Complementary Feeding

The WHO recommends exclusively feeding on milk, whether it is maternal breastfeeding or artificial feeding, until 6 months of age, and it should be the main source of nutrition during the first year of life.

Whenever possible, breastfeeding is recommended for its numerous advantages: it is the best-suited to the nutritional needs and digestive characteristics of the infant, it transfers immunity from mother to child, reduces the risk of sudden infant death syndrome, and promotes the bond between mother and baby.

When opting for formula feeding, it should be with an infant formula (type 1) until 6 months, with a follow-on formula (type 2) from 6 to 12 months (although it is also possible to continue with type 1 infant formula), and with whole milk from 12 months. Formulas should be given on demand and respecting the baby’s needs.

Introducing new foods before 4 months is not justified, but it is also not advisable to do it beyond 26 weeks. Milk as the sole food after 6 months does not provide sufficient energy and nutrients, and the lack of diversification can lead to poorer acceptance of new textures and flavors, an increased risk of allergies and food intolerances, and a greater possibility of disrupting oral motor skills. It is a valuable time for taste education and getting to know basic foods that will allow the baby to adapt to a balanced, varied, and adequate diet.

It is appropriate to wait until the infant shows signs that they are ready to start:
– Showing active interest in food.
– The disappearance of the extrusion reflex (pushing out non-liquid food with the tongue).
– Being able to grasp food with the hand and bring it to the mouth.
– Being able to sit with support.

There are no strict guidelines for introducing complementary feeding, and no foods are better than others to start with, although it is good to introduce iron-rich and zinc-rich foods early on.

Once complementary feeding is established, they should consume about 500ml of milk daily and eat fruits, vegetables, cereals, and protein (meat, fish, eggs, or legumes), in other words, a varied diet adapted to their nutritional needs. Ideally, they should have 4 meals a day (approximately one every 4 hours) and not need to be fed during the night. The recommended meals are:
– Breakfast: cereals, fruit…
– Lunch: vegetables with protein.
– Snack: fruit.
– Dinner: cereals, vegetables, protein…

Breastfeeding should continue on demand, without forgetting that complementary feeding is not a “replacement” but a “complement” to breast milk.

CEREALS: Gluten-containing cereals can be introduced between 4 and 11 months, but ideally around 6 months. They can be offered in powder form dissolved in milk, added to purees, in the form of boiled and mashed rice, bread, pasta, corn cakes, quinoa, or oats. Choose whole grains, without added sugars (in the carbohydrate section, sugars should contain less than 5g per 100g), and avoid hydrolyzed or dextrinated cereals.

FRUITS: Varied and seasonal fresh fruits should be used. They should always be given whole (pureed, mashed, or in large pieces), but not as juice as it provides no nutritional benefits and can contribute to inappropriate weight gain and increase the risk of tooth decay. Fruits are usually given as a snack but can be given at any other time between meals or as a dessert.

VEGETABLES: They are usually introduced at lunchtime. During the first year, leafy green vegetables such as chard, spinach, or borage should be avoided as they can cause methemoglobinemia due to their high nitrate content. They should be steamed or cooked with little water, and the cooking broth should be used. Do not add salt or commercial broths. It is recommended to add a tablespoon of raw olive oil before serving.

PROTEIN: Once vegetables are introduced, meat, fish, eggs, and legumes can be started. It is recommended to vary the ingredients so that each day there is a protein-rich food containing iron, and for the child to become accustomed to trying different flavors.

Example of vegetable puree with chicken or white fish: Boil green beans, leek, potato, and skinless chicken (about half a thigh or drumstick per serving) or a small fillet of white fish for 20 minutes, then puree. Do not keep it for more than 48 hours in the refrigerator. It can be frozen in daily portions and thawed as needed. The approximate amount per serving is a 250ml bowl.

MEAT: 20-30g/day. Chicken, turkey, beef, rabbit, lamb… Avoid fatty parts. Do not use game meats containing lead in children under 6 years old.

FISH: 30-40g/day. It should be previously frozen to avoid contact with anisakis. Offer small-sized white or oily fish (sardine, mackerel, red mullet…). Large-sized oily fish (swordfish, tuna, shark, and pike) contain high levels of methylmercury, so they are not recommended. Avoid consuming crustacean heads and crab bodies due to their high cadmium content.

EGGS: They should always be well-cooked, starting with the yolk (increase by ¼ every 2-3 days) and then the white (increase by ¼ every 2-3 days) until the whole egg is given. Add to vegetables as a substitute for other proteins.

LEGUMES: Chickpeas and lentils are the easiest to digest. Soak them overnight before preparing them, and sprouted legumes are even better for better digestion. Add them to vegetables and use them as a substitute for other proteins.

NUTS: Crushed from 6 months. Never give them whole due to the risk of choking.

SALT: Salt should not be added to meals before 12 months.

DAIRY: Milk is the main food during the first year of life and should be given on demand. When opting for formula feeding, it should be with an infant formula (type 1) until 6 months, with a follow-on formula (type 2) from 6 to 12 months (although it is also possible to continue with type 1 infant formula), and with whole milk from 12 months. Formulas should be given on demand and respecting the baby’s needs. From 9 months, they can consume (but it is not obligatory) unsweetened plain yogurt and unsalted fresh cheese. Yogurts labeled as follow-on milk formulas are not recommended due to their inappropriate carbohydrate content.

WATER: While the infant receives only breast milk or adapted formula, additional fluids are not required. However, since complementary feeding involves a greater renal load of solutes, water should be offered, and the child will regulate their intake. The same type of water consumed by adults can be offered without boiling it.

SWEETS: Consumption of sugar and sweeteners is not recommended. Honey should not be introduced before one year of age due to the risk of transmitting botulism.

From 8-9 months, and individualizing it for each baby according to their interest in food, a more varied dinner can be introduced (omelet,

shredded fish or meat, cooked or pureed vegetables, etc.). Without forgetting that complementary feeding complements and does not replace milk.

It is recommended not to delay the introduction of different lumpy, semi-solid, and solid textures and involve the baby in their feeding, allowing them to feed themselves. Monitor the size of the food (as big as their fist or as small as a grain of rice) to prevent choking.

It is very common for a baby to reject a food the first few times it is offered, so it may need to be offered several times before they show interest in new foods. If a food is repeatedly rejected, replace it with another from the same group and offer it again after a few weeks. Do not force-feed the child; respect their appetite. Feed them in a calm environment, without stimuli that distract their attention, and without rushing. Avoid using games, television, or mobile phones to distract them, as they prevent the child from actively participating in their feeding. It is good for the child to participate by picking up and touching the food. It is recommended to eat together as a family, and if the child shows interest in the parents’ food, offer it unless there is a choking risk.

A regular meal schedule should be maintained, trying to have meals at the same time every day (e.g., breakfast at 8:00, lunch at 12:00, snack at 16:00, dinner at 20:00).

Solid foods that can pose a choking hazard, such as whole nuts, popcorn, whole grapes, raw carrots or apples, etc., should be avoided until the age of 6.

The above are guidelines and recommendations that will help guide the introduction of complementary feeding. There are no strict rules; each baby and family is different, and everyone will find the best way to feed their baby, adapting to their routines, preferences, and habits.