21 Apr 2020
The aim of this position statement is to provide guidance for dietitians working with parents and caregivers on appropriate complementary feeding in the healthy term infant.
For the purposes of this statement, complementary food refers to solid foods as a nutritional source, other than breastmilk or infant formula. Solid foods are needed to complement milk when it is no longer sufficient to meet the energy and nutrient requirements of the growing infant1. The timing of the introduction of solid foods to an infant’s diet is important for nutritional and developmental reasons1, 2.
In 2003, the UK Department of Health (DH), adopted the World Health Organization (WHO) Global Infant Feeding Recommendation which advised exclusive breastfeeding for the first six months of life as optimal for most infants. WHO recommended that “to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods whilst breastfeeding continues up to two years of age or beyond”3.
Advice given to parents and caregivers should be based on accurate information that will help them make informed choices about feeding their infant. However, infant feeding choices are influenced by multiple factors, including cultural, socio-economic and lifestyle. Healthcare Professionals (HCPs) must take these factors into account when advising about infant feeding. HCPs consistently report that parents experience difficulties adhering to DH guidelines regarding the appropriate age for the introduction of solid foods.
Surveys conducted in the UK have found that many infants receive solid foods before the age of six months. The Diet and Nutrition Survey of Infants and Young Children (2011) reported that 42% of infants had received solid foods by four months of age. More recently, the Scottish Maternal and Infant Survey (2017) reported that while only 3% of infants began complementary feeding before four months, more than half (54%) had received solid foods before six months of age 4, 5. These surveys suggest that some parents and caregivers perceive their baby is ready for solid foods before six months or provide solid foods for other reasons. Therefore, HCPs must balance the needs of individuals against population-based recommendations.
In the UK and other middle- to high-income countries there is much debate regarding the applicability of the WHO Global Infant Feeding Recommendation. Evidence to support the benefits of exclusive breastfeeding to six months versus four months of age is not strong, and it is recognised that parents and caregivers introduce solid foods for various reasons and follow advice from many sources6. In view of this the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the UK Scientific Advisory Committee on Nutrition (SACN) recently reviewed evidence informing the appropriate age for the introduction of complementary foods to the healthy term infant1, 6. ESPGHAN found no evidence of harm associated with the introduction of solid foods between four and six months of age. However, there was also no evidence of benefit associated with the introduction of solid foods before six months of age6.
Responsive feeding is needed to support good complementary feeding practices7. In this type of feeding parents and caregivers recognise and respond appropriately to infant cues that signal hunger or satiety. This allows the infant to self-regulate how much milk they drink or how much solid food they eat.
The introduction of allergenic foods is another important consideration. Previously, advice has been to delay introducing these foods to children at high risk of food allergy. However, recent research suggests that high-risk children may benefit from earlier introduction of peanut-containing foods. The Learning Early About Peanut Allergy (LEAP) study found that introduction of peanuts, at four compared with six months of age, decreased the frequency of the development of peanut allergy among children at high risk for this allergy8. A substantial body of evidence, including the Eating and Tolerance (EAT) study, found that earlier introduction of potentially allergenic foods was protective against the development of allergy in the general population9. Based on available evidence, the SACN statement concluded that there were insufficient data to support a recommendation for the introduction of potentially allergenic foods before six months. The committee recommended the introduction of foods containing peanut and hen’s egg from the start of feeding solids, at around six months of age, alongside other complementary foods1. Hen’s egg and foods containing egg should be given cooked.
The BDA Paediatric Specialist Group makes the following recommendations for the introduction of complementary foods based on the available evidence.