The first year of a child’s life is a critical window during which not only the foundations for healthy growth and development are built, but also it determines long term adult health.1  Adequate infant feeding is a major determinant of health in this period2 which ensures growth, health and development to their full potential.3  If poor nutrition and stunting occur, the effects continue throughout life, contributing to poor school performance, reduced productivity, and impaired intellectual and social development. 2  Thus, the requirements for energy, macronutrients and micronutrients are of immense importance to be met.

Dietary recommendations: 0-6 months

Exclusive breastfeeding offers ideal nutrition and is sufficient to support optimal growth and development for the first six months after birth.4,5  Human milk is more than efficient to meet the infant’s estimated energy requirements since reported intakes of children receiving exclusive breastfeeding exceed requirements by 10% to 20% up to the age of 6 months.6  No other foods or fluids are necessary during this period of exclusive breastfeeding. While in many countries it is still common for mothers to give the infant additional water, this is not needed since breast milk itself is 88% water, which is enough to satisfy a baby’s thirst.7  Vitamin D-supplementation is recommended in many parts of the world as infants are often not sufficiently exposed to sunlight.3  As the mother’s diet is related to the breast milk composition, it is also very important to ensure that breastfeeding mothers receive adequate amounts of energy and nutrients.8

However, if breastfeeding is not possible, an appropriate for age infant formula enriched with nutrients such as iron, vitamin D and omega-3 polyunsaturated acids, as indicated in relevant directives and/or expert recommendations, will accommodate the infant’s needs.9,10  Attention should be given to the preparation instructions, since overly dense or diluted formula will not offer adequate nutrient concentration.11,12

Dietary recommendations: 6-12 months

After 6 months of age the differences between nutrient requirements and the estimated nutrient intake from human milk2 or follow-on formula9,10 are assumed to be covered by complementary foods. This is in timely coherence with infant’s developmental readiness (oral, gross and fine motor skills) and gastrointestinal tract capability of handling foods at about the 6th month of life.11 Special attention should be given if the child is exclusively breastfed after six months of age (as often recommended) since requirements for specific nutrients such as iron, zinc, vitamin B-6, niacin, vitamin D, vitamin E, magnesium, phosphorus, biotin, and thiamin may not be met by the average intake of human milk.11  If the infant is formula fed, it is more likely that higher intakes for some of those nutrients are achieved since most formulas, depending on the relevant legislations, are additionally fortified with those nutrients.10  However, regardless whether the infant is breastfed or formula fed, complementary feeding should include nutrient-dense foods in order to ensure adequate nutrient intake to meet nutritional needs as presented in the appendix.

Furthermore, beyond covering nutritional needs, complementary feeding offers new tasting experiences to the infant, it assists the development of skills, such as biting and chewing13 and finally, it is the first step to a gradual transition to family food choices by the end of this life stage2 as presented in table 1.

Table 1. Stages of complementary feeding13,14
Stage Age range consistency   foods
1 6 months Smooth pureed foods.  Nutrient needs in the first year of life 1 Fruit, vegetables, rice, potatoes, yam, meat, yoghurt, cheese and custard
2 6-9 months Thicker consistency with some lumps; soft finger foods can also be introduced at this stage.  Nutrient needs in the first year of life 2 Fruit, vegetables, rice, potatoes, yam, meat, fish, pulses, eggs, yoghurt, custard, cheese, bread and cereals
3 9-12 months Mashed, chopped, minced consistency; more finger foods  Nutrient needs in the first year of life 3 Fruit, vegetables, rice, potatoes, yam, meat, fish, pulses, eggs, yoghurt, custard, cheese, bread and cereals

 

Complementary foods for 6-12 months old infants should include a variety of foods to ensure that nutrient needs are met. Based on recommendations from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), cereals should be the first food to be introduced between the 4-6th month of age since this may lower the risk of food allergies.15  The common advice to start vegetables before fruits before meats does not appear to be based on scientific evidence. The guidelines, therefore, state that the order of introduction of complementary foods is not critical, except with respect to providing the nutrients needed from complementary foods.11  Drinks with low nutritional value, such as tea, coffee and sugary drinks such as soda should be avoided.16

APPENDIX

Summary of the US dietary reference intakes (DRIs) and food sources of the key nutrients for infants (0-12 months of age)
Nutrient Age DRIsa Sources of nutrients for infants b, c
Energy 0-3mo (89*weight of infant [kg]-100)+175 Human milk or iron-fortified infant formula, complementary foods.
4-6mo (89*weight of infant [kg]-100)+56
7-12mo (89*weight of infant [kg]-100)+22
       
Protein 0-6mo 9,1g/d or 1,52g/kg/d Human milk or iron-fortified infant formula, meats
7-12mo 13,5g/d (RDA)
     
Carbohydrate 0-6mo 60g/d Human milk or iron-fortified infant formula, complementary foods.
7-12mo 95g/d
     
Total fat 0-6mo 31g/d Human milk or iron-fortified infant formula, meat, chicken, vegetable oils, margarines
7-12mo 30g/d
n-6 polyunsaturated

fatty acids (linoleic acid)

0-6mo 4.4 g/d Corn, safflower and

soybean based oils or spreads

7-12mo 4.6 g/d
n-3 polyunsaturated

fatty acids

(α-linolenic acid, docosahexaenoic acid DHA, eicosapentaenoic acid EPA)

0-6mo 0.5 g/d Alpha-linolenic acid: Soybean and canola based oils and spreads,

DHA and EPA: fish

7-12mo 0.5 g/d
Vitamin D 0-6mo 10μg Iron-fortified infant formula, vitamin D supplement
7-12mo 10μg
Iron

 

 

0-6mo 0,27mg Iron-fortified infant formula,

meats, iron-fortified infant cereals

7-12mo 6,9mg (EAR)
Zinc 0-6mo 2mg Human milk or iron-fortified infant formula, meats, zinc-fortified infant cereal
7-12mo 2,5 mg (EAR)
Vitamin B-6 0-6mo 0,1mg Human milk or iron-fortified

infant formula, infant cereal, enriched or whole-grain products

7-12mo 0,3mg
Niacin 0-6mo 2mg NE Human milk or iron-fortified

infant formula, infant cereal

7-12mo 4mg NE
Vitamin E 0-6mo 4mg Human milk or iron-fortified

infant formula, infant cereal,

vegetable oils, mashed avocado

7-12mo 5mg
Magnesium 0-6mo 30mg Human milk or iron-fortified infant formula, infant cereals, meats
7-12mo 75mg
Biotin 0-6mo 5μg Human milk or iron-fortified infant formula, infant oatmeal cereal
7-12mo 6μg
Thiamin 0-6mo 0,2mg Human milk or iron-fortified

infant formula, infant cereal

7-12mo 0,3mg
Phosphorus 0-6mo 100mg Human milk or iron-fortified

infant formula, infant cereals, meats

7-12mo 275mg

AI: Adequate Intake.
RDA: Recommended Dietary Allowance
EAR: Estimated Average Requirement.
NE: niacin equivalents which represent preformed niacin plus tryptophan equivalents (60 mg tryptophan = 1 mg niacin)

DRIs include four nutrient-based reference values that are used to assess and plan the diets of healthy people. The reference values include the Estimated Average Requirement (EAR), the Recommended Dietary Allowance (RDA), the Adequate Intake (AI), and the Tolerable Upper Intake Level (UL). Unlike the RDAs and RNIs (prior to 1990), which focused primarily on reducing the incidence of diseases of deficiency, the DRI-values are also intended to help individuals optimize their health, prevent disease, and avoid consuming too much of a nutrient.

a:   AIs are presented unless otherwise indicated. In general, for infants 0 to 6 months, the AI reflects the average nutrient intake from human milk. For infants 7 to 12 months, the AI may be based on average nutrient intake from human milk plus infant foods or extrapolated from estimates of older children or adult requirements.
b: Adapted from sources of nutrients provided by Duyff RL. American Dietetic Association Complete Food and Nutrition Guide, 2nd ed. Hoboken, NJ: John Wiley and Sons; 2002.
c:   Breast milk is the preferred choice for the first six months

  • Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty acids, Cholesterol, Protein and Amino acids. Washington, DC: National Academy Press; 2002.
  • Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press; 2002.
  • Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press; 2000.
  • Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 2000.
  • Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC

References

  1. Barker, D.J., Maternal nutrition, fetal nutrition, and disease in later life. Nutrition, 1997. 13(9): p. 807-13.
  2. WHO, Complementary feeding: report of the global consultation, and summary of guiding principles for complementary feeding of the breastfed child. Geneva, Switzerland, 2001.
  3. WHO, Infant and young child feeding : model chapter for textbooks for medical students and allied health professionals. France, 2009.
  4. Gidding, S.S., et al., Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the American Heart Association. Circulation, 2005. 112(13): p. 2061-75.
  5. http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/ (assessed on 21-05-2014)
  6. Devaney, B., et al., Nutrient intakes of infants and toddlers. J Am Diet Assoc, 2004. 104(1 Suppl 1): p. s14-21.
  7. LINKAGES, Exclusive breastfeeding: The only water source young infants need. FAQ Sheet 5 Frequently asked Questions. . Washington DC, Academy for Educational Development, 2002.
  8. WHO, Nutrition and breastfeeding promotion. Ch. 6: Opportunities for Africa’s Newborns,.
  9. European Comission Directive 2006/141/EC on infant formulae and follow-on formulae and amending Directive 1999/21/EC, O.J.o.t.E.U.
  10. Koletzko, B., et al., Global standard for the composition of infant formula: recommendations of an ESPGHAN coordinated international expert group. J Pediatr Gastroenterol Nutr, 2005. 41(5): p. 584-99.
  11. Butte N, C.K., Dwyer J, Graney L, Heird W, Rickard K, The Start Healthy Feeding Guidelines for Infants and Toddlers. Journal of the American Dietetic Association, 2004. 104(3 Suppl): p. S442-454.
  12. Shelov S. Feeding your baby: breast and bottle. In: American Academy of Pediatrics Caring for Your Baby and Young Child— Birth to Age 5. New York, N.B.
  13. Centre for Excellence in Interprofessional Education, F.a.N.i.I.a.C., 2009 Queen’s University Belfast.
  14. BDA Paediatric Group, W.-F.f.s., 2013 www.bda.uk.com/foodfacts.
  15. Agostoni, C., et al., Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr, 2008. 46(1): p. 99-110.
  16. WHO, Feeding the non-breastfed child 6-24 months of age. Geneva 2004.