(4303-480)

Essay
Impact of complementary feeding programs in promoting child
growth and lowering the prevalence of stunting, wasting and
underweight as well as anaemia in children aged 6-36 months a review.

By
Aleem Muhammad
Yitbarek Kidane

August 10, 2015

Global Nutrition

COMPLEMENTARY FEEDING

Aleem & Yitbarek

1. Introduction
Complementary feeding for infants refers to the timely introduction of safe and nutritional
foods in addition to breastfeeding; i.e., clean and nutritionally rich additional foods introduced
at about six months of age (Imdada A. et al. 2011).
The terms weaning foods and
supplementary feeding, widely used for a long time, are not recommended as synonyms for
complementary feeding, since their use is incorrect (Piwoz et al., 2003) giving the impression
that foods are introduced to replace breast milk, instead of complementing it (Andorson, 2001)
The use of the term weaning is not advisable, since in many countries (Daelmans, 2003) it
may be understood as total cessation of breastfeeding (PAHO/WHO, 2003) and cause problems
in breastfeeding promotion. Nowadays, the term full weaning is used to indicate the total
cessation of breastfeeding.
A proper complementary feeding consists of foods that are rich in energy and in micronutrients
(especially iron, zinc, calcium, vitamin A, vitamin C and folates), free of contamination
(pathogens, toxins or harmful chemicals), without much salt or spices, easy to eat and easily
accepted by the infant, in an appropriate amount, easy to prepare from family foods, and at a
cost that is acceptable by most families (Daelmans, 2003; WHO/UNICEF, 1998).
Complementary feeding interventions include a wide variety of strategies, these include
nutritional education to mothers designed to promote healthy feeding practices; provision of
complementary foods offering extra energy (with or without micronutrient fortification); and
increasing energy density of complementary foods through simple technology (Dewey & AduAfarwuah, 2008; Caulfield, Huffman & Piwoz, 1999). In this review, we assessed the impact of
the different
intervention types on child growth, stunting, wasting, under-weight and
anaemia.

2. Objectives
To assess impact of complementary feeding programs in promoting child growth and
lowering the prevalence of stunting, wasting and underweight as well as anaemia in
children aged 6-36 months - a review.

3. Methods of literature review

A comprehensive search of studies was performed from different data sources (e.g.
PubMed, Science Direct, googlescholar). We considered all available published and
unpublished papers/reports on the impact of complementary feeding interventions and
sources were not restricted by date, study design or country, but were restricted to those
written in English language.

4. Results and Discussion

4.1.

Impact of Nutritional Education intervention

A meta-analysis reviewing 11 randomized controlled trials (RCTs) and 7 non-RCTs found

significant impact of nutritional education on linear growth and weight gain as evident by
improvement in HAZ scores, stunting, and WAZ scores (Bhutta et al 2013). These results are
consistent with other previous reviews by Bhutta (2008) and Imdad (2011) which showed
significant improvements in linear growth and weight gain with nutrition education
intervention.

Global Nutrition

COMPLEMENTARY FEEDING

Aleem & Yitbarek

As depicted in the figures below, a cluster

randomized trial in Peru also showed that
nutrition education without the provision
of food supplements can improve the
dietary intake of young children and
improve growth (Penny et al., 2005)

Higher growth impact, however, occurs

in food-insecured regions (Dewey &
Adu-Afarwuaha, 2008)

4.2.

Impact of Provision of Complementary feeding alone or in

combination with Nutritional Education

Several randomized control trials of interventions that have included nutrition education
combined with other strategies found improvements in growth and prevention of
malnutrition (McNelly B, Dunford C, 1998; Schroeder et al., 2002; Kramer et al., 2001). A
cluster-randomized trial in India (Vazir et al, 2013) revealed that the 12-month
complementary feeding intervention significantly (P < 0.05) increased median intakes of
energy, protein, Vitamin A, calcium, iron and zinc and reduced stunting [0.19, confidence
interval (CI): 0.00.4].
However, a meta-analysis by Bhutta et al. (2013) found that complementary feeding with
or without education had a non-significant impact on stunting & underweight; HAZ scores
(SMD 0.46; 95% CI: 0.24 - 1.17) and WAZ (SMD 0.15; 95% CI: 0.09 - 0.40).

4.3.

Increasing energy density of CF through simple technology

A study in China showed that applications of foods that come from animals, vegetable/fruit
and dairy product in complementary feeding were negatively correlated to the prevalence
of stunting and underweight. Attributable risk (AR) of no application of vegetable/fruit in
complementary feeding to stunting was 30.2%, to underweight 35.4%; AR of no application
of foods from animal products in complementary feeding to stunting was 28.2%, to
underweight 11.7%; and the AR of no application of dairy products in complementary
feeding to stunting was 27.4%, to underweight was 15.9%.

The impact of complementary feeding on Anaemia

A study in India indicated a significant increment in haemoglobin concentration over 12
months of Complementary Feeding intervention (Shahnaz et al., 2012);
0.3 + 0.066 g/dL
and 0.08 + 0.065 g/dL for the intervention and control group respectively. Consumption of
iron-fortified milk among 11-18 months Chilean children was associated with lower
prevalence of anemia (odds ratio, 0.50; 95% CI, 0.26 to 0.96).

Global Nutrition

COMPLEMENTARY FEEDING

Aleem & Yitbarek

Time of initiation of Complementary Feeding

In developed countries time of initiation of complementary feeding studies do not provide
compelling evidence of benefit or risk related to growth and the timing of introduction of
complementary foods at any specific time between 4 and 6 months of age. Thus, postnatal
growth appears to not be sensitive to the differential timing of introduction of
complementary foods nor to differential types and frequencies of complementary foods in
healthy infants living in environments without major economic constraints and low rates of
illness (WHO, 2002).
However, a study in Nigeria (environments with major economic constraints and low rates
of illness) revealed that Weight-for-age (WFA) indices were significantly lower for those
who initiated early than the later group (t = 3.00, p = 0.004). The prevalence of
underweight (WFA SD scores below -2.0) was 7.5% in the later complementary feeding
group and 28.6% in the early group (X2 = 4.76, p = 0.0292). Severe underweight (WA SD
scores below -3.0) prevalence were 0% and 14.3% respectively (p = 0.0259). Thus, poorer
nutritional status was significantly associated with earlier complementary feeding. Another
study reported lower rate of childhood obesity & diseases like asthma among those who
started complementary food later (Cristina et al., 2004)

5. Conclusion
The scarcity of available studies and their heterogeneity, as well as the variety in
complementary feeding interventions, make it difficult to conclude one particular type of
complementary feeding intervention as the most effective. Moreover, the variation in the
reported outcomes amongst studies makes it difficult to compare them. However, overall,
the evidence from our review highlights the importance of complementary feeding
interventions in improving childrens nutritional status, despite the fact that results were
highly heterogeneous.
Education on complementary feeding alone has a potential to improve the nutritional
status of children; the impact on growth is higher in food insecure regions. However,
provision of complementary food alone has a mixed effect. This might be due to
heterogeneity of the complementary feeding interventions and also variation in the quality
of the complementary food provided. Early initiation CF is significantly associated with
poorer nutritional status and increases infant morbidity and mortality. Complementary
feeding has an impact on the reduction of anemia and improvement of the iron status of
children.

6. Recommendations
Accelerated and concerted actions are needed to deliver and scale up nutritional education
and complementary feeding interventions that are cost-effective, feasible, and effective in
improving the nutritional status of children. In the future, further studies in this area must
use consistent outcomes and durations of the intervention.
Future highquality research trials are required to assess the impact of such interventions
on child growth the prevalence of stunting, wasting and underweight as well as anaemia.
Moreover, these trials should consider using standardized types of food as the intervention
so that evidence can be formulated on which type of food is most effective. Trials should
report consistent outcomes.

Global Nutrition

COMPLEMENTARY FEEDING

Aleem & Yitbarek

References
1. Anderson AS, Guthrie C, Alder EM, Forsythe S, Howie PW, Williams FLR. Rattling the place:
reasons and rationales for early weaning. Health Educ Res. 2001;16:471-9.
2. Brasil/Ministrio da Sade/OPS. Guia alimentar para crianas menores de 2 anos. Serie A.
ormas e manuais tcnicos no 107. Braslia, DF: Ministrio da Sade; 2002.
3. Caulfield LE, Huffman SL, Piwoz EG. Interventions to improve intake of complementary foods by
infants 6 to 12 months of age in developing countries: impact on growth and on the prevalence
of malnutrition and potential contribution to child survival. Food Nutr Bull. 1999;20:183200.
4. Daelmans B, Martines J, Saadeh R. Conclusions of the Global Consultation on Complementary
Feeding. Food Nut Bull. 2003;24:126-9.
5. Dewey KG, AduAfarwuah S. Systematic review of the efficacy and effectiveness of
complementary feeding interventions in developing countries. Matern Child Nutr. 2008;4(Suppl
1):2485.
6. Imdad A, Yakoob MY, Bhutta ZA. Impact of maternal education about complementary feeding
and provision of complementary foods on child growth in developing countries. BMC Public
Health. 2011;11(Suppl 3):S25.

7. Kramer MS, Chalmers B, Hodnett ED, et al. Promotion of Breastfeeding Intervention

Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001; 285: 413
20).
8. McNelly B, Dunford C. Impact of credit with education on mothers and their young
childrens nutrition: lower Pra rural bank credit with education program in Ghana
(research paper no 4). Davis, CA: Freedom from Hunger, 1998.
9. PAHO/WHO. Guiding principles for complementary feeding of the breastfed child. Division of
Health Promotion and Protection. Food and Nutrition Program. Pan American Health
Organization/ World Health Organization. Washington/Geneva; 2003.

10. Penny E. et al. Effectiveness of an educational intervention delivered through the

health services to improve nutrition in young children: a cluster-randomized
controlled trial. Lancet 2005; 365: 186372
11. Piwoz EG, Huffman SL, Quinn VJ. Promotion and advocacy for improved complementary
feeding: Can we apply the lessons learned from breastfeeding? Food Nut Bull. 2003;24:29-44.

12. Schroeder DG, Pachon H, Dearden KA, et al. An integrated child nutrition
intervention improved growth of younger, more malnourished children in Northern
Viet Nam. Food Nutr Bull 2002; 23: 5361.
13. SU-YING C. et al. Complementary Feeding and Growth of Infant and Young Child in
China Biomedical And Environmental Sciences (2008), 21, 264-268
14. Vazir et al. Cluster-randomized trial on complementary and responsive feeding
education to caregivers found improved dietary intake, growth and development
among rural Indian toddlers. Maternal and Child Nutrition (2013), 9, pp. 99117
15. WHO/UNICEF. Complementary feeding of young children in developing countries: a review of
current scientific knowledge. Geneva: World Health Organization, WHO/NUT/98.1,1998.
16. WHO: Report of Informal Meeting to Review and Develop Indicators for Complementary
Feeding. Washington, D.C.: World Health Organization; 2002.

17. WHO: Report of Informal Meeting to Review and Develop Indicators for
Complementary Feeding. Washington, D.C.: World Health Organization; 2002.
18. Zohra S. et al. Systematic Review of Complementary Feeding Strategies amongst

Children Less than Two Years of Age. Pakistan; 2005.