Complementary feeding 6–23 months: local foods to fill nutrient gaps

Provision of targeted local foods (in kind) to improve the quality of the complementary diet can be delivered using the following platforms:

• Blanket supplementary feeding to all 6–23-month-olds – take home rations or onsite feeding
• Additional targeted ration provided as part of household support/general food assistance
• IYCF support through health services and/or programmes

• In addition to breastmilk, WHO (2023) recommends a diverse diet that provides nutrient dense foods to ensure their nutritional needs are met. These include:
  • Animal source foods, including meat, fish, eggs, or diary should be consumed daily.
  • Fruits and vegetables should be consumed daily.
  • Pulses, nuts and seeds should be consumed frequently, particularly when meat, fish, or eggs and vegetables are limited in the diet.
• There is now good evidence that the risk of developing acute malnutrition and of mortality is higher amongst children under 2 years (than over 2 years), and some argue that this may justify targeting preventative services among children to this age group, particularly where resources are constrained.^{78, 79} However, in many humanitarian contexts, access to quality diet and good quality health and other nutrition sensitive services as well as household and family practices for nutrition can be severely disrupted such that those whom would normally be relatively well protected from undernutrition, become vulnerable.
• Where possible in humanitarian and food insecure contexts improving access to appropriate local foods is always optimal. These should include foods that are rich in micronutrients, fats and proteins that are able to fill the nutrient gaps identified in complementary diets as part of context analysis and assessment.
• Animal–source foods, fruits and vegetables, nuts, pulses and seeds should be key components of energy intake because of their overall higher nutrient density compared to cereal grains. While ASFs, particularly red meat, have been identified as problematic aspects of sustainable food systems, infants and young children have unique nutritional needs that merit special consideration.
• Starchy staple foods should be minimised. They commonly comprise a large component of complementary feeding diets, particularly in low resource settings, but do not provide proteins of the same quality as those found in animal source foods and are not good sources of critical nutrients such as iron, zinc and Vitamin B12. Many also include anti–nutrients that reduce nutrient absorption.
• When cereal grains are used, whole cereal grains should be prioritised and refined ones minimised. Foods high in sugar, salt and trans fats and sugar–sweetened beverages should not be consumed.
• Direct provision of appropriate complementary foods requires that the foods are available locally in the quantities required and that markets will not be unduly disrupted with their purchase.
• Households must be food secure to ensure that the impact of targeted nutritional support for children is not diluted. This may require household assistance in the form of food (in kind) or cash/vouchers to improve food security at this level (see household level response options).
• Good quality infant and young child feeding counselling should be delivered at the same time as the provision of nutritional support by health workers (facility–based and CHWs) with the relevant skills needed to support recommended breastfeeding and complementary feeding practices for children from 0 up to 24 months.
• Screening and referral for wasting and nutritional oedema should be done alongside delivery of preventive interventions as part of a continuum of care.

⁷⁸ United Nations Children’s Fund (UNICEF). Key Issues Brief: Age prioritization of nutrition interventions for child survival, growth and development in resource-constrained contexts. UNICEF, 2024. UNICEF, New York. World Health Organization (WHO. Risk-differentiated care: a paradigm shift to improve child mortality. Webinar. Sept 2024. First results (childhealthtaskforce.org)

⁷⁹ It is important to note that the extrapolation of this to individual treatment for wasting is not currently justified given that mortality risk in children who are malnourished is not concentrated in those under 2. The risk is equal in under and over 2 years in these children (Thurstans, S., et al., Anthropometric deficits and the associated risk of death by age and sex in children aged 6-59 months: A meta-analysis. Matern Child Nutr, 2023. 19(1): p. e13431. doi: 10.1111/mcn.13431. https://pubmed.ncbi. nlm.nih.gov/36164997/).