caused by poor attachment and not by prolonged feeds. The mother learns to respond to her baby’s cues of hunger and readiness to feed, such as restlessness, rooting (searching) with his mouth, or sucking hands, before the baby starts to cry. The baby should be allowed to continue suckling on the breast until he or she spontaneously releases the nipple. After a short rest, the baby can be offered the other side, which he or she may or may not want. If a baby stays on the breast for a very long time (more than one half hour for every feed) or if he or she wants to feed very often (more often than every 1–1½ hours each time) then the baby’s attachment needs to be checked and improved. Prolonged, frequent feeds can be a sign of ineffective suckling and inefficient transfer of milk to the baby. This is usually due to poor attachment, which may also lead to sore nipples. If the attachment is improved, transfer of milk becomes more efficient, and the feeds may become shorter or less frequent. At the same time, the risk of nipple damage is reduced. Guiding Principles for Complementary Feeding After 6 months of age, it becomes increasingly difficult for breastfed infants to meet their nutrient needs from human milk alone. Furthermore most infants are developmentally ready for other foods at about 6 months. In settings where environmental sanitation is very poor, waiting until even later than 6 months to introduce complementary foods might reduce exposure to food-borne diseases. However, because infants are beginning to actively explore their environment at this age, they will be exposed to microbial contaminants through soil and objects even if they are not given complementary foods. Thus, 6 months is the recommended appropriate age at which to introduce complementary foods (1). During the period of complementary feeding, children are at high risk of undernutrition (2). Complementary foods are often of inadequate nutritional quality, or they are given too early or too late, in too small amounts, or not frequently enough. Premature cessation or low frequency of breastfeeding also contributes to insufficient nutrient and energy intake in infants beyond 6 months of age. The Guiding principles for complementary feeding of the breastfed child, summarized in Box 1, set standards for developing locally appropriate feeding recommendations (3). They provide guidance on desired feeding behaviours as well as on the amount, consistency, frequency, energy density and nutrient content of foods. The Guiding principles are explained in more detail in the paragraphs below. A Guiding Principle 1. Practise exclusive breastfeeding from birth to 6 months of age and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed Exclusive breastfeeding for 6 months confers several benefits to the infant and the mother. Chief among these is the protective effect against gastrointestinal infections, which is observed not only in developing Box 1 Guiding principles for complementary feeding of the breastfed child 1. Practise exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed. 2. Continue frequent, on-demand breastfeeding until 2 years of age or beyond. 3. Practise responsive feeding, applying the principles of psychosocial care. 4. Practise good hygiene and proper food handling. 5. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding. 6. Gradually increase food consistency and variety as the infant grows older, adapting to the infant’s requirements and abilities. 7. Increase the number of times that the child is fed complementary foods as the child gets older. 8. Feed a variety of nutrient-rich foods to ensure that all nutrient needs are met. 9. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed 10. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, favourite foods. After illness, give food more often than usual and encourage the child to eat more. but also in industrialized countries. According to the WHO growth standards, children who are exclusively breastfed grow better in the first 6 months than other infants (4). By the age of 6 months, a baby has usually at least doubled his or her birth weight, and is becoming more active. Exclusive breastfeeding is no longer sufficient to meet all energy and nutrient needs by itself, Session 3 20 Infant and Young Child Feeding – Model Chapter for textbooks and complementary foods should be introduced to make up the difference. At about 6 months of age, an infant is also developmentally ready for other foods (5). The digestive system is mature enough to digest the starch, protein and fat in a non-milk diet. Very young infants push foods out with their tongue, but by between 6 and 9 months infants can receive and hold semi-solid food in their mouths more easily. A Guiding Principle 2. Continue frequent on-demand breastfeeding until 2 years of age or beyond Breastfeeding should continue with complementary feeding up to 2 years of age or beyond, and it should be on demand, as often as the child wants. Breast milk can provide one half or more of a child’s energy needs between 6 and 12 months of age, and one third of energy needs and other high quality nutrients between 12 and 24 months (6). Breast milk continues to provide higher quality nutrients than complementary foods, and also protective factors. Breast milk is a critical source of energy and nutrients during illness (7), and reduces mortality among children who are malnourished (8, 9). In addition, as discussed in Session 1, breastfeeding reduces the risk of a number of acute and chronic diseases. Children tend to breastfeed less often when complementary foods are introduced, so breastfeeding needs to be actively encouraged to sustain breast-milk intake. A Guiding Principle 3. Practise responsive feeding applying the principles of psychosocial care Optimal complementary feeding depends not only on what is fed but also on how,