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Complementary Feeding: Keeping the Message Simple

Briend, André*; Dewey, Kathryn G.

Journal of Pediatric Gastroenterology and Nutrition: March 2014 - Volume 58 - Issue 3 - p 275
doi: 10.1097/MPG.0000000000000218
Invited Commentaries

*Department for International Health, University of Tampere, Tampere, Finland

Department of Nutrition, University of California, Davis.

Address correspondence and reprint requests to André Briend, Department for International Health, University of Tampere, Lääkärinkatu 1, Tampere FI-33014, Finland (e-mail:

Received 15 October, 2013

Accepted 15 October, 2013

The authors report no conflicts of interest.

See “Effect of Sequencing of Complementary Feeding in Relation to Breast-Feeding on Total Intake in Infants” by Shah et al on page 339.

During the first 6 months of life, the dietary advice given to mothers is simple and boils down to “start breast-feeding within one hour from birth” and “exclusively breast-feed up to the age of 6 months.” During the complementary feeding period, the message is more complex. In 2003, the Pan American Health Organization (PAHO) and the World Health Organization (WHO) published a short document with 10 guiding principles to advise mothers during the complementary feeding period (1). Despite the remarkable efforts to coin simple messages in this document, they remain difficult to deliver in the context of a typically overcrowded poor country under-5 clinic or by overworked community health workers. This is a problem because diets are often inadequate during this period and/or they lacked some key nutrients.

The maintenance of breast-feeding beyond 6 months is one of the key PAHO-WHO guiding principles. To preserve this principle, some programmes also advise “always” breast-feeding before each meal of complementary food. This makes the message more complex, but this advice was not included in the PAHO-WHO guiding principles. A review of the literature carried out during the preparation of the PAHO-WHO guiding principles did not find any evidence in favour of the advice (2). One study from the United Kingdom (published in a journal not referenced in the usual bibliographic medical databases) suggested that breast-feeding before or after complementary food did not have an effect on total breast milk or energy intake (3). Because of the weak evidence base, no message about the order of breast and complementary feeds was included in the PAHO-WHO guiding principles.

An article from India published in an upcoming issue of the Journal of Pediatric Gastroenterology and Nutrition helps to fill this evidence gap (4). This well-designed crossover study confirms the lack of effect of the timing of complementary feeds in relation to breast-feeding on daytime energy intake and breast milk volume. Although the study had limitations and examined this effect only in the short term, current evidence does not support the advice, that is, to always breast-feed before each complementary feeding.

The practical difficulties of preparing adequate complementary feeds in the context of poverty should not be underestimated. Asking the mother to breast-feed before giving complementary foods makes the process more complicated, especially if she is trying to juggle feeding both an infant and other family members. Thus, this new evidence from India is a welcome addition to the evidence base on complementary feeding.

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1. Pan American Health Organization/World Health Organization. Guiding principles for complementary feeding of the breastfed child. Accessed January 27, 2014.
2. WHO-UNICEFComplementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva:World Health Organization; 1998.
3. Drewett R, Payman B, Whiteley S. Effect of complementary feeds on sucking and milk intake in breast fed babies: an experimental study. J Reprod Infant Psychol 1987; 5:133–143.
4. Shah D, Singh M, Gupta P, Faridi MMA. Effect of sequencing of complementary feeding in relation to breast-feeding on total intake in infants. J Pediatr Gastroenterol Nutr 2014; 58:339–343.
© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,