Complementary feeding must include a responsive feeding style, diverse options, and foods available in the region and season, according to the updated consensus on complementary feeding from the Latin American Society for Pediatric Gastroenterology, Hepatology, and Nutrition: COCO 2023. Complementary feeding is not different for children with or without a risk for allergies, according to the document. The time to start complementary feeding in an infant is from 4 to 6 months of age, as per each case.
"A first-contact doctor who is in charge of monitoring children in their early stages has a very powerful tool in their hands, through good nutritional practices," said Rodrigo Vázquez Frías, MD, PhD, the first author of this publication. "Nutrition in the first 1000 to 1500 days of life is so important. It is the basis of a large number of illnesses." Vázquez, a physician at the Children's Hospital of Mexico Federico Gómez in Mexico City, elaborated that "it's the way in which an individual is programmed. For example, if a child in their first 1000 days of life consumes a large amount of protein or sugar, this can misprogram them and leave fertile ground for diseases such as obesity, diabetes, and hypertension to develop shortly or long after."
What's Complementary Feeding?
Complementary feeding is defined as the feeding of infants that complements breastfeeding, or alternatively, feeding with a breast milk substitute. It is a process in which various aspects must be considered, such as encouraging it to be perceptual (which implies creating the correct sensory environment) and observing the nursing infant's hunger and satiety signals.
In addition, the determination of the correct time for introducing food should consider cultural aspects and the perception of parents or caregivers. It also involves a progression in the change of textures to promote movements of the tongue, lips, and jaw that ensure the correct development of the organs involved in chewing and speech. It is a vitally important period for the establishment of future food preferences.
The purpose of this work was to develop a consensus on complementary feeding that, whenever possible, incorporates local information adaptable to regional conditions.
The document was the product of a group of specialists who represented each member country of the Nutrition Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (LASPGHAN).
Twenty-one representatives of LASPGHAN member countries participated: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Portugal, Spain, Uruguay, and Venezuela.
"It was a challenge to get 21 different countries to agree, with totally different thoughts, idiosyncrasies, traditions and culture," said Vázquez. "We had to clarify definitions and totally conceptual issues. A titanic task: we talked about the fact that this project began 5 years ago and is only now being completed."
The specialists were randomly assigned to one of five working subgroups to address the various topics of complementary feeding. The facilitators developed a series of statements in accordance with the topics and subsequently searched for evidence (published between January 1, 1990, and October 31, 2019) that supported these statements.
Vázquez pointed out that reaching this consensus required confronting recommendations that are not based on evidence, but rather on traditions that doctors uphold because they are not up to date.
"Considerations based on traditional issues are not wrong, but they lacked some degree of evidence," he said. "For example, the idea that children cannot eat eggs because they are supposedly allergic to them is deeply rooted in the general population. The other problem is that many doctors who are not up to date on the subject also believe in this idea. Breaking through these barriers — not only medical in nature, but also cultural — was very hard."
A series of meetings was held, the initial one during the LASPGHAN congress in November 2019, at which the statements were presented and submitted for evaluation. Each of the statements was evaluated through a Delphi process of anonymous electronic voting. Each statement also was evaluated on a 3-point Likert scale: a) in agreement, b) in disagreement, and c) abstained.
The statements on which consensus was reached (≥ 75% in agreement) were accepted. The others (< 75% in agreement) were reevaluated for either elimination or reformulation by the members of the subgroup who had worked on them. A second anonymous voting round took place, and so on successively, as many times as needed, and the process ultimately resulted in 33 statements.
"If this had remained on paper, it would have been a waste of time. In Mexico, there has been very good acceptance by pediatricians. But it's important to remember that it has to reach the general practitioner who is in charge of implementing complementary feeding in the vast majority of children. It would also have to permeate nurseries or children's daycare centers, all the places where children go to receive complementary feeding," said Vázquez.
Regarding the perspectives that arise from the publication of this consensus, Vázquez highlighted the importance of its adaptation in each of the participating countries. "The first country that will make this adaptation is Colombia, which is already working on adapting the words and the typical foods or regionalisms, with the aim of making it even more specific, and that would ideally need to be done in the 21 countries."
Mexico already has the Official Mexican Standard NOM-043-SSA2-2012, which addresses the issue of complementary feeding. However, this has not been updated since 2013, even though the Medical Bulletin of the Children's Hospital of Mexico published a consensus for complementary feeding practices in healthy nursing infants in 2016. The publication of this document should encourage the revision of the standard to keep it up to date with the most recent evidence-based recommendations.
Abisai Arellano Tejeda, MD, a pediatric gastroenterology specialist at Siglo XXI Pediatric Hospital in Mexico City, commented on the importance of publishing this consensus. "The last version was out of date, although there were not many changes in some respects. There is no harm in reaffirming them and having more current factual support. There are still many errors in the introduction of food due to beliefs or customs that have not been left behind."
She added, "It is necessary to introduce information on the different methods of complementary feeding to these consensuses. It will be shared widely. The recommendations should be further described, because they only indicate that they should be carried out under the guidance of experts. But in the end, this type of text is for doctors who are going to recommend or initiate complementary feeding.
"I think they should focus a bit more on certain specific recommendations of the three types of food introductions, such as baby-led introduction to solids and baby-led weaning, about which little is said, and many parents request the information from us,” Arellano concluded.
Vázquez and Arellano had no relevant financial relationships.
This article was translated from the Medscape Spanish Edition.
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Cite this: Latin American Complementary Feeding Guidelines Updated - Medscape - Mar 06, 2023.