Download Article - Lebanese Pediatric Society

Complementary Foods Of Infancy
Introduction:
Milk in general and Breast milk particularly is the essential food for babies during their first year of life. However, around the age of 6
months nutritional needs of babies increase and they should be supplemented with complementary feedings to provide them with
adequate amounts of calories minerals and vitamins. There is no specific sequence or rate about starting this new experience in your
baby’s life, and babies differ in their readiness to accept complementary foods which depends on achievement of certain
developmental milestones. The following feeding protocols are derived from several guidelines advocated by World Health
Organization, International Scientific Societies, Expert Pediatricians’ Opinions and recommendations of the dietary department at
AUBMC. Our recommendations (Table - 1) aim at helping parents about the best time and sequence to start this exciting process and
to prevent disease like obesity malnutrition and food allergy in you child. Our guidelines do not replace the professional advice of
your corresponding pediatrician who will determine the best time to start this exciting experience in your baby’s life.
Developmental milestones that indicate your baby’s readiness to accept complementary food
1. Fading of the extrusion reflex (the tongue-thrust reflex that pushes food out of the mouth) and elevating the tongue to move
pureed food forward and backward in mouth (It usually occurs between 4 and 6 months of age).
2. The infant indicates his desire for food, by opening his mouth and leaning forward, and indicates disinterest or satiety by
leaning back and turning away (It usually occurs between 4 and 6 months of age).
3. Ability to sit independently and trying to grasp foods with his palms. He is ready then to progress to thicker pureed foods and
soft, mashed foods without lumps. He also can begin to sip from a small cup. (It usually occurs between 7 and 9 months of
age).
4. When the infant develops a pincer grasp (the ability to pick up objects between thumb and forefinger), becomes able to crawl
and to pull to stand (usually at 9 - 10 months), he begins to mash food by using his jaw and tongue. He can play with a spoon
at mealtime (but does not use it for self-feeding yet), and tries to hold a cup independently. At this stage, you can progress to
ground or soft, mashed foods with small, soft, noticeable lumps (eg, finely chopped meat or poultry). Finger foods, foods that
can be picked up by the baby, such as baby crackers or dry cereal are good choices. Avoid finger foods that can cause choking,
such as popcorn, grapes, raw carrots, nuts, hard candies, and hot dogs, should be avoided.
Finally, your PEDIATRICIAN can tell you about the normal progression of the development of feeding and eating skills of your
baby, and his/her ability to safely eat to make this new experience in your infant’s life enjoyable to both of you.
GENERAL CONSIDERATIONS
1. An exclusively breast-fed infant would be expected to plot higher for weight in the 1st 6 months, but relatively lower in the
2nd half of the 1st year compared to bottle fed infants. Do not warm bottles in microwave.
2. Infants may lose up to 10% of their birth weight in the 1st week of life and regain it by the end of the 2nd week.
3. Feeding quantity varies from one baby to another and may vary in the same child between health and illness. (Table 2)
4. Always start with small feedings e.g. two teaspoons, and increase gradually to reach your baby’s actual needs. Adequate
feeding practice is reflected in adequate weight gain for age.
5. Use well cooked meat to feed your baby and replace saturated fat with 2 teaspoonful of vegetable oil e.g. olive or corn oil
during lunch food preparation. (Table-1). Don’t give saturated fat, margarine or butter before the age of 1 year.
6. Do not put baby to bed with bottle.
7. Brush baby teeth with soft brush with water only. Discuss fluoride administration with your doctor.
8. No spicy or hot foods before 1 year of age.
9. No white egg or honey before 1 year of age.
10. No Peanut butter before 2 years of age because of high risk of peanut butter allergy.
11. No nuts before 3 year of age because of risk of chocking and foreign body aspiration.
12. Avoid carbonated soda and limit the use of fruit drinks and foods that are high in calories, fat, and sugar, such as sweetened
drinks, sodas, chips, and french fries before the age of 24 months.
13. Dairy products should be delayed till one year of age if there is a family history of cow’s milk allergy.
14. Offer full fat milk for infants <2 years of age; low fat from 2 to 4 years and skimmed milk to children after 4 years of age.
15. No coffee or alcoholic beverage.
16. Fluoride, vitamin D, and iron supplementations should be considered as recommended by your pediatrician and as follows:a. Fluoride supplementation is recommended after age of 6 months if fluoride content of water is less than 0.3 mg/L (0.3
ppm F).
b. Formula milk contains enough amount of vitamin D. Breastfed and preterm infants should be supplemented with
Vitamin D.
c. Formula milk contains enough amount of iron. Breastfed and preterm infants should be supplemented with iron.
TABLE -1. Feeding Protocols
Age
0-6
months
6-8
months
8-10
months
10-12
Months
> 12
months
Brest Milk /
Formula
Cereals
(AM snack)
Up to 10 feeds in
breast fed babies.
Number of feedings
decrease to 4-6 feeds
at 6 months. Formula None
fed babies are less
frequently fed.
Start with Iron fortified
Up to 4 feed of milk / single ingredient cereal
day.
e.g. rice, maize,
semolina, or wheat
cereal followed by
mixed cereals.
Vegetables
(Lunch)
Fruits / Juices
(PM snack)
Meat
(Lunch)
None
None
None
Start with one item apart with
blended baked or cooked
vegetable item e.g. skinless
potato zucchini, carrots, green
beans, peas, avocado,
broccoli, or spinach. Start by
small amounts and increase
gradually. Multiple ingredient
vegetable soup at around 7
months.*
Add cauliflower and cabbage
in addition to above
vegetables.
Start with one item
apart e.g. blended
skinless apple,
skinless pear,
banana, carrots,
melon, & peaches.
Juices include
unsweetened apple,
grape and carrot
juice.*
Add mango,
apricot, plums and
seedless grapes.
After semisolid mixed
vegetables are
administered vegetable
soup may be prepared
in boiled meat water.
Meat may be added a
later each at a time.
You may start with
chicken, turkey, or beef
meat.*
Add dry bean, fava
bean, lentils and
chickpeas.
All fruits. Use
orange & citrus
juices with caution
in cases of allergy.
All types of juices.
Add egg yolk and fish.
Up to 4 feed of milk /
day. Include cheese
slices, & full fat
Labneh.
Up to 4 feeds of milk
/ day.
Mashed wheat & whole
grain cereals, noodles,
pasta, bread.
All types of cereals.
Vegetables chopped and
sliced into small pieces.
2-3 cups per day of
milk or dairy
products.
All types of cereals,
milk puddings.
Semi solid family food
introduced. Non-spicy
All types of meat.
* Solid foods should be introduced as a single-ingredient item at 2-7 days intervals to check for symptoms of allergy to any food item.
Allergy manifests as excessive crying, vomiting, diarrhea or skin rash.
Suggested Feeding Practice
Absolute milk feeding is recommended during the first 6 months* of life. To ensure an adequate amount of
protein, fat, and carbohydrate during the next sixth to twelfth months, infants should be offered and should
consume no more than an average of 850 ml of milk (28 oz) each day in addition to their quota of solids.
Different types of infant diets may be prepared according to age from Table – 1 as examples:
Example 1
Breakfast
: Milk
Midmorning Snack
: Cereals with or without milk OR Cereals with or without milk OR Fruits
Lunch
: Meat, yellow or green vegetables plus 2 tea spoonful of oil, fruit OR Milk
Mid-afternoon Snack
: Cereals with or without milk OR Cereals with or without milk OR Fruits
Dinner
: Milk OR Yogurt, or cereals with milk
Bedtime
: Milk
Night*
: Milk
Example 2 (Add any example you follow in your practice ………………………….)
Breakfast
:
Midmorning Snack
:
Lunch
:
Mid-afternoon Snack
:
Dinner
:
Bedtime
:
Night*
:
* Your Pediatrician may choose to start your baby on complementary food after the end of his 4th month
depending on achievement of adequate milestones.
**Milk feedings should be discouraged at night.
Suggested progression through cereals, vegetables, meats, and eggs:
6-7 months
7-8 months
9-10 months
12-13 months
: Cereals, fruits and vegetables (avoid citrus fruits before 10 months)
: Meats (calf, chicken and turkey)
: Family food, egg yolk, Fish, and citrus fruits
: Egg white and Honey
Table -2. Growth and respective Caloric Requirements
AGE
0-3 mo
APPROXIMATE
WEIGHT GAIN
(gram/month)
GROWTH IN
LENGTH
(cm/month)
GROWTH IN HEAD
CIRCUMFERENCE
(cm/month)
RECOMMENDED DAILY
ALLOWANCE
(Kcal & Volume)
900
3.5
2
170ml/kg/day of milk
2
1
165ml/kg/day of milk
1.5
0.5
150ml/kg/day of fluids1
1.2
0.5
150ml/kg/day of fluids1
(30 grams / day)
3-6 mo
500
( 20 grams / day)
6-9 mo
450
(15 grams / day)
9-12 mo
350
(12 grams / day)
1-
The above amount represents total amount of fluid requirements from milk and other food items. After the age of 6 months
complementary food will decrease amount of daily milk intake which should not be less than 850 ml/day at any time.
Table 3- Average Feeding Quantities1
Daily Requirements
Age
4-6 months
6-9 months
9-12 months
Milk
4-6 feedings per day (150-200 ml
of milk per feeding)
3-5 feedings per day (not less than
850 ml / day)
2-4 feedings per day (not less than
850 ml /day)
Foods
1-4 teaspoonful of iron fortified rice cereal once or twice/day after
consultation of your primary care pediatrician.
4-8 Tbsp (Table spoonful) iron fortified cereal.
6-9 Tbsp fruits
4-6 Tbsp vegetables
1-3 Tbsp meat or alternative
4-6 Tbsp cereal (preferably iron-fortified)
8-11Tbsp fruit
6-10 Tbsp vegetables
4-6 Tbsp meat or alternative
Last updated June, 2009
References:
1- Nutritional adequacy at 2, 4, 6, 9 & 12 months visits. Textbook of Pediatric Care Online. AAP publications,
2009.
2- B. Dubern. Diversification Alimentaire Chez le Jeune Enfant. Encyclopedie Medico-Chirurgicale Pédiatrie.
Elsevier Masson SAS, 2008.
3- L Charafeddine. Regular pediatric diets. (Parents’ hand outs, 2007)
4- V Keane. Assessment of Growth. Nelson Text book of pediatrics 18th edition, 2007.
5- AAP released clinical reports on the effect of early nutritional interventions. Pediatrics February, 2006: 544559.
6- M Itani. Infant Diet List. (Parents’ hand outs, 2003)
7- Infant and Young Child feeding. Nutrition, UNICEF. http://www.unicef.org/nutrition/index_24826.html
8- Guidelines for health supervision of infants. Bright futures 2nd edition, Revised 2002.
9- Manual of clinical dietetics, 2000.