National Recommendations for Infant and Young Child Feeding in the World Health Organization European Region

ABSTRACT Objectives: Complementary feeding should provide a healthy diet with critical nutrients for growth and development. Information is limited on child and infant feeding recommendations within the World Health Organization (WHO) European Region. Methods: The WHO Regional Office for Europe and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) performed a survey of national recommendations on infant and young child nutrition aimed at national government departments of health and national paediatric experts. Questions addressed national recommendations on breast-feeding and complementary feeding. Results: Information was available from 48 of the 53 Member States. Forty-five of 48 countries (94%) have national recommendations on infant and young child feeding, of which 41 are endorsed by official public health authorities. Regarding introduction of complementary feeding, 25 countries (out of 34, 74%) recommend 6 months of age as the ideal age. The earliest age of introduction recommended varies from 4 to 5 months in (31/38 countries, 82%) to 6 months (6/38, 16%) and 7 months (1/38, 2.6%). The recommended meal composition varies widely; introduction of iron-rich foods (meat, fish, eggs) at the age of 6 months is recommended in 30 out of 43 countries, whereas 13 (30%) recommend later introduction. Conclusions: National infant feeding recommendations vary widely between studied countries and partly differ from international recommendations. Too early introduction of complementary feeding can reduce duration of exclusive breast-feeding (EBF). Too late introduction of iron-rich complementary foods might increase anemia risk and adversely affect child development. A review and further harmonization of national recommendations appears desirable.


What Is Known
The complementary feeding period requires particular attention because of the rapid growth and development and high susceptibility for nutrient deficiencies and excesses. Information on present guidelines and recommendations on infant and young child feeding across the World Health Organization European Region Member States is lacking.

What Is New
National recommendations on infant and young child feeding are established in 94% of 48 countries in the World Health Organization European region, but they vary widely and often differs from international guidance.
Some 93% of countries recommend promotion and support of exclusive breast-feeding (EBF) for the first 6 months of life. Seventy-four percentage of countries recommended an ideal age of 6 months for introducing complementary feeding, whereas 82% recommend for exclusively breastfed infants an earliest start of complementary feeding from about 4 months onwards, and 30% recommend providing iron-rich foods later than at 6 months. The considerable heterogeneity between infant feeding recommendations of countries of the WHO European Regionshouldbereducedandperiodicupdatesofguidelines based on present evidence should be performed.
T he introduction of solid foods constitutes a crucial turning point in an infant's nutrition and development (1)(2)(3)(4). The World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) recommend exclusive breast-feeding (EBF) for the first 6 months of life, followed by the introduction of complementary foods (CF) along with continued breast-feeding up to the age of 2 years and beyond (5). Scientific studies and systematic reviews showed several short-and long-term benefits associated with breast-feeding, such as lower risk of death among breastfed children, protection against diarrhea, otitis media and respiratory infections, and lower odds of overweight and obesity, type-2 diabetes, and high systolic blood pressure later in life (6)(7)(8)(9)(10). Thus, promoting, protecting and supporting breastfeeding is an important public health priority.
Adequate complementary feeding is critical because of the rapid growth and development of the infants and high susceptibility for nutrient deficiencies and excesses, while marked dietary changes occur with exposures to new foods, tastes, textures, and feeding experiences (1,4). Therefore, the complementary feeding period requires particular attention for providing adequate nutrition. Recommended practices include the introduction of CF at about 6 months of age, sufficient meal frequency and portion sizes, dietary diversification, appropriate food texture, safety regarding preparation, storage and hygiene, and responsiveness to feeding cues (1,3,5,11). It is of utmost importance to provide sources of critical nutrients, such as iron and zinc with the introduction of CF (4,12). This is especially important for exclusively breastfed infants whose iron stores become depleted in the first 4 to 6 months of life (13,14), and during late infancy and toddlerhood when iron status continues to be critical for healthy brain development (15,16).
In line with the WHO recommendations, the European Food Safety Authority (EFSA) and learned societies including the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) support EBF for the first 6 months as an ideal goal (17)(18)(19). For infants in Europe, both ESPGHAN and EFSA suggested that CFs should not be introduced before the age of 4 months and not later than 7 months (1,2,18,19). ESPGHAN and EFSA define CFs as anything other than breast milk or formula, therefore, their recommendations are not directly comparable with those of WHO that categorizes formula as a CF.
There is broad literature on breast-feeding and formula feeding, whereas less attention has been devoted to the CF period and the protection of timely introduction to appropriate, nutritious, and safe CF for infants and young children. Information on present guidelines and recommendations on infant and young child feeding (IYCF) across the WHO European Region Member States is lacking. This study aims to provide information from the WHO European Region on national recommendations on infant and young child nutrition and feeding practices.

Questionnaire Design
The questionnaire constituted single and multiple-choice questions and was developed, pilot tested, and revised jointly by ESPGHAN and WHO. It was designed to obtain information about national IYCF recommendations, including timely introduction to appropriate, nutritious, and safe CF. The questions were designed to explore national and/or regional actions within the following 3 areas: 1. Guidelines on IYCF questions addressed national and/or regional recommendations on nutrition and/or food-based dietary guidelines and bodies responsible for their implementation and review. 2. Promotion and support of breast-feeding questions addressed national and/or regional recommendations on exclusive and partial breast-feeding. 3. Introduction to CF questions addressed national and/or regional IYCF recommendations; age of introduction; first 3 foods (food groups sequentially added); introduction to meat and other ironrich food sources; recommended drinks; frequency of meals consisting of solid foods (other than milk and other liquids).

Data Analysis
Manually entered data were transferred and entered into the online version. Data submitted online were automatically extracted from the online platform SurveyGizmo using Microsoft Excel. The WHO Regional Office for Europe carried out data cleaning and validation to ensure consistency with responses within a question and its sub-questions.
For analysis, countries for which no information was available for some questions or that responded ''No'' were identified separately and coded as ''No guideline available,'' ''No information available,'' or ''Respondent unable to answer.'' These were not included for the analysis in that corresponding question-hence reported percentages are ''percentage reporting out of the countries for which a response was available on this question''. Countries for which no responses were obtained to the survey were identified separately, coded as ''Did not participate'' and excluded from the main analysis. Hence, for each indicator, different denominators are applied, according to the number of countries with data for that indicator.
Regarding the 3 food groups introduced to infants during CF, it was assumed that if a food group was recommended as first, it would also be recommended as second and third, to enable analysis of the diversity of the diet.

Existence of National Recommendations
Among the participating countries, the majority (45/48 countries; 94%) reported to have national recommendations on IYCF. Three countries (3/53; 6%) reported not to have recommendations on this topic. All national recommendations referred to in the survey were published between 2003 and 2017.
In most countries with national recommendations on IYCF, these were reported to be issued or endorsed by the government (41/ 45; 91%). In 4 countries (4/45; 9%) without formal governmental endorsement, professional bodies are responsible for the nationally used recommendations on IYCF.
Information on authorities responsible for implementation of recommendations was available for 44 of 45 countries. Seven countries (7/44; 16%) reported that the professional bodies are responsible for implementation, while 11 of 44 countries (25%) reported that their governmental authorities are the only entity responsible. In more than half of the countries (26/44; 59%), governments and professional bodies are jointly responsible for the implementation of recommendations. The review of these recommendations is a governmental responsibility in 19 of 45 countries (42%) and a joint responsibility in 18 of 45 countries (40%). Eight of 45 countries (18%) rely solely on professional bodies for this review process.

Information on Promotion and Support of Breast-feeding and on Breast Milk Substitutes
Forty-two of 45 countries (93%) with national recommendations reported that their nutrition recommendations and/or FBDGs for IYCF promote and support EBF for the first 6 months of life, whereas 3 countries (7%) promote and support EBF for 4 months. Twenty-nine of 45 countries (64%) promote and support continued breast-feeding up to 2 years of age and beyond, while 9 countries (20%) promote and support continued breast-feeding up to 1 year. The national recommendations include a direct reference to substitutes for breast milk as an acceptable alternative in 23 of 44 countries (52%) that reported data on this topic for infant formula, 27 of 44 countries (61%) for follow-on formula and 18 of 44 countries (41%) for young child formula, respectively.

Age of Introduction to Complementary Foods
Data on the recommended age for introduction to CF was available for 34 among 45 countries with national recommendations for IYCF and unavailable for 9 countries. The ideal age for introducing CF was recommended to be 6 months in 25 of 34 countries (74%); 4 months in 6 countries (18%); and 5 months in 3 countries (9%) (Fig. 1). The recommended earliest age for introducing CF varied, with 27 of 38 countries (71%) recommending 4 months, 1 country (2.6%) 4 1 /2 months, 3 countries (8%) 5 months (ie, 31 countries or 82% before the age of 6 months), 6 countries (16%) 6 months and 1 country (2.6%) 7 months, whereas 5 countries did not report data on the earliest recommended age. Only 29 countries reported data on the recommended latest age to introduce CF, while no information was available for 14 of 43 (33%). The responses varied between 5 1 /2 months (1/29; 3.5%) to 9 months (1/29; 3.5%). The majority of countries recommended the latest introduction at 6 months (25/29; 86%). One country (3.5%) recommended the latest introduction at 6 1 /2 months and another country (3.5%) at 7 months. Different age recommendations for introducing CF in breastfed and formula-fed infants were reported in 6 of 40 countries (15%) that responded to this question. Almost all of these countries recommended earlier introduction of CF for nonbreastfed infants, generally starting around 4 months of age.

Recommendations on Liquids Other Than Water
Recommendations on liquids for IYCF exist in 44 of 45 countries (Supplemental Figure 1, http://links.lww.com/MPG/B942). Twenty-one of 44 countries (48%) recommend EBF (''breast-milk only'') up to 6 months of age, while 23 of 44 countries (52%) recommend breast-feeding together with other liquids during this period. Recommendations to provide juice increase with agefrom 14 of 44 countries (32%) before 12 months to 18 countries (41%) before 2 years. Tea (including sweetened tea) is recommended in 12 of 44 countries (27%) before 2 years of age. Feeding of cows' milk is recommended by 5 of 44 countries (11%) before 12 months of age.
Four countries do not provide information on which complementary food groups as first foods. Seven countries do not have information on second food groups and 6 countries do not provide information on introducing third food groups.

Age of Introduction to Meat and Iron-rich Foods
Forty-four countries reported information on the recommended age of introduction of meat and other iron-rich food sources, though 1 country did not specify the age and was not included in this analysis. Some 26 of 43 countries (61%) recommend the introduction of protein and iron-rich sources at 6 months, while 4 countries (9%) recommend an earlier introduction. Therefore, most countries recommend introduction of an iron-rich food source by the age of 6 months (30/43; 70%). Thirteen of 43 countries (30%), however, recommend a later introduction, at 7months in 8 countries (19%), 8 months in 3 countries (7%) and 9 months in 3countries (5%).
One-third of countries (14/41; 34%) recommend introduction of an animal-source food (meat, fish, or egg) in the first food group, 28 of 41 countries (68%) add this as a second food group, and most countries (36/43; 88%) recommend introduction of an animalsource food by the time of introduction of the third food group (Fig. 3).

Complementary Food Meals
Nearly one-third of countries with recommendations ( Cumulative percentage of countries

Months of age
Age of introduction per day before the age of 6 months. One country (2%) recommends 4 to 5 meals per day for infants younger than 6 months. For 6 to 9 months old infants, 13 of 36 countries (36%) recommend 1to 2 meals per day, while 17 countries (47%) recommend 2 to 3 meals per day; 4 countries (11%) 3 to 4 meals per day and 2 countries (6%) 4 to 5 meals per day.
Twenty-five of 45 countries (56%) include information on dietary reference intakes in their FBDGs for IYCF.

DISCUSSION
The aim of this study is to provide information on national recommendations on IYCF practices in the WHO European Region. Respondents from 94% of the WHO European Region Member States reported data on IYCF practices. In most of the countries, the government endorses the IYCF recommendations, while in 9% of the countries, professional bodies are the responsible entities. Governments participate in the implementation of the IYCF recommendations in most countries, either alone or jointly with professional bodies. We consider it important that governments actively endorse the implementation of IYCF recommendations, which should increase the chances of effective implementation.
In the majority of countries in the European Region, IYCF recommendations differ from WHO guidelines. WHO recommends EBF for the first 6 months of life and, consequently, the introduction of CFs from 6 months onwards (5). Recommendations in 93% of countries state that they promote and support EBF for the first 6 months of life. Eighty-two percent of the countries, however, also provide a recommendation that infants who are nonexclusively breastfed should not start CFs before the age of 4 months, in line with the conclusions of ESPGHAN and EFSA who did not identify harmful effects of introducing CFs after around 4months, alongside breast-feeding or formula feeding (1,2,18,19).
WHO and UNICEF recommend initiating CF at about 6 months of age (5) with adequate food sources, meal frequency, portion sizes, texture, and hygiene (3,5). Food groups recommended most frequently for consumption among the first foods include vegetables, cereals, and fruits; followed by foods that are good ironsources (meat, fish, and egg), rice and dairy products, and lastly bread and pasta. Many countries also recommended that CF should be preferentially prepared at home with fresh ingredients. Some commercially available products have been considered problematic for child health, such as pureed, semiliquid foods for infants and young children packed in squeezable plastic pouches, which tend to be high in energy density and sugar content but low in contents of critical nutrients (20)(21)(22). The European Commission's Joint research centre found large variation of the contents of sugar, saturated fats, and salt in a wide range of commercial CF marketed in Europe (23), often with undesirably high contents. The WHO Regional Office for Europe reported a poor nutritional quality of many commercial baby foods in several European countries, often with high amounts of sugar and inappropriate nutrition claims (22).
Although 70% of the countries recommended the introduction of iron-rich food sources by the time the infant reaches the age of 6 months, 13 countries recommend later introduction, some only at 9 months. It is essential to provide sources of iron with the introduction of CF, as iron deficiency continues to be the most common micronutrient deficiency in early childhood (24,25), which induces anemia and can have adverse effects on brain development, with potentially lifelong sequelae (26)(27)(28). From the end of the first half-year of life onwards, infants require additional iron from CF naturally rich in iron or fortified with iron, to meet their needs (12). It is worrying that 13 countries recommend the introduction of ironrich foods later and some considerably later than desirable.
A further concern is that the WHO Regional Office for Europe published the last guidelines on IYCF more than 15 years ago (29). Since then, new information and new questions have arisen, for example, new information on frequent gaps in meeting nutrient requirements in older infants and young children (24,25) and relating to the impact of complementary feeding practices on the risk of developing celiac disease and allergies (1,30,31), and potential differences in needs among different groups of infants, for example, with lower birthweights or with certain genetic polymorphisms relating to nutrient metabolism (12,32). Moreover, the world has seen many changes, such as a markedly increased prevalence of childhood overweight and obesity, a greater variety of commercial complementary food products, changing practices of food marketing, greater recognition of benefits of regional production and environmentally sustainable food choices, and other changes, such as an increasing popularity of plant-based diets. It may be worthwhile to explore whether 1 global recommendation for IYCF or more differentiated recommendations adapted to the conditions of different populations may be preferable. Updated guidelines for IYCF that take these aspects into account should be considered a priority for the WHO European Region.
Strengths of the present study are the inclusion of information from most countries in the WHO European Region, use of a standardized method of data collection, and the review of data from all participating countries by their respective public health authorities. Limitations are the reliance on data reporting by individual experts in the participating countries and some missing data. Although WHO, Codex Alimentarius, and paediatric organisations established generally agreed definitions for key terms used in our questionnaires (eg, follow-on formula, young child formula, iron-rich food sources, solid foods), those completing the questionnaires might at times have applied different definitions. The evaluation and reporting of the data collected in 2016 to 2017 was delayed because of interrupted employment of staff involved in data processing.

CONCLUSIONS
Considerable heterogeneity between recommendations on IYCF exists among the countries of the WHO European Region. We consider several aspects not to be in line with present scientific evidence. We recommend efforts for periodic updates on IYCF guidelines notably by the WHO Regional Office for Europe, greater attention by governments on reviewing and updating their national guidelines in line with present evidence and recommendations, and regular national surveys on CF, in order to improve and monitor IYCF practices.