Pediatric Nutrition in Practice

110 Fewtrell

in 2001 [3] , the WHO recommended that in-
fants should be exclusively breastfed for 6
months, although this contrasts with current
practice in many countries, where complemen-
tary foods may be introduced as early as 3–4
months of age.

Timing of Complementary Feeding

Complementary feeding recommendations and
practices are generally not evidence based and
vary between countries. Gastrointestinal and re-
nal functions are likely to be sufficiently mature
by around 4 months of age to enable infants to
process some complementary foods, whereas the
age at which infants attain the necessary motor
skills is likely to fall within the 4- to 6-month pe-
riod. There is general consensus that comple-
mentary foods should not be given before 17
weeks of age as this may be associated with in-
creased later fatness, respiratory symptoms and
eczema. The WHO recommends that infants
should be exclusively breastfed for 6 months be-
fore the introduction of complementary foods
[3] , based on a systematic review of the optimal
duration of exclusive breastfeeding [2] compar-
ing mother and infant outcomes with exclusive
breastfeeding for 6 months versus 3–4 months
(updated in 2012 [4] ). While there is agreement
that exclusive breastfeeding for 6 months is de-
sirable in situations where there is a lack of clean
drinking water or of safe nutritious complemen-
tary foods, there is less consensus regarding in-
fants in higher-income settings. Although many
countries have adopted the new WHO recom-
mendation, other countries still recommend 4–6
months of breastfeeding. The ESPGHAN Com-
mittee on Nutrition concluded that complemen-
tary foods should not be introduced before 17
weeks of age, but that all infants should start by
26 weeks of age [1]. A review by an expert panel
of the European Food Safety Authority also con-
cluded that the introduction of complementary

food to healthy term infants in the EU between 4

and 6 months is safe and does not pose a risk for

adverse health effects [5].

Content of the Diet

Most current guidelines on the gradual introduc-

tion of different foods during complementary

feeding are based on cultural factors and food

availability rather than scientific evidence. In de-

veloping countries, the focus is still on providing

adequate nutrients to support growth and devel-

opment, whereas in more affluent environments,

achieving a better balance of nutrients and avoid-

ing excess may be more important. Recommen-

dations are based on the concept that breast milk

cannot meet the full requirements for energy,

protein and micronutrients beyond about 6

months of age.

Energy

Energy requirements remain high during the first

year of life. The fat content of the diet is an impor-

tant determinant of its energy density and should

not be less than 25% of energy intake. A higher

proportion might be required if the infant’s ap-

petite is poor or if the infant has recurrent infec-

tions or is fed infrequently. Reduced-fat cow’s

milk reduces the energy density of the diet, and

consideration should be given to the rest of the

infant’s diet and to its growth when deciding to

introduce this. However, in countries with high

rates of childhood obesity, it may be advanta-

geous to accustom children to low-fat products

from a fairly early age.

Iron and Zinc

More than 90% of iron requirements during the

complementary feeding period of a breastfed in-

fant must be provided by complementary foods.

Strategies for achieving adequate iron and zinc in-

takes include the use of fortified weaning foods,

iron-fortified infant formulas, foods rich in bio-

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 109–112

DOI: 10.1159/000360327