Complementary Feeding of Infants and Young Children 6-23 Months of Age

Publication Date: October 13, 2023
Last Updated: January 19, 2024

Breastfeeding and milks

Breastfeeding should continue up to 2 years or beyond. (S, VL)
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To carry out this recommendation, all breastfeeding women will require an enabling environment and supportive services (11). For example:
  • Women who work outside the home need services such as onsite daycare, workplace breastfeeding rooms, and flexible work schedules.
  • All women need access to breastfeeding counselling services to address questions and challenges that arise when breastfeeding.
  • Pregnant women, mothers, families, and health care workers need to be protected from exploitative marketing from manufacturers and distributors of breastmilk substitutes.
  • Health care providers must be knowledgeable and skilled in supporting breastfeeding mothers with evidence-based care.
For infants 6–11 months of age who are fed milks other than breast milk, either milk formula or animal milk can be fed. (C, L)
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For young children 12–23 months of age who are fed milks other than breast milk, animal milk should be fed. Follow-up formulas are not recommended. (C, L)
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  • Dairy products, including liquid animal milks are part of a diverse diet and can contribute to nutritional adequacy (see also Recommendation 4a). They are particularly important for non-breastfed children when other animal source foods (ASFs) are not available.
  • Types of animal milks that could be used include pasteurized animal milk, reconstituted evaporated (but not condensed) milk, fermented milk, or yogurt.
  • Flavoured or sweetened milks should not be used.
  • If infants 6–11 months of age are fed animal milks, full fat milk should be used.
  • Safe storage and handling practices of animal milks should be followed.

Age of introduction of complementary foods

Infants should be introduced to complementary foods at 6 months (180 days) while continuing to breastfeed. (S, L)
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  • The recommendation is a public health recommendation and recognizes that some infants may benefit from earlier introduction of complementary foods.
  • Mothers concerned about the adequacy of breast milk might benefit from lactation support.
  • Iron in breast milk is highly bioavailable, but some infants may be at risk of iron deficiency (ID), especially if they were preterm or low birthweight. Early introduction of complementary foods, even if iron-fortified, does not adequately prevent iron deficiency anaemia in high-risk populations.

Dietary diversity

Infants and young children 6–23 months of age should consume a diverse diet
Animal source foods, including meat, fish, or eggs, should be consumed daily (S, L)
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Fruits and vegetables should be consumed daily (S, L)
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Pulses, nuts and seeds should be consumed frequently, particularly when meat, fish, or eggs and vegetables are limited in the diet (C, VL)
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  • Animal-source foods, fruits and vegetables, and nuts, pulses and seeds should be key components of energy intake because of their overall higher nutrient density compared to cereal grains.
  • Starchy staple foods should be minimized. They commonly comprise a large component of complementary feeding diets, particularly in low resource settings, and do not provide proteins of the same quality as those found in animal source foods and are not good sources of critical nutrients such as iron, zinc and Vitamin B12. Many also include anti-nutrients that reduce nutrient absorption.
  • When cereal grains are used, whole cereal grains should be prioritized, and refined ones minimized.
  • Care should be taken to ensure that pulses, nuts and seeds are given in a form that does not pose a risk of choking.

Unhealthy foods and beverages

Foods high in sugar, salt and trans fats should not be consumed. (S, L)
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Sugar-sweetened beverages should not be consumed. (S, L)
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Non-sugar sweeteners should not be consumed. (S, VL)
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Consumption of 100% fruit juice should be limited. (C, L)
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  • Broad policy actions will be needed to support the implementation of these recommendations, including, but not limited to agricultural policies that take into consideration the nutritional requirements of young children, policies regarding front-of-package labelling and marketing practices, among others.
  • Counselling caregivers about the short- and long-term harms of foods high in sugar, salt and trans fats, sugar sweetened beverages (SSBs), and non-sugar sweeteners is needed.

Nutrient supplements and fortified food products

  • In some contexts where nutrient requirements cannot be met with unfortified foods alone, children 6–23 months of age may benefit from nutrient supplements or fortified food products.
Multiple micronutrient powders (MNPs) can provide additional amounts of selected vitamins and minerals without displacing other foods in the diet. (, M)
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For populations already consuming commercial cereal grain-based complementary foods and blended flours, fortification of these cereals can improve micronutrient intake, although consumption should not be encouraged. (, M)
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Small-quantity lipid-based nutrient supplements (SQ-LNS) may be useful in food insecure populations facing significant nutritional deficiencies. (, M)
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  • WHO guidelines for micronutrient supplementation provide recommendations about the contexts when such supplements are recommended.
  • None of the three products should ever be distributed as standalone interventions, rather they should always be accompanied by messaging and complementary support to reinforce optimal infant and young child feeding practices.
  • None of the products are a substitute for a diverse diet consisting of healthy and minimally processed foods.

Responsive feeding

Children 6–23 months of age should be responsively fed, defined as “feeding practices that encourage the child to eat autonomously and in response to physiological and developmental needs, which may encourage self-regulation in eating and support cognitive, emotional and social development”. (S, L)
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  • Delivering the intervention of responsive feeding will require health care workers and others charged with delivering the intervention to have the capacity to provide the necessary guidance to caregivers and families.
  • Implementation of the recommendation will require caregivers to have time to be present while the young child eats or selffeeds and have resources so that food loss during self-feeding does not present a problem.

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Complementary Feeding of Infants and Young Children 6-23 Months of Age

Authoring Organization

Publication Month/Year

October 13, 2023

Last Updated Month/Year

December 19, 2023

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

Global

Document Objectives

Complementary feeding, defined as the process of providing foods in addition to milk when breast milk or milk formula alone are no longer adequate to meet nutritional requirements, generally starts at age 6 months and continues until 23 months of age. This is a developmental period when it is critical for children to learn to accept healthy foods and beverages and establish long-term dietary patterns. It also coincides with the peak period for risk of growth faltering and nutrient deficiencies.  This guideline provides global, normative evidence-based recommendations on complementary feeding of infants and young children 6–23 months of age living in low, middle- and high-income countries. It considers the needs of both breastfed and non-breastfed children. The guideline supersedes the earlier Guiding Principles for Complementary Feeding of the Breastfed Child and Guiding principles for feeding non-breastfed children 6-24 months of age.

Target Patient Population

Infants and young children 6–23 months of age who were full term at birth

Target Provider Population

Pediatricians, nutritionists and other clinicians caring for children 6-23 months of age

Inclusion Criteria

Male, Female, Child, Infant

Health Care Settings

Ambulatory, School

Intended Users

Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Management

Diseases/Conditions (MeSH)

D053198 - Child Nutrition Sciences

Keywords

nutrition, Breastfeeding, Complementary Feeding, breast milk

Source Citation

WHO Guideline for complementary feeding of infants and young children 6–23 months of age. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.