Monday, June 18, 2007

Solids as the first complementary food? Hmmmm

Re: Pureed food 'isn't natural for babies - Unicef nutrition expert sparks controversy with attack on spoon-feeding from tins and jars. Amelia Hill, social affairs correspondent, Sunday June 17, 2007, The Observer
http://www.guardian.co.uk/medicine/story/0,,2104953,00.html

There seems to be an increasingly heated debate as to the best first foods to be introduced to the exclusively breastfed child at 6 months or so. Research by Kay Dewey and others has convinced me that the most appropriate first foods should be high in high quality protein, iron- and nutrient-rich. But what is the best way to introduce them? and would the answer vary by individual status, setting, and caretaker time conflicts?

I am responding only to the statement that appeared in a recent Observer article that seemed to state that UNICEF is against spoon feeding and pureed foods, and in favor of solids. This is an area that arguably deserves much increased evidence-based attention, not only in terms of foods, but also in respect to manner of feeding, continued intensity of breastfeeding, settings, maternal time availability and scale-up.

While moving directly to solids is an interesting notion, I think it is important to clarify that this statement was issued by one country's BFHI Deputy Director, and that this is not UNICEF policy, as far as I know.

I was recently asked to review a British video on a solid, non-ground or treated, food introduction approach - perhaps the one referred to in the article - and to me, it does seem a feasible alternative - for a self-selected population who fully understands how to do it, what to expect, and with regular health status monitoring. But what can be recommended globally?

It may very well be true that much of what is available out there for purchase has problems, but statements on what is "natural" can be off base, as well. Traditionally, it is thought that humans pre-masticated foods for their infants, adding natural enzymes and achieving a ground version of the food; while this may be natural, it is unlikely to return as the norm.

In fact, I may not be entirely up to date on UNICEF policy as I have been here at Carolina for over a year, but my guess is that there has been no such statement from UNICEF/HQ, which supports WHO policy. My understanding of WHO policy, as outlined in the Global Strategy, is that it encourages a continuum of appropriate complementary foods, starting with 1) local foods, prepared for nutrient density and infant consumption, possibly with nutrient supplement where needed, followed by 2) locally produced community or commercial foods, followed by 3) national or international manufactured foods.

There is also now a very well considered document online on treatment of malnutrition in the community, that may add to this discussion.

In Great Britain, availability of nutrients may not be a big issue, but in settings where nutrient load in local solids is poor, and where infants are already behind in growth due to compromised intrauterine development and depleted maternal stores, moving directly to harder to consume, less nutrient dense foods would not be optimal. The current guidance on the best complementary food is that it be high in protein and iron and nutrient rich. Unless foods are ground, and possibly pretreated with enzymes, cooked or otherwise made more ready for digestion, it would be difficult for the infant to successfully consume and absorb all the nutrients it needs. Therefore, in my opinion, some preparation and/or supplementation of staples is indicated in these situations for best growth.

AND where caretakers are already overwhelmed with other tasks, feeding may be the only time that there is any responsive interaction with the child. This also should be encouraged.

I know that these statements may be a bit of an outlier from the IBFAN and WABA statements' clarity on complementary foods. However, this is my considered opinion, based on my experience as a Pediatrician and in the field, and based on the evidence that has been shared with me by well-schooled colleagues.

Thanks to IBFAN and WABA for keeping the word out there and circulating it. Patty Rundall, who brought this to wide attention, is an invaluable resource to those of us seeking to enable all women and caretakers to make the right decisions.

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