementary feeding after 6 months along with Continued breastfeeding for two years or beyond Introducing appropriate and adequate complementary feeding after 6 months along with Continued breastfeeding for two years or beyond

8. Definition of Complementary feeding The process of giving an infant other foods and liquids along with breast milk or non-human milk as breast milk alone is no longer sufficient to meet the nutritional requirements. The process of giving an infant other foods and liquids along with breast milk or non-human milk as breast milk alone is no longer sufficient to meet the nutritional requirements. These foods should complement rather than replace breastmilk. These foods should complement rather than replace breastmilk.

9. Appropriate Complementary Feeding Timely: Introduced when need for energy and nutrients exceeds that provided by BF Timely: Introduced when need for energy and nutrients exceeds that provided by BF Adequate: Should provide sufficient energy, protein, and micronutrients Adequate: Should provide sufficient energy, protein, and micronutrients Properly Fed: Active feeding method and proper frequency according for age Properly Fed: Active feeding method and proper frequency according for age Safe: Should be hygienically prepared, stored and fed Safe: Should be hygienically prepared, stored and fed

10. Timing of Complementary Feeding Soon after completing 6 months of age Breast milk sufficient to promote growth and development till 6 months Breast milk sufficient to promote growth and development till 6 months Energy and nutrient gap appears after 6 months and widens thereafter Energy and nutrient gap appears after 6 months and widens thereafter Infant’s development and behavior makes him ready for other foods Infant’s development and behavior makes him ready for other foods Holds objects (e.g. biscuit) and takes everything to mouth Holds objects (e.g. biscuit) and takes everything to mouth Chewing movements start Chewing movements start Tendency to push solids out decreases Tendency to push solids out decreases Eruption of teeth and beginning of biting movements Eruption of teeth and beginning of biting movements

11. Age of Introduction Energy Needs Excl. BreastfeedingComp. feeding & continued BF

12. Timing of Complementary Feeding Disadvantages of adding foods too soon Decrease the intake of breast milk resulting in a low nutrient diet Decrease the intake of breast milk resulting in a low nutrient diet Increase risk of illness esp. diarrhea Increase risk of illness esp. diarrhea Disadvantages of adding foods too late Growth and development slows down or stops Growth and development slows down or stops Risk of deficiencies and malnutrition Risk of deficiencies and malnutrition

13. Importance of continued breastfeeding for 2 years and beyond

14. Why Continue Breastfeeding? Vital source of energy (30-40%) and nutrients into 2nd yr of life Vital source of energy (30-40%) and nutrients into 2nd yr of life Key source of Key source of Good quality proteins & essential fatty acids Good quality proteins & essential fatty acids Micronutrients: Micronutrients: 45% of Vitamin A 45% of Vitamin A 40% of calcium & riboflavin 40% of calcium & riboflavin 95% of Vitamin C 95% of Vitamin C Fluids and nutrients during infection Fluids and nutrients during infection Associated with greater linear growth Associated with greater linear growth Linked to lower risk of chronic diseases & obesity Linked to lower risk of chronic diseases & obesity

15. Key Message-1 (Timely) Complementary feeding should begin soon after completing 6 months of age along with continued breastfeeding Complementary feeding should begin soon after completing 6 months of age along with continued breastfeeding

16. Adequacy (Quality) Staples: Cereals (Rice, wheat, maize, millets) and Legumes Staples: Cereals (Rice, wheat, maize, millets) and Legumes Fats (Vegetable oils/butter/ghee; 1g ~ 9 Kcal) and sugars to improve energy density and taste Fats (Vegetable oils/butter/ghee; 1g ~ 9 Kcal) and sugars to improve energy density and taste Foods of animal origin (Milk, curd, eggs, meat, fish) to provide good quality proteins, vitamin A and calcium. Foods of animal origin (Milk, curd, eggs, meat, fish) to provide good quality proteins, vitamin A and calcium. Vegetables and Fruits to provide micronutrents e.g. iron and vitamins. Supplements e.g. iron might be required. Vegetables and Fruits to provide micronutrents e.g. iron and vitamins. Supplements e.g. iron might be required.

17. Other Attributes of Complementary Foods Right consistency Right consistency Soft Soft Easy to digest Easy to digest Inexpensive Inexpensive Locally available Locally available Culturally acceptable Culturally acceptable Easily prepared at home Easily prepared at home

18. Variety of Foods Start at 6 mo with small amounts of food; increase quantity with age, maintaining frequent breast feeding Start at 6 mo with small amounts of food; increase quantity with age, maintaining frequent breast feeding Increase food consistency & variety with age Increase food consistency & variety with age Can feed mashed & semi-solids (e.g. porridge) at 6 mo; Can feed mashed & semi-solids (e.g. porridge) at 6 mo; Can feed finger foods by 8-9 mo Can feed finger foods by 8-9 mo By 12 mo, family foods can be eaten By 12 mo, family foods can be eaten Combine foods (e.g. rice and legumes) to provide good mixture of amino acids Combine foods (e.g. rice and legumes) to provide good mixture of amino acids

19. Foods to Avoid Tea & coffee: interfere with iron absorption Tea & coffee: interfere with iron absorption Aerated beverages: No nutritional value Aerated beverages: No nutritional value Too much sugary drinks & Fruit juices: cause decreased appetite for other nutritious foods and also may cause loose stools. Too much sugary drinks & Fruit juices: cause decreased appetite for other nutritious foods and also may cause loose stools. Nuts: may cause choking Nuts: may cause choking

20. Stomach size

21. Adequacy (Frequency and Amount) 6-12 months Give at least one katori (150-200 mL) serving* at a time of Give at least one katori (150-200 mL) serving* at a time of Khichdi or dalia or sooji (semolina) with added oil/ghee Khichdi or dalia or sooji (semolina) with added oil/ghee Mashed roti/rice/bread mixed in thick dal or sweeetened undiluted milk Mashed roti/rice/bread mixed in thick dal or sweeetened undiluted milk Add cooked/pureed vegetables or meat also in the servings Add cooked/pureed vegetables or meat also in the servings Sevian/dalia/halwa/kheer/biscuits prepared in milk or any cereal porridge cooked in milk Sevian/dalia/halwa/kheer/biscuits prepared in milk or any cereal porridge cooked in milk Mashed boiled/fried potatoes Mashed boiled/fried potatoes Mashed banana/cheeko/ mango/ papaya Mashed banana/cheeko/ mango/ papaya *3 times per day if breastfed; 5 times per day if not breastfed

22. Frequency and Amount (1-2 yrs) Offer food from the family pot Give at least 1½ katori (250 mL) serving* at a time of: Mashed roti/rice/bread mixed in thick dal with added ghee/oil or khichri with added oil/ghee. Mashed roti/rice/bread mixed in thick dal with added ghee/oil or khichri with added oil/ghee. Add cooked vegetables/meat also in the servings Add cooked vegetables/meat also in the servings Mashed roti/ rice /bread/biscuit mixed in sweetened undiluted milk Mashed roti/ rice /bread/biscuit mixed in sweetened undiluted milk Egg preparations/ soft meat pieces without bones Egg preparations/ soft meat pieces without bones - Sevian/dalia/halwa/kheer prepared in milk or any cereal porridge cooked in milk OR - Sevian/dalia/halwa/kheer prepared in milk or any cereal porridge cooked in milk OR Fruits (banana/cheeko/apple/orange/mango/papaya) Fruits (banana/cheeko/apple/orange/mango/papaya) * 5 times per day.

23. Amounts of foods to offer AgeTextureFrequency Amount of each meal 6 months Soft porridge, well mashed vegetable, meat fruit 2 times per day plus frequent breastfeeds 2-3 tablespoonfuls 7-8 months Mashed foods 3 times per day plus frequent breastfeeds Increasing gradually to more than 3/4 of katori (150ml) 9-11 months Finely chopped or mashed foods, and foods that baby can pick up 3 meals plus 1 snack between meals plus breastfeeds a full katori (200ml) 12-24 months Family foods, chopped or mashed if necessary 3 meals plus 2 snacks between meals plus breastfeeds more than katori (250ml)

24. Ensure Adequacy Growth Monitoring: Measure weight and length periodically and interpret by plotting in growth curves. Growth Monitoring: Measure weight and length periodically and interpret by plotting in growth curves. Investigate causes of poor growth: Dietary history; evaluate for any illness. Investigate causes of poor growth: Dietary history; evaluate for any illness. Counsel mother/caregivers on growth, feeding and caring practices Counsel mother/caregivers on growth, feeding and caring practices

25. Key Message-2 (Adequacy) Complementary foods should be of right consistency, energy dense and the variety to provide all nutrient demands of a growing child. Complementary foods should be of right consistency, energy dense and the variety to provide all nutrient demands of a growing child.

26. Feeding Techniques Feed infants directly & assist older toddlers eat; be sensitive to hunger & satiety cues Feed infants directly & assist older toddlers eat; be sensitive to hunger & satiety cues Feed patiently; encourage, but don’t force Feed patiently; encourage, but don’t force If child refuses, experiment with different food combinations, tastes, textures If child refuses, experiment with different food combinations, tastes, textures Minimize distractions during meals Minimize distractions during meals Talk to child during feeding; maintain eye contact Talk to child during feeding; maintain eye contact

27. Responsive feeding

28. Suitable Feeding Situation

29. Key Message-3 (Properly Fed) Child should be fed patiently giving adequate attention and time Child should be fed patiently giving adequate attention and time

30. Safe Unhygienic feeding  the risk of infectious illness (esp. diarrhea) compromising nutritional status  the risk of infectious illness (esp. diarrhea) compromising nutritional status Undermines the parents’ confidence leading to delay in CF Undermines the parents’ confidence leading to delay in CF

31. Ensuring Food Hygiene Washing caregiver’s and child’s hands before preparing, handling and eating food Washing caregiver’s and child’s hands before preparing, handling and eating food Clean water and raw materials to cook food Clean water and raw materials to cook food Storing foods safely: Keeping food covered and serving shortly after preparation Storing foods safely: Keeping food covered and serving shortly after preparation Use clean utensils to prepare & serve food Use clean utensils to prepare & serve food Use clean bowls & cups when feeding child Use clean bowls & cups when feeding child No feeding bottles No feeding bottles

32. Key Message-4 (Safety) Foods should be prepared, stored and fed hygienically to the children. Foods should be prepared, stored and fed hygienically to the children.

33. Feeding the child who is ill Encourage the child to drink and to eat - with lots of patience Encourage the child to drink and to eat - with lots of patience Feed small amounts frequently Feed small amounts frequently Give foods that the child likes Give foods that the child likes Give a variety of nutrient-rich foods Give a variety of nutrient-rich foods Continue to breastfeed Continue to breastfeed

34. Feeding during Recovery Feed an extra meal Feed an extra meal Give an extra amount Give an extra amount Use extra rich foods Use extra rich foods Feed with extra patience Feed with extra patience Give extra breastfeeds as often as child wants Give extra breastfeeds as often as child wants

35. Key Message-5 (During Illness) Continue feeding during illness and increase during convalescence. Continue feeding during illness and increase during convalescence.

36. Key Messages Complementary feeding should begin soon after completing 6 months of age along with continued breastfeeding Complementary feeding should begin soon after completing 6 months of age along with continued breastfeeding Complementary foods should be of right consistency, energy dense and the variety to provide all nutrient demands of a growing child. Complementary foods should be of right consistency, energy dense and the variety to provide all nutrient demands of a growing child. Child should be fed patiently giving adequate attention and time Child should be fed patiently giving adequate attention and time Foods should be prepared, stored and fed hygienically to the children. Foods should be prepared, stored and fed hygienically to the children. Continue feeding during illness and increase during convalescence. Continue feeding during illness and increase during convalescence.

37. Thank You