600 400 200 0 Energy (Kcal/day) 1 The age ranges should be interpreted as follows: a child 6–8 months is 6 months or older (≥ 180 days) but is not yet 9 months old (< 270 days). 22 Infant and Young Child Feeding – Model Chapter for textbooks A Guiding Principle 6. Gradually increase food consistency and variety as the infant grows older, adapting to the infant’s requirements and abilities The most suitable consistency for an infant’s or young child’s food depends on age and neuromuscular development (19). Beginning at 6 months, an infant can eat pureed, mashed or semi-solid foods. By 8 months most infants can also eat finger foods. By 12 months, most children can eat the same types of foods as consumed by the rest of the family. However, they need nutrient-rich food, as explained in Guiding principle 8, and foods that can cause choking, such as whole peanuts, should be avoided. A complementary food should be thick enough so that it stays on a spoon and does not drip off. Generally, foods that are thicker or more solid are more energy- and nutrient-dense than thin, watery or soft foods. When a child eats thick, solid foods, it is easier Table 1 Practical guidance on the quality, frequency and amount of food to offer children 6–23 months of age who are breastfed on demand Age Energy needed per dayin Texture Frequency Amount offood an average addition to breast milk child will usually eat at each meala 6–8 months 200 kcal per day Start with thick porridge, 2–3 meals per day Start with 2–3 tablespoonfuls well mashed foods per feed, increasing gradually Depending on the child’s appetite, to ½ of a 250 ml cup Continue with mashed 1–2 snacks may be offered family foods 9–11 months 300 kcal per day Finely chopped or mashed 3–4 meals per day ½ of a 250 ml cup/bowl foods, and foods that baby can pick up Depending on the child’s appetite, 1–2 snacks may be offered 12–23 months 550 kcal per day Family foods, chopped or 3–4 meals per day ¾ to full 250 ml cup/bowl mashed if necessary Depending on the child’s appetite, 1–2 snacks may be offered Further information The amounts of food included in the table are recommended when the energy density of the meals is about 0.8 to 1.0 kcal/g. If the energy density of the meals is about 0.6 kcal/g, the mother should increase the energy density of the meal (adding special foods) or increase the amount of food per meal. For example: — for 6 to 8 months, increase gradually to two thirds cup — for 9 to 11 months, give three quarters cup — for 12 to 23 months, give a full cup. The table should be adapted based on the energy content of local complementary foods. The mother or caregiver should feed the child using the principles of responsive feeding, recognizing the signs of hunger and satiety. These signs should guide the amount of food given at each meal and the need for snacks. a If baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day (18). to give more kcal and to include a variety of nutrient-rich ingredients including animal-source foods. There is evidence of a critical window for introducing ‘lumpy’ foods: if these are delayed beyond 10 months of age, it may increase the risk of feeding difficulties later on. Although it may save time to continue feeding semi-solid foods, for optimal child development it is important to gradually increase the solidity of food with age. A Guiding Principle 7. Increase the number of times that the child is fed complementary foods as the child gets older As a child gets older and needs a larger total quantity of food each day, the food needs to be divided into a larger number of meals. The number of meals that an infant or young child needs in a day depends on: 3. Complementary feeding 23 K how much energy the child needs to cover the energy gap. The more food a child needs each day, the more meals are needed to ensure that he or she gets enough. K the amount that a child can eat at one meal. This depends on the capacity or size of the child’s stomach, which is usually 30 ml per kg of the child’s body weight. A child who weighs 8 kg will have a stomach capacity of 240 ml, about one large cupful, and cannot be expected to eat more than that at one meal. K the energy density of the food offered. The energy density of complementary foods should be more than breast milk, that is, at least 0.8 kcal per gram. If the energy density of food is lower, a larger volume of food is needed to fill the gap, which may need to be divided into more meals. As shown in Table 1, a breastfed infant 6-8 months old needs 2–3 meals a day, and a breastfed infant 9–23 months needs 3–4 meals a day. Depending on the child’s appetite, 1–2 nutritious snacks may be offered. Snacks are defined as foods eaten between meals, often self-fed finger foods, which are convenient and easy to prepare. If they are fried, they may have a high energy density. The transition from 2 to 3 meals, and from smaller to larger meals, happens gradually between those ages, depending on the child’s appetite and how he or she is developing. If a child eats too few meals, then he or she will not receive enough food to cover energy needs. If a child eats too many meals, he or she may breastfeed less, or may even stop breastfeeding altogether. In the first year of life, displacement of breast milk may reduce the quality and amount of the child’s total nutrient intake. A Guiding Principle 8. Feed a variety of nutrient-rich foods to ensure that all nutrient needs are met Complementary foods should provide sufficient energy, protein and micronutrients to cover a child’s energy and nutrient gaps, so that together with breast milk, they meet all his or her needs. Figure 11 shows the energy, protein, iron and vitamin A gaps that need to be filled by complementary foods for a breastfed child 12–23 months of age. The light part of each bar shows the percentage of the child’s daily needs that can be provided by an average intake of 550 ml of breast milk. The dark part of the bar shows the gap that needs to be filled by complementary foods. Figure 11 Gaps to be filled by complementary foods for a breastfed child 12–23 months Energy Protein Iron Vitamin A Nutrient Gap Provided by 550