Abstract
Good nutrition in the first “1000 days,” including breastfeeding and appropriate complementary foods, prepares for a healthy childhood and adult life, also contributes to the prevention of the double burden of malnutrition. Exclusive breastfeeding provides all required nutrients until an infant is around 6 months of age when complementary foods are needed. A literature review was undertaken of complementary foods in the Asia Pacific region. The foods being used at present are often of low nutrient density may provide insufficient amounts of some critical nutrients, and generally the variety is limited. Guidelines for complementary feeding are provided to assist in education and in public health planning.
What We Already Know
The first 1000 days, from conception, are a critical period for nutrition and development and establishing a life pattern of health.
The World Health Organization recommends exclusive breastfeeding for 6 months for optimum health.
At 6 months of age, infants require additional foods to meet their nutritional needs.
What This Article Adds
Infants need complementary foods at around 6 months of age. Breastfeeding should continue while foods are introduced and for as long as the mother and infant desire (2 years plus).
Complementary foods need to be selected carefully, preferably from locally available foods, to provide all of the required nutrients. A variety of foods is more likely to provide all required nutrients, and variety may protect against allergies.
Monitoring of growth is important.
Introduction
Infant and young child nutrition is one of the most important factors in determining current health and the future trajectory of growth and disease patterns later in life. The Asia Pacific Academic Consortium for Public Health (APACPH) includes membership from the teaching and research institutes and individuals in our region. It previously published guidance on public health nutrition for infants and adults for academic teaching and public health policy development.1,2 The APACPH guidelines recommend the introduction of complementary foods at around 6 months of age to provide the additional nutrients and energy and food variety needed by the growing infant. 1 The complementary feeding period (6-24 months) provides an opportunity to reduce rates of stunting and wasting and at the other end of the spectrum to control overweight and obesity. 3 It is now well established that early life nutrition and growth are important for establishing a lifetime trajectory for health, and the first 1000 days from conception provide an opportunity for interventions to reduce growth faltering and stunting, improve mental development, and reduce chronic disease later in life.4-10
Low- and middle-income countries, which comprise the major proportion of the population in the Asia Pacific Region, also have the greatest burden of malnutrition. The low- and middle-income countries worldwide have a high 0 to 5 years prevalence of stunting (28%), wasting (8∙8%), and underweight (17∙4%). 9 These affected children have an increased risk of overweight later in childhood and continuing into adulthood if given more energy than needed. Good nutrition in the first “1000 days,” including breastfeeding and appropriate complementary foods, prepares for a healthy childhood and adult life, also contributing to the prevention of the double burden of malnutrition. Obesity is becoming increasingly prevalent in children and adults in countries at all levels of development and can also be considered as “malnutrition.” 11
As with most nutrition practices, the impact of nutrition during the complementary feeding period (6-24 months) is U-shaped, ranging from stunting or poor growth at one extreme, to obesity at the other. 12 With the nutrition transition in many Asia Pacific countries, and its accompanying increasing prevalence of obesity, it is important that guidelines on complementary feeding address both prevention of undernutrition and prevention of overweight, obesity, and noncommunicable diseases later in life. 3
Current global morbidity and mortality statistics, including from the Asia Pacific Region, have been summarized in the global burden of diseases project.4,13,14 Infections and other nutrition-related conditions are the most common causes of death and morbidity in infants in the Asia Pacific Region. 14 This reinforces the need for continuing emphasis on appropriate complementary feeding and evidence-informed guidance.
Any recommendations on complementary feeding must be within the context of the Sustainable Development Targets relevant to the 6- to 24-month age group: Goal 2.2: By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons Goal 3: Ensure healthy lives and promote well-being for all at all ages Goal 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age and reduce under-5 mortality to at least as low as 25 per 1000 live births Goal 3.4: By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being.
15
Appropriate nutrition and complementary feeding offer potential gains in achieving these targets. The aim of this review of complementary feeding is to provide guidelines and principles for nutrition promotion program and academic teaching for the Asia Pacific Region.
Methods
These guidelines are applicable to infants and toddlers aged from about 6 months to 2 years. The APACPH complementary feeding guidelines were developed using a consensus approach. They are based on major background documents, reviews of robust scientific literature, and consultations with members and academic experts. Appropriate guidelines from member countries were reviewed where available. A literature search was undertaken using the PubMed and Web of Science databases using combinations of the key words: “Complementary feeding,” “Infant,” “Guidelines,” “Review,” and Asia or Pacific or China or Korea or Japan or Taiwan or Laos or Cambodia or Vietnam or Philippines or Malaysia or Singapore or Myanmar or Indonesia or Papua New Guinea or India or Bangladesh or Pakistan or Maldives or Nepal or Iran. Only English language articles were reviewed. Further references were consulted from international organizations, especially the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) and other regional publications.1,16 A total of 393 abstracts of articles were reviewed, and 161 full texts were retrieved and read. Where relevant, they are cited in this review.
Definitions
Exclusive Breastfeeding (EBF)
“The infant receives only breast milk. No other liquids or solids are given, not even water, with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals, or medicine.” 17 If the infant has had anything else since birth they are not classified as exclusively breastfed according to the WHO definition. However, in practice, EBF may be measured by what has happened in the past 24 hours. Thus, published statistics may differ greatly from true EBF rates and often do not reflect accurately the WHO definition.18,19 This caveat also applies to WHO and UNICEF statistics on EBF, which should probably be interpreted as a point prevalence or as “predominant” breastfeeding.
Complementary Foods/Feeding
The WHO definition includes caloric liquids (including infant formula). However, most other organizations, including the American Academy of Pediatrics, European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), the UK Scientific Advisory Committee on Nutrition (SACN), and the United States Department of Agriculture (USDA), restrict the meaning to the introduction of solid or semisolid foods, and infant formula is not considered a complementary food.21,22 Other terms that are in use are first foods, spoon foods, solid foods, and finger foods. Research on the importance of all foods in changes to the microbiome suggest that liquid foods should be included in the definition. In a cohort of infants (n = 323) that included detailed infant feeding information, breastfeeding, compared with formula feeding, was associated with greater intestinal microbial diversity. 23 Breastfeeding was associated with higher concentrations of Bifidobacterium and other microbes that have been associated with health outcomes. Therefore, in this review, liquid food, including formula, will be included in the definition of complementary foods.
Weaning is a term that is defined in several different ways in the literature and so will not be used in this article.
No ethics review was required for this article as it is a review of the literature and evidence-based policy documents. A preliminary paper was prepared by three authors (CB, MKL, and WYL) and discussed at a workshop at the APACPH Conference in Bangkok in 2019. Further drafts were circulated to all of the authors for comment and their agreement.
Results
Current Practices in the Asia Pacific Region
From the 161 full texts that were retrieved and read, we identified 15 cohort studies from seven countries in the region (N = 11 437). These studies described the rates of complementary feeds and prelacteal feeds before discharge and the 6-month breastfeeding rate. We identified 17 studies from eight countries that listed the types of solid foods given to infants.
In the Asia Pacific Region, complementary foods are frequently introduced before the usually recommended age of around 6 months. Table 1 presents data representative of the region showing that complementary foods are commonly given very early in life. In these studies, the most commonly used first solid foods were rice porridge and gruel, noodles, vegetable paste, yoghurt, and traditional foods based on flour mixtures. Commercially prepared packaged cereals, usually fortified with minerals and vitamins, are increasingly being used, especially in the cities. In almost all the surveys, there was a very low level of dietary diversity. The majority of infants were breastfeeding, as recommended, during the time solids were introduced.
Breastfeeding Rates From Cohort Studies Using the Same Methodology in the Asia Pacific Region, Including 7 Countries, 15 Cohort Studies (Total Sample Size N = 11 437).
Abbreviations: Any = any breastfeeding; Full = full or predominant breastfeeding; Exc = Exclusive breastfeeding; Trad = traditional foods.
UNICEF has compiled a detailed review of complementary feeding in South Asia, that is, the eight countries under the umbrella of the South Asia Association for Regional Cooperation, noting that many of the studies were small and the methodology needed improvement. 24 In this review, which excluded countries to the east of Bangladesh, 88.1% were breastfeeding at 12 months and 73.1% at 2 years. The majority (57%) were introduced to solid, semisolid, or soft foods by 6 to 8 months. Minimum diet diversity scores were met by one third, 20% had a minimally acceptable diet overall, and only 19% included the consumption of iron-rich foods.
In East Asia and the Pacific region, there are a number of small studies, but partly because of the variety of cultural practices, it is difficult to give a universal description of the complementary feeding practices in the region.25-29
Reasons for a Discussion of Complementary Foods in 2020
The UNICEF review gives several reasons why a review of complementary food guidelines is needed. 30 Changes and adjustments may have to be made to complementary practices to account for the following:
The increasing evidence about the importance of the first 1000 days of life (from conception to about 2 years).
There is an increasing emphasis on the importance of the microbiome in health and disease, which may be influenced by diet, including the type and timing of complementary foods. 31
Climate change is occurring at a rate faster than anticipated and is likely to affect this region more than most others.
32
Climate change will put pressure on traditional food crops, decrease biodiversity, and change nutrient and micronutrient content. The increase in severe weather events may intermittently change or interrupt food supply.33,34 Shortages of potable water for drinking and food preparation will increase Increased temperatures will cause problems with food storage
Changes to food systems and supply are continuing to occur: Increased availability of highly processed, refined, and ultraprocessed foods. There is increased consumption of fast foods, high-salt and high-sugar foods.
35
Ultraprocessed foods during the first 1000 days are likely contribute to stunting while at the same time exposing infants to foods that are energy-dense and micronutrient-poor.
36
Other researchers have expressed concern about links between sugary soft drinks and snacks and stunting and overweight.
37
Production methods are changing. Fish farms instead of wild caught fish or feedlot production of meat, result in changes to nutrient compositions, for example, from unsaturated fats to saturated. “Convenience” pouches or packs—“squeeze and feed” will come to our region.
38
Changing growth and morbidity patterns. Obesity: The Asia Pacific Region has increased rates of obesity and more chronic disease later in life. Nutrition is a “U-shaped” distribution, with both undernutrition and obesity continuing to be problems; manifesting a double burden of malnutrition. Changing physical activity patterns affects children. Allergy: There has been an increase in the rate of food allergies in recent decades in Western societies and increasingly in Asia. Hypotheses to explain the increased prevalence include misuse of the widespread use of antibiotics, the hygiene hypothesis, dietary changes, higher rates of cesarean section, and increasing infant formula use that have changed the microbiome.39,40 Allergy is not prevented by delaying the introduction of complementary foods.
Food Diversity (Variety): Food variety is essential for providing all nutrients, and it reduces exposure to toxins and environmental contaminants. Dietary diversity is threatened by changes in food production, food trade, and climate change.
Loss of interest in preserving food culture (children live in high-rise apartments, eating processed foods from the retail sector, and never see a rice paddy or a buffalo). Use of local complementary foods where appropriate will preserve cultures and mitigate the effects of the nutrition transition.
The Global Strategy for Infant and Young Child Feeding (WHO/UNICEF) states that children need to be properly fed, meaning that they are given food consistent with a child’s signals of appetite and satiety, and that meal frequency and feeding method are appropriate. Children should be actively encouraged, even during illness, to consume sufficient food.
41
For complementary feeding, education and counseling on improved use of locally available foods is the cornerstone of interventions in all contexts. Where the main nutritional problems are micronutrient deficiencies and locally available foods cannot provide sufficient micronutrients (which is most often the case for iron), supplementation with multiple micronutrients may be recommended in addition to optimizing use of locally available foods. In food-insecure populations with significant nutrient deficiencies and where locally available foods are inadequate in macro- and micronutrients, additional components such as fortified complementary foods and/or lipid-based nutrient supplements may be needed to fill nutrient gaps.
41
The WHO provides guiding principles for appropriate complementary feeding 42 :
continue frequent, on-demand breastfeeding until 2 years of age or beyond;
practice responsive feeding (eg, feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child, and maintain eye contact);
practice good hygiene and proper food handling;
start at 6 months with small amounts of food and increase gradually as the child gets older;
gradually increase food consistency and variety (variety is now regarded as important from the beginning of complementary feeding to provide all nutrients and some protection against allergy);
increase the number of times that the child is fed: 2 to 3 meals per day for infants 6 to 8 months of age and 3 to 4 meals per day for infants 9 to 23 months of age, with 1 to 2 additional snacks as required;
use fortified complementary foods or vitamin-mineral supplements as needed; and
during illness, increase fluid intake including more breastfeeding, and offer soft, favorite foods.
Recommendations for the Asia Pacific Region
Exclusive breastfeeding to 6 months and continue breastfeeding while introducing complementary foods (breastfeeding until at least 2 years is optimum) from around 6 months. Complementary foods should never be given before 4 months).
Complementary foods should provide sufficient energy and all nutrient (macro- and micro-) requirements (including iron, calcium, iodine, vitamin A, etc). This is best done using a variety of foods, including meat, poultry, fish, legumes, fruits, vegetables and so on, that can all be introduced (in suitable texture and size) from 6 months. Variety in foods should include different textures and tastes (variety results in more complete nutrition, provides phytonutrients, improves safety, and reduces allergies). No nuts in solid form should be given until the infant is old enough to eat safely (about 3 years), but nut pastes are safe from 6 months (see note on dietary diversity).
Consider food volume and nutrient density. Many early foods in our region are of low nutrient density (eg, sweet potato, rice, and rice porridges). Food diversity is important to overcome this issue (see 2 above).
Avoid sugar and salt (sodium) in both home prepared and commercial foods. Tastes experienced in infancy establish lifetime preferences and habits.
Use clean, safe water, prepare food hygienically, and cook food if possible. Food should be eaten as soon as possible after preparation and if needed should be stored safely.
Promote adequate growth. Weight and height should be measured, recorded, and monitored regularly (nutrition is a U-shaped curve, too little results in stunting and undernutrition, and too much food in overweight/obesity). Visual appearance is unreliable and infants should be measured and their growth charted. 43
Frequency of meals. The WHO suggested minimum meal frequency is44,45: 2 to 3 times for breastfed infants 6 to 8 months 3 to 4 times for breastfed infants 9 to 11 months 3 to 4 times for breastfed infants 12 to 24 months, with additional nutritious snacks offered 1 to 2 times per day, as desired. 4 to 5 times for nonbreastfed infants 6 to 23 months
Be affordable, sustainable, climate change resistant, pure (no chemical or micro contamination). Sufficient food must be available continuously throughout the year.
Food during illnesses. Increase fluids and breastfeeding and maintain solids. Respect food cultures in developing local recommendations.
Growing up milk formula is not necessary. This product contains more protein than needed and could promote obesity (also known as level 3 formula, toddler milk). 46 Breast milk is best. Other forms of cow milk can be given after 12 months. Additional problems are difficulty in storage, lack of clean water, less diversity of nutrient sources, and the environmental burden.
Practice “responsive or responsible feeding as recommended by WHO with the caregiver feeding the child responding to the child’s cues of hunger and satiety.” There is no need to force children to eat as much as possible. Some mothers and grandmothers may work hard to force their children to eat as much as possible while others are not attentive to the children’s cues. Eating while watching television or playing with a smartphone/iPad is not a healthy practice. Healthy growth is the most important outcome in early childhood, and growth (weight and height) should be measured regularly and plotted on a growth chart to assess nutritional health.
Other Nutrition Issues
Options for improving diets during the first 1000 days include dietary diversification and increased intake of nutrient-rich foods, improved complementary feeding practices, micronutrient supplements, and fortified foods or products specifically designed for these target groups. 47 The nutrients most likely to be at risk in the region are the following:
Iron: Meat (pureed or very finely chopped or smashed) is a good source.
Iodine: Usually given through community-wide fortification programs, for example, iodized salt.
Vitamins A and D, and calcium: Dairy products and dietary diversity are important.
Micronutrient deficiencies occur widely in Southeast Asia and have an impact on public health. Most efforts toward eliminating micronutrient deficiencies have focused on vitamin A, iron, and iodine deficiency. But deficiency of other micronutrients also affects public health. Representative and up-to-date data on micronutrient status in Southeast Asia are limited. Deficiencies are an important regional problem, but there is considerable variation in prevalence and decisions on use of fortification, and supplementation and the use of micronutrient “sprinkles” have to be made locally.48,49
Dietary diversity is important and refers to the child receiving more than 4 of the following food groups:
grains, cereals, roots, and tubers
legumes and nuts
dairy products (milk, yogurt, cheese)
flesh foods (meat, fish, poultry, seafood and liver/organ meats, and other protein sources)
eggs and tofu
vitamin A–rich fruits and vegetables, and of course
other fruits and vegetablesNote: The flesh foods (see 4 above) provide good sources of minerals, vitamins, trace elements, and proteins. For a number of countries in which nutrient intakes are inadequate, nutrients available from fishing are important, and fish should be a part of young children’s diet where available. 50
Barriers to appropriate infant and young child nutrition include the following:
Marketing and promotion of breast milk substitutes including growing up formulas.
Promotion of commercial infant foods that contain high levels of salt and sugar and which lack diversity in tastes and textures. Squeeze packs leading to increased consumption.
Promotion of sugar-sweetened beverages
Contamination of complementary foods—environment, aflatoxins, and so on. 51
Nonresponsive feeding
Feeding only scanty amounts at low meal frequencies
Inappropriate advice from family and friends and lack of correct professional support.
In some locations, micronutrient deficiencies can be an important issue. Initially, efforts should be made to meet these needs with a diverse locally available diet or with food fortification (eg, iodized salt).52,53 Home fortification of infant foods with micronutrient powders has proved useful in some situations. However, careful monitoring of the effects of iron and folate fortification are recommended because of possible side effects.54,55
Limitations
Because of cultural diversity and variations in food availability, only general guidance can be given in this review. More well-designed studies are needed on the short- and long-term outcomes of complementary feeding.
Conclusion
The aim of these guidelines is to provide general principles that are applicable for teaching and program implementation in our region. Common first feeds in the region include rice and other cereal products, homemade or commercial. Diversity of cereal, vegetable, fruits, meat, and fish is important. Legumes, pulses, lentils, and sprats (small dried fish) are sources of protein for those who wish to avoid foods based on animal origin. Micronutrient deficiencies are common and require locally based analysis and action. The third decade of the new Millennium brings new challenges to health workers teaching, giving advice and implementing interventions for the introduction of affordable, sustainable, culturally appropriate, complementary foods to infants. This is important because of the short- and long-term benefits and risks require both short- and long-term action to prevent undernutrition and emerging overnutrition during the first 1000 days of life.
Simple Messages for Parents
The best way to feed your infant:
“Breast is best.” Exclusive breastfeeding to 6 months and continuing while solid foods are introduced to 24 months or longer. Introduce solid foods at around 6 months of age
Mixed foods are strong (good/nutritious) foods. Dietary diversity (variety) is important. Use foods with varied textures and tastes, but appropriate for age.
Prepare and store your infant’s food carefully.
Respect your culture and use a variety of healthy traditional foods as a part of your child’s diet.
Responsively feed. Spend time and enjoy mealtimes with your infant.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.