when, where and by whom a child is fed (10,11). Behavioural studies have revealed that a casual style of feeding predominates in some populations. Young children are left to feed themselves, and encouragement to eat is rarely observed. In such settings, a more active style of feeding can improve dietary intake. The term “responsive feeding” (see Box 2) is used to describe caregiving that applies the principles of psychosocial care. A child should have his or her own plate or bowl so that the caregiver knows if the child is getting enough food. A utensil such as a spoon, or just a clean hand, may be used to feed a child, depending on the culture. The utensil needs to be appropriate for the child’s age. Many communities use a small spoon when a child starts taking solids. Later a larger spoon or a fork may be used. Whether breastfeeds or complementary foods are given first at any meal has not been shown to matter. A mother can decide according to her convenience, and the child’s demands. A Guiding Principle 4. Practise good hygiene and proper food handling Microbial contamination of complementary foods is a major cause of diarrhoeal disease, which is particularly common in children 6 to 12 months old (12). Safe preparation and storage of complementary foods can prevent contamination and reduce the risk of diarrhoea. The use of bottles with teats to feed liquids is more likely to result in transmission of infection than the use of cups, and should be avoided (13). All utensils, such as cups, bowls and spoons, used for an infant or young child’s food should be washed thoroughly. Eating by hand is common in many cultures, and children may be given solid pieces of food to hold and chew on, sometimes called “finger foods”. It is important for both the caregiver’s and the child’s hands to be washed thoroughly before eating. Bacteria multiply rapidly in hot weather, and more slowly if food is refrigerated. Larger numbers of bacteria produced in hot weather increase the risk of illness (14). When food cannot be refrigerated it should be eaten soon after it has been prepared (no more than 2 hours), before bacteria have time to multiply. Basic recommendations for the preparation of safe foods (15) are summarized in Box 3. Box 2 Responsive feeding K Feed infants directly and assist older children when they feed themselves. Feed slowly and patiently, and encourage children to eat, but do not force them. K If children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement. K Minimize distractions during meals if the child loses interest easily. K Remember that feeding times are periods of learning and love – talk to children during feeding, with eye-to-eye contact. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding The overall quantity of food is usually measured for convenience according to the amount of energy – that is, the number of kilocalories (kcal) – that a child needs. Other nutrients are equally important, and are either part of, or must be added to, the staple food. Figure 10 shows the energy needs of infants and young children up to 2 years of age, and how much can be provided by breast milk. It shows that breast milk covers all needs up to 6 months, but after 6 months there is an energy gap that needs to be covered by complementary foods. The energy needed in addition to breast milk is about 200 kcal per day in infants 6–8 months, 300 kcal per day in infants 9–11 months, and 550 kcal per day in children 12–23 months of age. The amount of food required to cover the gap increases as the child gets older, and as the intake of breast milk decreases (16). Table 1 summarizes the amount of food required at different ages,1 the average number of kilocalories that a breastfed infant or young child needs from complementary foods at different ages, and the approximate quantity of food that will provide this amount of energy per day. The quantity increases gradually month by month, as the child grows and develops, and the table shows the average for each age range. The actual amount (weight or volume) of food required depends on the energy density of the food offered. This means the number of kilocalories per ml, or per gram. Breast milk contains about 0.7 kcal per ml. Complementary foods are more variable, and usually contain between 0.6 and 1.0 kcal per gram. Foods that are watery and dilute may contain only about 0.3 kcal per gram. For complementary foods to have 1.0 kcal per gram, it is necessary for them to be quite thick and to contain fat or oil, which are the most energy-rich foods. Complementary foods should have a greater energy density than breast milk, that is, at least 0.8 kcal per gram. The quantities of food recommended in Table 1 assume that the complementary food will contain 0.8–1.0 kcal per gram. If a complementary food is more energy dense, then a smaller amount is needed to cover the energy gap. A complementary food that is more energy-dilute needs a larger volume to cover the energy gap. When complementary food is introduced, a child tends to breastfeed less often, and his or her intake of breast milk decreases (17), so the food effectively displaces breast milk. If complementary food is more energy diluted than breast milk, the child’s total energy intake may be less than it was with exclusive breastfeeding, an important cause of malnutrition. A young child’s appetite usually serves as a guide to the amount of food that should be offered. However, illness and malnutrition reduce appetite, so that a sick child may take less than he or she needs. A child recovering from illness or malnutrition may require extra assistance with feeding to ensure adequate intake. If the child’s appetite increases with recovery, then extra food should be offered. Box 3 Five keys to safer food K Keep clean K Separate raw and cooked K Cook thoroughly K Keep food at safe temperatures K Use safe water and raw materials Figure 10 Energy required by age and the amount from breast milk Energy from breastmilk Energy gap 0–2 m 3–5 m 6–8 m 9–11 m 12–23 m Age (months) 1200 1000 800