Contents Special Issue Based on a World Health Organization Expert Consultation on Complementary Feeding Guest Editors: Bernadette Daelmans, Jose Martines, and Randa Saadeh Foreword..................................................................................................................................................................... 3 Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs —Kathryn G. Dewey and Kenneth H. Brown...................... 5 Promotion and advocacy for improved complementary feeding: Can we apply the lessons learned from breastfeeding? —Ellen G. Piwoz, Sandra L. Huffman, and Victoria J. Quinn.................................. 29 Improving feeding practices: Current patterns, common constraints, and the design of interventions —Gretel H. Pelto, Emily Levitt, and Lucy Thairu .............................................................................................. 45 Macrolevel approaches to improve the availability of complementary foods —Chessa K. Lutter .............. 83 Household-level technologies to improve the availability and preparation of adequate and safe complementary foods —Patience Mensah and Andrew Tomkins........................................................... 104 Conclusions of the Global Consultation on Complementary Feeding —Bernadette Daelmans, Jose Martines, and Randa Saadeh...................................................................................................................... 126 List of participants ................................................................................................................................................. 130 Books received ....................................................................................................................................................... 135 News and notes...................................................................................................................................................... 138 UNU Food and Nutrition Programme ................................................................................................................... 139 The Food and Nutrition Bulletin encourages letters to the editor regarding issues dealt with in its contents. Food and Nutrition Bulletin Editor: Dr. Nevin S. Scrimshaw Managing Editor: Ms. Susan Karcz Manuscripts Editor: Mr. Jonathan Harrington Associate Editor—Clinical and Human Nutrition: Dr. Irwin Rosenberg, USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Mass., USA Associate Editor—Food Policy and Agriculture: Dr. Suresh Babu, International Food Policy Research Institute, Washington, DC, USA Editorial Board: Dr. Ricardo Bressani, Institute de Investigaciones, Universidad del Valle de Guatemala, Guatemala City, Guatemala Dr. Hernán Delgado, Director, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala Dr. Cutberto Garza, Professor, Division of Nutritional Sciences, Cornell University, Ithaca, N.Y., USA Dr. Joseph Hautvast, Secretary General, IUNS, Department of Human Nutrition, Agricultural University, Wageningen, Netherlands Dr. Peter Pellett, Professor, Department of Food Science and Nutrition, University of Massachusetts, Amherst, Mass., USA Dr. Zewdie Wolde-Gabreil, Director, Ethiopian Nutrition Institute, Addis Ababa, Ethiopia Dr. Aree Valyasevi, Professor and Institute Consultant, Mahidol University, Bangkok, Thailand Food and Nutrition Bulletin, vol. 24, no. 1 © The United Nations University, 2003 United Nations University Press Published by the International Nutrition Foundation for The United Nations University 53-70 Jingumae 5-chome, Shibuya-ku, Tokyo 150-8925, Japan Tel.: (03) 3499-2811 Fax: (03) 3406-7345 E-mail: [email protected] ISSN 0379-5721 Design and Production by Digital Design Group, Newton, MA USA Printed on acid-free paper by Webcom Ltd., Toronto, ON Canada Foreword The importance of nutrition as a foundation for healthy During the past decade, there has been considerable development is underestimated. Poor nutrition leads to progress in the implementation of interventions to ill health, and ill health causes further deterioration in improve breastfeeding practices. Clear recommenda- nutritional status. These effects are most dramatically tions and guidelines, combined with political com- observed in infants and young children, who bear the mitment and increased allocation of resources, have brunt of the onset of malnutrition and suffer the high- enabled many governments to establish programs that est risk of disability and death associated with it. In combine the necessary actions to protect, promote, and 2001, 50% to 70% of the burden of diarrheal diesases, support breastfeeding. Consequently, a steady improve- measles, malaria, and lower respiratory infections was ment in breastfeeding practices, as demonstrated by attributable to malnutrition. increased rates of exclusive breastfeeding, has been But the children who die represent only a small observed in various countries. part of the total health burden due to nutritional However, similar progress has not made been in the deficiencies. Maternal malnutrition and inappropriate area of complementary feeding. While research and breastfeeding and complementary feeding represent development have contributed to an expanding evi- huge risks to the health and development of those dence base for making recommendations on appropri- children who survive. Deficiencies in the diet of vita- ate feeding and developing effective interventions for min A, iodine, iron, and zinc are still widespread and children more than six months of age, translation of are a common cause of excess morbidity and mortality, new knowledge into action has lagged behind. particularly among young children. Over 50 million To address this gap, the World Health Organization children are wasted, and in low-income countries one (WHO) convened a global consultation on comple- in every three children is stunted by the age of five mentary feeding (Geneva, 9 to 13 December 2001), years. Indeed, many children never reach this age. The which brought together over 60 experts from a variety effects of poor nutrition and stunting continue over the of disciplines and agencies. As a background for discus- child’s life, contributing to poor school performance, sion, WHO commissioned five papers, which examined reduced productivity, and other measures of impaired the current state of knowledge concerning: intellectual and social development. » Energy and nutrient requirements of infants and Inappropriate feeding practices are a major cause of young children, and the relative requirements of the onset of malnutrition in young children. Children complementary foods to meet these needs at vari- who are not breastfed appropriately have repeated ous ages; infections, grow less well, and are almost six times more » Caregiver behaviors influencing infant and young likely to die by the age of one month than children who child feeding; receive at least some breastmilk. From the age of six » Household-level technologies to improve the avail- months onwards, when breastmilk alone is no longer ability of safe and adequate complementary foods; sufficient to meet all nutritional requirements, infants » Macrolevel approaches to improve the availability of enter a particularly vulnerable period of complemen- adequate complementary foods; tary feeding, during which they make a gradual transi- » Lessons learned from the implementation of pro- tion to eating ordinary family foods. The incidence of grams to improve breastfeeding practices. malnutrition rises sharply during the period from 6 to The consultation was asked to review and update 18 months of age in most countries, and the deficits recommendations for appropriate complementary acquired at this age are difficult to compensate for later feeding and to identify actions needed to acceler- in childhood. ate programmatic efforts, including priorities for Food and Nutrition Bulletin, vol. 24, no. 1 © 2003, The United Nations University. 3 4 Foreword research and development of tools for planning and Acknowledgments implementation of interventions. The participants discussed issues relating to foods and feeding, and The World Health Organization gratefully acknowl- considered the intricate links between maternal nutri- edges the financial support provided by The Nether- tion and appropriate breastfeeding and complementary lands Ministry of Foreign Affairs that made it possible feeding practices. to commission the background papers and to convene This special issue of the Food and Nutrition Bulletin the consultation. presents the background papers and proceedings of the consultation; it is meant to help guide policymakers Bernadette Daelmans and program planners at all levels in taking appro- Department of Child and Adolescent priate action to give effect to the Global Strategy for Health and Development, WHO Infant and Young Child Feeding,* which the World Jose Martines Health Assembly adopted in May 2002. It is hoped Department of Child and Adolescent that the results will motivate all concerned parties Health and Development, WHO to make the investments required to ensure that the nutritional needs of infants and young children are Randa Saadeh met worldwide. Department of Nutrition for Health and Development, WHO * WHA55/2002/REC/1, Annex 2 and http://www.who.int/ gb/EB_WHA/PDF/WHA55/ea5515.pdf. Update on technical