Titis Prawitasari

UKK Nutrisi & Penyakit Metabolik

Ikatan Dokter Anak Indonesia
Complementary feeding:
 Transition from breastmilk or milk based diet to solid
 Vulnerable phase to develop nutritional deficiencies
 Foundations of meal and food preferences and habit as
well as eating behavior
 Relation to later health: chronic disease and NCD
Guidelines & practices: based on organization or country
by organization and/or
country
 Exclusive breastfeeding
 For the first 6 months of life: WHO/UNICEF, USA (AAP), Canada, Brazil,
Sub-Saharan Afica, India, Philippines, Hongkong, Singapore, Malaysia
 For about/around 6 months: ESPGHAN, Australia, New Zealand

 Continued breastfeeding
 At least 1 year or beyond: New Zealand
 Until 2 year or beyond: WHO/UNICEF, AAP, Canada, Brazil, Sub-
Saharan Afica, India, Malaysia
Black RE, Makrides M, Ong KK, 2017
 themes and terminology used
by organizations and/or country
 At/from/after 6 months: WHO/UNICEF, USA (NIH),
Canada, Sub-Saharan Afica, India, Philippines, Singapore
(181 days), Malaysia
 At approximately/around 6 months: USA (AAP), Australia,
New Zealand, Hongkong
 Not before 17 or after 26 weeks: ESPGHAN
 When “developmentally ready”: New Zealand

Black RE, Makrides M, Ong KK, 2017

 Meet energy/protein needs: USA (AAP), Philippines
 Food high in iron: USA (AAP and NIH), Australia, New
Zealand (+ vitamin C), Canada, Singapore, Malaysia
 Food high in zinc: USA (AAP)
 Nutrient-dense foods: Sub-Saharan Africa vitamin A, zinc,
iron, iodine), Philippines (micronutrient)

Black RE, Makrides M, Ong KK, 2017

 Consistency increasing with age: WHO/UNICEF, Australia,
New Zealand, Canada, Brazil, Malaysia
 Variety of foods: WHO/UNICEF, USA (AAP), Australia, New
Zealand, Canada, Brazil
 Specify how often and how much: WHO/UNICEF, USA
(NIH), New Zealand, Canada, Brazil, Sub-Saharan Africa,
Malaysia

Black RE, Makrides M, Ong KK, 2017

 Specific food idea: USA (NIH), Brazil, Hongkong (from
family food basket), Singapore, Malaysia
 Use fortified complementary foods: WHO/UNICEF,
Australia (iron), New Zealand, Canada
 Vitamin/mineral supplements as needed: WHO/UNICEF,
Sub-Saharan Africa, India, Philippines (vitamin A, iron,
iodine)

Black RE, Makrides M, Ong KK, 2017

 Responsive feeding: WHO/UNICEF, USA (AAP & NIH), Canada, Brazil,
Hongkong, Malaysia
 Self feeding: USA (AAP), Canada, Malaysia
 Progression to healthy family food: Australia, New Zealand, Brazil
 Hygienic food preparation & handling: WHO/UNICEF, USA (AAP & NIH),
Australia, Canada, Brazil, Sub-Saharan Afica, India
 Guidelines for feeding during illness: WHO/UNICEF, Brazil, India, Malaysia
 No added salt, sugar, nutrient-poor foods: USA (NIH), Australia, New Zealand,
Brazil, Malaysia
 Limited or no juice: USA (AAP), New Zealand, Malaysia
 Do not delayed allergens: USA (AAP), ESPGHAN, Australia
Black RE, Makrides M, Ong KK, 2017
 Low-middle countries issues:
 Early and delayed complementary feeding (CF)
 Timing & types of foods related to cultural, socio-economic status,
education level of the parents

 Higher income countries issues:

 Most infants commence CF 4-6 months of age
 Most infants and toddlers consume nutritional adequate diets, but
numbers of them not getting enough iron & zinc
 Low intake of fruits & vegetables
 Frequent consumption of high fat & sugar foods
• Introduction of semi solid, and soft foods
 optimal timing
• Minimal dietary diversity (MDD)
 micronutrient adequacy of the diet (diet quality)
• Minimum meal frequency (MMF)
 energy adequacy (quantity of food)
• Minimum acceptable diet (MAD)
 composite indicator combining breastfeeding and indicator 2 & 3
• Consumption of iron-rich and iron-fortified foods
 adequacy of iron intake
 WHO Recommendation

Global Strategy for Infant and Young

Child Feeding

• Up to 6 months
Exclusive
Breastfeeding • Early initiation of breast
feeding

• Continued breastfeeding
Complement until 2 years of age or beyond
ary Feeding • Timely, Adequate, Safe and
Properly fed
WHO, 2013
 Breastfeeding: exclusive breastfeeding up to 6 months and
continued until 2 years or beyond
 Amount complementary feeding
 6-8 months = 200 kcal; 9-11 months =300 kcal; 12-23 months =
550 kcal
 Frequency complementary feeding
 6-8 months: 2-3 times/day; 9-24 months: 3-4 times/day; add
nutritious snacks
 Consistency: increase as infants get older
 Nutrient content: variety foods
 Meat, poultry, fish, eggs should be eaten daily or as often as
possible, adequate fat content needed
WHO, 2009
 No evidence to disagree with
the current international
recommendation that healthy
infants exclusively breastfeed
for the first six months
 WHO, 2009
Infant and young child feeding
 WHO, 2009
Infant and young child feeding
Source: Iron Panel, 2004
Source: Iron Panel, 2004
per 100 gram

Dept of Nutrition for Health and Development WHO, 2000

 KECUKUPAN ZAT BESI
(ANGKA miligram/hari)
Umur Laki-laki Perempuan
0-6 bulan 0,27 0,27
(asupan yang adekuat
berdasarkan ASI)

7-12 bulan 11 11
1-3 tahun 7 7
4-8 tahun 10 10
9-13 tahun 8 8
14-18 tahun 11 15
DOES SOURCE OF PROTEIN MATTER?

Potential high protein intake may differ between breastfed

and formula infant, and by the source of protein
 HOME MADE VS COMMERCIAL
INDICATOR HOME MADE COMMERCIAL
 Tailor made  Depend on manufacture
• Variation
 Few time
 More time
• Preparation time  Manufacture portion
 Parent’s portion  Inaccuracy of dilution and
miscalculation of volume
• Volume  Need more volume to meet
nutrient requirement  Already calculated precisely

 Cannot be calculated correctly

• Micronutrient
Sari Pediatri 2012;14:265-8
TERIMA KASIH