Feeding the baby

Complementary feeding - any food or liquid other than breast milk or its substitutes, which children are fed in the first year of life. Revision of some provisions on the accepted schemes for introducing complementary feeding cannot be called exclusively fundamental, but here too the positions of specialists are often very ambiguous. First of all, the degree of necessity in the introduced complementary feeding directly depends on the degree of confidence in the quality of mother's milk and breastfeeding in general. Optimal feeding with good nutrition of the pregnant and nursing mother can fully ensure good development of the child without complementary feeding up to 1 - 1 1/2 years. Accordingly, such prolongation is exclusively breastfeeding, but at the same time optimal feeding can be associated with the greatest biological advantages for the child or future adult. The lack of confidence in the optimality of feeding in the overwhelming majority of nursing women can be the basis for recommendations and indications on the mandatory introduction of thick complementary feeding in the interval from 4 to 6 months.

According to WHO recommendations, a child should be fed exclusively with breast milk through breastfeeding for about 6 months, with subsequent introduction of complementary foods. Other organizations advise introducing complementary foods between 4 and 6 months of life, while continuing breastfeeding or formula feeding during this time. Up to 4 months, a child does not need complementary foods, and the expulsion reflex, in which the tongue pushes out of the mouth everything that is put there, significantly complicates feeding the child.

Complementary foods should be introduced first after breastfeeding or formula feeding to ensure that the baby is getting enough nutrition. Traditionally, iron-fortified rice cereal is introduced as the first food, as it has the advantage of being non-allergenic, easy to digest, and providing the baby with the iron it needs. It is generally recommended that each new ingredient be introduced separately over a period of a week, so that food allergies can be identified. There is no specific order in which to introduce complementary foods, although they are usually introduced in a progressively less processed manner, such as from rice cereal to pureed foods and then to coarsely grated foods. Meat, when pureed to prevent aspiration, is a good source of iron and zinc, which are limited in breast milk, making it a good complementary food. Vegetarian babies can also get enough iron from iron-fortified cereals, grains, peas, dried beans, and zinc from fermented whole grain breads and fortified baby cereals.

Home-cooked foods are equivalent to commercially produced baby food, but ready-made vegetable purees such as carrots, beets, turnips, and spinach are preferable for children under one year of age because they are controlled for nitrates, which are present if vegetables are grown using water with added fertilizers, and which can cause methemoglobinemia in young children. Eggs, peanuts, and cow's milk should not be given to children under one year of age to prevent food sensitization. Honey should be avoided until one year of age because of the risk of infant botulism. Foods that can cause airway obstruction if aspirated should not be given (e.g., nuts, jelly beans, round candies) or should be given pureed (meat) or cut into small pieces (grapefruit). It is better to give nuts after 2-3 years, since they are not completely chewed and small pieces can get into the respiratory tract during aspiration with or without the development of bronchial obstruction and cause pneumonia or other complications.

Whole cow's milk can be introduced at or after age one; skim milk should not be given until age two, when the child's diet has become much closer to that of the rest of the family. Parents should be advised to limit daily milk intake to 16 to 20 ounces for younger children; more milk may reduce the amount of other important foods and lead to iron deficiency.

Juice is low in nutrients, causes dental caries, and should be limited to 4-6 ounces per day or avoided altogether.

At about one year of age, the growth rate usually slows. Children need less food and may refuse some meals. Parents should be reassured and advised to estimate the amount of food the child eats per week, not per feeding or per day. Malnutrition should only be considered if the child is not gaining weight in accordance with his or her age and physical development.

Based on the calculations of American specialists in child nutrition, it was concluded that at 6-8 months, a child fed exclusively with breast milk receives approximately 50% less iron, zinc, manganese, fluorine, vitamins D and B6, E, niacin, biotin, thiamine, magnesium, and phosphorus.

Estimated amounts of energy and nutrients required from complementary foods for breastfed infants according to EER, AL or RDA (WHO, 1998, Institute of Medicine, Food and Nutrition Board, American Academy of Pediatrics 2004-2006 rr.)

Nutrients and energy	The amount that needs to be obtained from complementary foods	Proportion of DRI to be obtained from complementary foods	The amount that needs to be obtained from complementary foods	Proportion of DRI to be obtained from complementary foods
	Age 6-8 months		Age 9-11 months
Energy, kcal	25	372	49
Protein, g	2.47	25	4.19	42
Vitamin A, mcg IU	146,00	29	228,00	46
Biotin, mcg	3.17	53	3.82	64
Folate, mcg	19.82	25	33.76	42
Niacin, mg	2.94	73	3.18	80
Pantothenic acid, mg	0.53	29	0.82	46
Riboflavin, mg	0.15	38	0.21	52
Thiamine, mg	0.15	50	0.19	62
Vitamin B6, mcg	234.16	78	249.41	83
Vitamin B-12, mcg	-0.19		-0.03
Vitamin C, mg	21.68	43	28,24	56
Vitamin D, mcg	4.61	92	4.70	94
Vitamin E, mg	3.37	67	3.75	75
Vitamin K, mcg	1.01	41	1.36	54
Calcium, mg	71,76	27	117.68	44
Chromium, mcg	-29.90		-21.70
Copper, mg	0.04	20	0.08	38
Fluorine, mcg	488.67	98	491.30	98
Iodine, mcg	52.12	40	70.16	54
Iron, mg	10.79	98	10.84	99
Magnesium, mg	50.22	67	55.96	75
Manganese, mcg	595.75	99	596.74	99
Phosphorus, mg	175.88	64	198.84	72
Selenium, mcg	5.84	29	9.12	46
Zinc, mg	2.15	72	2.35	78

Note: EER - estimated energy requirements; AL - adequate intake; RDA - recommended daily intake; DRI - dietary reference values.

The amount of nutrients to be provided with complementary foods was calculated based on the difference between the DRI and the estimated amount of nutrients supplied with human milk.

The recommendations change relatively little. Of the new and well-founded trends that have emerged in recent years, the following should be noted first and foremost:

1. tendency to delay the introduction of complementary foods;
2. transition from formal age-based selection of terms to formulations of individual indications and terms;
3. the allocation of preparatory, or “training”, complementary feeding;
4. trends in replacing traditional home-cooked complementary foods with factory-made cereals, vegetables and meat purees produced by the baby food industry; the advantage of the latter is that they are enriched with essential nutrients, which is essential for achieving a multi-component balanced diet;
5. the tendency to replace whole cow's milk or kefir (step 3) with a new group of dairy products for baby food - second-line formulas, or "follow up"; this tendency also arose from the need to ensure a multi-component balance of the daily diet with a decreasing amount of breast milk in its composition; the second reason for limiting cow's milk is the desire to reduce the direct immunotoxic effect of cow's milk casein on the intestinal epithelium.

The general trend is to introduce complementary foods somewhat later during breastfeeding. Currently, the complementary foods introduction scheme developed by the Institute of Nutrition of the Russian Academy of Medical Sciences is in effect.

Scheme for introducing complementary foods during breastfeeding (methodological guidelines of the Ministry of Health of the Russian Federation No. 225 “Modern principles and methods of feeding children in the first year of life”, Moscow, 1999)

Products and dishes	Age, months
	0-3	3	4	5	6	7	8	9-12
Fruit juice, ml		5-30	40-50	50-60	60	70	80	90-100
Fruit puree, g*		5-30	40-50	50-60	60	70	80	90-100
Vegetable puree, g			10-100	150	150	170	180	200
Milk porridge, g				50-100	150	150	180	200
Cottage cheese, g				10-30	40	40	40	50
Yolk, pcs.						0.24	0.5	0.5
Meat puree, g						5-30	50	60-70
Fish puree, g							5-30	30-60
Kefir and fermented milk products, ml						200	200	400-500
Whole milk, ml			200**	200**	200**	200**	200**	200
Rusks, cookies, g					3-5	5	5	10-15
Wheat bread, g						5	5	10
Vegetable oil, ml**			1-3	3	3	5	5	6
Butter, g				1-4	4	4	5	6

• * - Fruit puree is introduced 2 weeks after the introduction of juice.
• ** - For preparing complementary foods (vegetable purees, porridges).

However, the accumulated experience allows us to introduce some clarifications and additions. First of all, this concerns the timing of introducing juices. Their introduction earlier than the 4th month is inappropriate. Juices do not make any significant contribution to satisfying the needs for vitamins and minerals, while at the same time they can lead to the development of allergic reactions and digestive breakdowns.

At the same time, it is often advisable not to use a simple chronological (age-based) prescription of complementary foods, but to introduce them individually. In this case, it is possible to maintain lactation for a long time in the mother and to maximally extend the period of exclusive breastfeeding. Such an individual delay should primarily apply to the energy-significant volume of complementary foods or non-dairy food. Along with this, all children should receive very small amounts (1-2 teaspoons per day) of vegetable or fruit puree as the so-called pedagogical, or training, complementary foods from the age of 4-6 months. “Training” complementary foods pursue their own goals - they allow the child to become familiar with different sensations of taste and consistency of food, train oral mechanisms of food processing and prepare the child for the period when he will need an energy supplement. The introduction of “training” complementary foods is not a departure from exclusive breastfeeding. Individualization of the time period for introducing “training” complementary foods can only be based on the following signs of the child’s maturity:

1. extinction of the "pushing out" reflex (with the tongue) with a well-coordinated reflex of swallowing food;
2. the child's readiness to chew when a pacifier or other objects enters the mouth.

As a "training" complementary food, you can use 5-20 g of grated apple or sugar-free fruit puree. From the tip of a teaspoon, insert some puree or apple into the middle part of the baby's tongue. It is advisable to do this after he has already sucked some milk from the breast, still retained a feeling of hunger, but has already enjoyed the beginning of feeding. If the baby swallows well, tolerates it well and does not have an allergic reaction to complementary food, it can be given regularly and transferred to the beginning of feeding. If an allergic reaction occurs, you should refuse this complementary food product for a long time and, if possible, postpone the introduction of complementary food in general. The age most suitable for "training" or testing complementary food in most European countries and the USA is between the 16th and 24th weeks of life. The duration of using this complementary food is about 2-3 weeks. However, “training” complementary feeding can be introduced for a long period of time if the child is satisfied exclusively with the mother’s breast milk, his body weight increases well, and he develops well psychomotorically.

An indication for introducing basic or energy-significant complementary feeding should be a clear manifestation of the child's dissatisfaction with the volume of milk received at such a state of physiological maturity when this dissatisfaction can already be compensated for by thick complementary feeding. The mother can easily recognize the baby's dissatisfaction after breastfeeding by the child's restlessness and increased frequency of crying. This leads to a greater frequency of latching on, repeated night awakenings of the baby with a hungry cry, a decrease in the number of wet diapers and a decrease in stool frequency. Some children may develop objective signs of malnutrition even in the absence of restlessness and crying. They become apathetic, their motor activity decreases. Often, already within a few days or 1 - 1 1/2 weeks, one can also detect a slowdown in the rate of weight gain with the crossing of the boundaries of the underlying centile zones. The identification of these signs should confirm the need to introduce additional feeding or complementary feeding.

The latter is chosen if the following conditions are met:

• age over 5-6 months;
• established adaptation to the movement and swallowing of thick food when using “training” complementary foods;
• the past or current eruption of some teeth;
• confident sitting and head control to express an emotional attitude towards food or to express satiety;
• maturity of the gastrointestinal tract functions, sufficient to assimilate a small amount of thick complementary food product without indigestion or allergic reaction to this product.

First, introduce a test dose of complementary food (1-2 teaspoons) and then (if well tolerated) quickly increase the amount to 100-150 g of pureed fruits or vegetables or porridge, prepared without salt and sugar and without adding butter. In this case, gluten-free porridges are introduced first - based on buckwheat or rice. The first porridges and vegetable purees of home preparation should be relatively thin on half-milk.

The following stages (steps) of expanding complementary feeding can be identified.

• Step 1 - "training" complementary foods (fruits or vegetables).
• Step 2 - one vegetable puree (potatoes, carrots, cabbage, spinach) or fruit puree (bananas, apples). It is highly desirable to use products specially produced by the baby food industry for complementary feeding.
• Step 3 - gluten-free porridges (rice, corn, buckwheat), preferably industrially produced. If the porridge is homemade, then first with half-and-half milk and semi-thick for 2 weeks. Then - thick porridge or puree with whole milk for another 2 weeks. After a month, the complementary feeding combines one puree and one porridge.
• Step 4 - adding minced meat, fish or poultry to the vegetable puree. Preferably from canned meat for baby food. Expanding the range of vegetables and fruits (excluding citrus fruits). The adaptation period for this step is about 1-1 1/2 months.
• Step 5 - porridge with wheat flour (cereals).
• Step 6 - cow's milk substitutes for baby food (follow up type formulas), non-adapted dairy products (milk, kefir, yogurt, cottage cheese), citrus fruits and their juices, hard-boiled egg yolk.
• Step 7 - start "piecemeal" feeding to further stimulate biting and chewing: cookies, pieces of bread and rolls, sliced fruits, steamed cutlets, unpureed vegetables, etc.

The advantages of industrially produced complementary feeding products are based on a higher degree of product homogeneity, a relative guarantee of control over the ecological purity of raw materials and wide enrichment with various micronutrients, which largely eliminates the risk of their deficiency during the weaning period or a reduction in the volume of formula for artificial feeding. Here are some examples.

Milk porridges "Milupa"

Compound	100 g granulate	Serving (40 g per 150 ml water)
Protein, g	11.9-15.6	5.2-7.4
Fats, g	14.1-17.4	5.9-7.9
Carbohydrates, g	58.1-67.7	26.4-31.7
Vitamin A, mcg	295-333	118-153
Vitamin E, mg	2.0-2.2	0.8-1.0
Vitamin C, mg	41-46	18-21
Vitamin K, mcg	5.2-5.6	2.5-2.6
Vitamin B, mg	0.49-1.4	0.24-0.6
Vitamin B2, mg	0.48-0.53	0.2-0.26
Niacin, mg	3.8-6.9	1.5-2.8
Vitamin B6, mg	0.25-0.47	0.1-0.22
Folacin, mcg	20	8
Vitamin B12, mcg	0.4-0.7	0.2-0.3
Biotin, mcg	7-8	3-4
Folic acid, mcg	60-67	30
Pantothenic acid, mg	1.7-1.9	0.7-0.9
Calcium, mg	400-500	200
Iron, mg	4.0-4.4	1.7-2.0
Iodine, mcg	48-55	19-26
Energy value, kJ	1823	758-923

A fairly wide range of complementary foods is also produced by the domestic food industry.

With any scheme for introducing complementary foods, the expansion of their range and quantity occurs due to the "displacement" of breast milk. Therefore, the period of introducing complementary foods simultaneously becomes the beginning of the weaning period. It is very useful to prolong the mother's lactation and the attachment of the child to the breast as much as possible. There is evidence of the positive effect on the development of children even a single attachment to the breast of a child of the second year of life.

The total daily amount of milk (breast milk and formula) should not be less than 600-700 ml at any time during the first year of life. It is advisable to distribute this amount evenly throughout the day over the number of feedings that is part of the child's individual diet (from 3 to 5 by the end of the year).

By the end of the first year of life, instead of follow-up mixtures for the milk component of the diet, it is advisable to use cow's milk substitutes for children of the 2nd and 3rd years of life.

If the complementary foods are well tolerated and the child has a good appetite, the volume of one feeding portion can exceed 200-240 g by the 3rd-4th quarter of the first year of life. In these cases, the number of feedings can be reduced to 4 times a day, not counting possible night feedings. Immediately after one year, you can try to switch to 3 main and one light feeding (milk formula, juice or fruit during the second breakfast or afternoon snack.)

As the number of breastfeedings decreases, the amount of milk produced by the mother also decreases. Weaning a baby from the breast at any age should be done gently and gradually, in no case accompanied by conflicts between the mother and child, exclusively in an atmosphere of joyful cooperation in mastering new products and dishes. If circumstances force the mother to end lactation more quickly, she can resort to loose bandaging of the breast, applying pieces of ice in a bladder, and slightly reducing the volume of liquid drunk. Taking small doses of estrogens can also contribute to the rapid cessation of lactation.

The entire period of introducing complementary foods is critical in relation to the development of taste sensations and preferences, conscious behavior "at the table", accustoming to family communication during meal times, and creating stereotypes of eating behavior. Reducing the proportion of dairy products in the diet is a risk of a persistent loss of appetite with the ensuing consequences for development and health. An adequate choice of dishes and their portions, the attractiveness of the taste and appearance of food, firmness of requirements regarding "finishing" what is put on the plate, a respectful attitude to the emotional state and appetite of the child, a reasonable combination of exactingness with a system of rewards and praise should become general rules for all family members and those around the child.