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This paper provides an update to the 1998 WHO/UNICEF report on complementary feeding. New research findings are generally consistent with the guidelines in that report, but the adoption of new energy and micronutrient requirements for infants and young children will result in lower recommendations regarding minimum meal frequency and energy density of complementary foods, and will alter the list of "problem nutrients." Without fortification, the densities of iron, zinc, and vitamin B6 in complementary foods are often inadequate, and the intake of other nutrients may also be low in some populations. Strategies for obtaining the needed amounts of problem nutrients, as well as optimizing breastmilk intake when other foods are added to the diet, are discussed. The impact of complementary feeding interventions on child growth has been variable, which calls attention to the need for more comprehensive programs. A six-step approach to planning, implementing, and evaluating such programs is recommended.

SummaryBackgroundDiarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering.MethodsThe WASH Benefits Bangladesh cluster-randomised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up. Pregnant women in geographically adjacent clusters were block-randomised to one of seven clusters: chlorinated drinking water (water); upgraded sanitation (sanitation); promotion of handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate child nutrition plus lipid-based nutrient supplements (nutrition); combined water, sanitation, handwashing, and nutrition; and control (data collection only). Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCC01590095.FindingsBetween May 31, 2012, and July 7, 2013, 5551 pregnant women in 720 clusters were randomly allocated to one of seven groups. 1382 women were assigned to the control group; 698 to water; 696 to sanitation; 688 to handwashing; 702 to water, sanitation, and handwashing; 699 to nutrition; and 686 to water, sanitation, handwashing, and nutrition. 331 (6%) women were lost to follow-up. Data on diarrhoea at year 1 or year 2 (combined) were available for 14 425 children (7331 in year 1, 7094 in year 2) and data on length-for-age Z score in year 2 were available for 4584 children (92% of living children were measured at year 2). All interventions had high adherence. Compared with a prevalence of 5·7% (200 of 3517 child weeks) in the control group, 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation (61 [3·5%] of 1760; prevalence ratio 0·61, 95% CI 0·46–0·81), handwashing (62 [3·5%] of 1795; 0·60, 0·45–0·80), combined water, sanitation, and handwashing (74 [3·9%] of 1902; 0·69, 0·53–0·90), nutrition (62 [3·5%] of 1766; 0·64, 0·49–0·85), and combined water, sanitation, handwashing, and nutrition (66 [3·5%] of 1861; 0·62, 0·47–0·81); diarrhoea prevalence was not significantly lower in children receiving water treatment (90 [4·9%] of 1824; 0·89, 0·70–1·13). Compared with control (mean length-for-age Z score −1·79), children were taller by year 2 in the nutrition group (mean difference 0·25 [95% CI 0·15–0·36]) and in the combined water, sanitation, handwashing, and nutrition group (0·13 [0·02–0·24]). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth.InterpretationNutrient supplementat...

This review summarizes the impact of stunting, highlights recent research findings, discusses policy and programme implications and identifies research priorities. There is growing evidence of the connections between slow growth in height early in life and impaired health and educational and economic performance later in life. Recent research findings, including follow-up of an intervention trial in Guatemala, indicate that stunting can have long-term effects on cognitive development, school achievement, economic productivity in adulthood and maternal reproductive outcomes. This evidence has contributed to the growing scientific consensus that tackling childhood stunting is a high priority for reducing the global burden of disease and for fostering economic development. Follow-up of randomized intervention trials is needed in other regions to add to the findings of the Guatemala trial. Further research is also needed to: understand the pathways by which prevention of stunting can have long-term effects; identify the pathways through which the non-genetic transmission of nutritional effects is mediated in future generations; and determine the impact of interventions focused on linear growth in early life on chronic disease risk in adulthood.

Table of Contents Summary251. Introduction33 1.1 Importance of complementary feeding for child health33 1.2 Guiding principles for complementary feeding34 1.3 Scope and organization of this report342. Energy and nutrients needed from complementary foods35 2.1 Energy, protein and lipids35 2.2 Micronutrients353. Methods36 3.1 Sources searched and search strategy36 3.2 Measurement of the treatment effect of interventions36 3.3 Evaluation of methodological quality and level of evidence37 3.4 Number of relevant studies identified384. Findings of the systematic review38 4.1 Types of intervention strategies38  4.1.1 Educational interventions38  4.1.2 Provision of food offering extra energy (with or without micronutrient fortification)43  4.1.3 Micronutrient fortification of complementary foods43  4.1.4 Increasing energy density of complementary foods through simple technology46  4.1.5 Categorization of results by intervention strategy46 4.2 Growth outcomes46  4.2.1 Interventions using educational approaches46  4.2.2 Interventions in which provision of complementary food was the only treatment49  4.2.3 Interventions in which provision of complementary food was combined with another strategy, usually education for mothers51  4.2.4 Interventions in which complementary foods were fortified with additional micronutrients53  4.2.5 Interventions to increase energy density of complementary foods55 4.3 Morbidity outcomes55  4.3.1 Interventions using educational approaches55  4.3.2 Interventions in which provision of complementary food was the only treatment57  4.3.3 Interventions in which provision of complementary food was combined with another strategy, usually education for mothers57  4.3.4 Interventions in which complementary foods were fortified with additional micronutrients58  4.3.5 Interventions to increase energy density of complementary foods59 4.4 Child development61  4.4.1 Interventions in which provision of complementary food was the only treatment61  4.4.2 Interventions in which complementary foods were fortified with additional micronutrients62 4.5 Micronutrient intake63  4.5.1 Intervention studies using educational approaches63  4.5.2 Interventions in which provision of complementary food was the only treatment64  4.5.3 Interventions in which provision of complementary food was combined with another strategy, usually education for mothers64  4.5.4 Interventions in which complementary foods were fortified with additional micronutrients65  4.5.5 Interventions to increase energy density of complementary foods66 4.6 Iron status66  4.6.1 Intervention studies using educational approaches66  4.6.2 Interventions in which complementary food was provided, with or without another strategy such as education for mothers68  4.6.3 Interventions in which commercially processed complementary foods were fortified with iron or multiple micronutrients68  4.6.4 Interventions in which home fortification of complementary foods was the primary intervention68 4.7 Zinc status72  4.7.1 Interventions in which complementary foods were fo...