Designing appropriate complementary feeding recommendations: tools for programmatic action

The strategy recommends early initiation of breastfeeding, exclusive breastfeeding for 6 months, and the introduction of adequate complementary foods at 6 months with continued breastfeeding for 2 years or beyond. The time of complementary feeding, typically between 6 and 23 months of age, is nutritionally the most vulnerable and in developing countries coincides with a rapid acceleration in the incidence of stunting, especially among children 6-12 months. Complementary foods may be dilute, lacking diversity, not given frequently enough, given in too little amounts, or prepared and given with insufficient attention to hygiene and food safety. The Pan American Health Organization/WHO Guiding Principles for Complementary Feeding of the Breastfed Child propose 10 guiding principles for complementary feeding. These principles include the introduction of complementary foods at 6 months, the promotion of breast milk as the primary source of nutrition, and the encouragement of a diverse diet. Similar guiding principles are available for feeding of non-breastfed children. National strategies should maximize the utilization of locally produced foods in any given setting, and consider the promotion of additional products only if they can fill a critical gap in nutrients in an acceptable, feasible, affordable, sustainable and safe way. Where locally available foods alone will not satisfy nutritional requirements, various types of products offer promise, including centrally produced fortified foods, micronutrient powders or lipid-based nutrient supplements. The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication. The objectives of this paper are to describe the basic principles and methods of each tool and provide an example of how the tools can be used jointly to design interventions. ProPAN is a tool designed for ministries of health, non-governmental organizations, and bilateral and international organizations working to improve the diets and feeding practices of children under 24 months of age to prevent early childhood malnutrition. It guides users through a step-by-step process for identifying problems related to young child nutrition, breastfeeding and complementary feeding, within a specific target population; defining the context in which these problems occur, including barriers to and facilitators of improved or 'ideal' practices; formulating, testing, and selecting behaviour-change recommendations and nutritional recipes; developing the interventions to promote them; and designing a monitoring and evaluation system to measure progress towards intervention goals. ProPAN materials include a multi-module field guide, a facilitator's guide, and a user's guide. The tool is designed to be used in a participatory and collaborative manner, involving stakeholders from government, civil society, and the private sector. ProPAN has been used in several countries, including Peru, to design and implement infant and young child-feeding programmes. Optifood is a computer-based platform that uses linear programming analysis to develop nutrient-adequate feeding recommendations at the lowest cost, based on locally available foods with the addition of fortified products or supplements when needed, or best recommendations when the latter are not available. The tool is designed to be used in conjunction with ProPAN, and provides a systematic and quantitative assessment of diet, including the identification of nutrient gaps and food-based feeding recommendations. The use of ProPAN and Optifood together provides a comprehensive approach to designing and implementing infant and young child-feeding programmes. The tools can be used to identify problems related to young child nutrition, develop locally appropriate and acceptable feeding recommendations, and design interventions to promote behaviour change and improve nutrition outcomes. The tools can also be used to monitor and evaluate the impact of interventions, and to make adjustments as needed. A case study from Peru illustrates how ProPAN and Optifood have been used jointly to design interventions. The study found that the use of ProPAN and Optifood together resulted in the development of a comprehensive and locally appropriate infant and young child-feeding programme, which included behaviour-change recommendations, nutritional recipes, and a monitoring and evaluation system. The programme was implemented in several communities, and resulted in significant improvements in nutrition outcomes, including a reduction in stunting and an increase in exclusive breastfeeding rates.