ISDI has taken note of the WHO Guideline for complementary feeding of infants and young children 6–23 months of age. ISDI is concerned that certain recommendations are neither in line with existing regulatory frameworks nor scientifically substantiated.

ISDI and its members reiterate their commitment to improve nutrition and providing the highest quality products that help meet the nutritional needs of mothers, infants and young children. Furthermore, ISDI supports the WHO’s recommendation of exclusive breastfeeding for the first six months of life and continued breastfeeding, along with the introduction of adequate complementary foods, for up to two years and beyond.

Contradictions of accepted science

The Guideline’s recommendation 2.a mentions that ‘either milk formula or animal milk’ can be fed as of 6 months. This is against generally accepted scientific evidence that (full fat) cow’s milk can be best introduced at the age of 12 months[1].

Recognising the role of Follow-up formula

The Guideline doesn’t recommend the use of Follow-up formula. WHO undermines the opinion of its own standardization body, Codex Alimentarius, which recently finalized a review of the Standard on follow-up formula for older infants (6-12 months) and Product for young children (12-36 months). The revised Standard integrates the latest available science on safety and composition and recognizes follow-up formula “for use as a liquid part of a diet for older infants when progressively diversified complementary feeding is introduced”[2].

The importance of a diversified diet with optimal nutrition intake

Young Children learn to experience new tastes and textures, gradually increasing food consistency and variety. A diversified diet ensures a balanced diet meeting the nutritional needs of the growing child.

Data show that the poor and uneven nutritional composition of unfortified complementary foods means that it is difficult to create varied diets that provide toddlers with optimal intakes of important nutrients like DHA (Docosahexaenoic acid), zinc, iron and vitamin D.  To illustrate, the point ISDI notes that

• For young children 12-23 months of age, the Guideline recognises that ‘milk formula provide supplemental sources of iron and other nutrients’ but still doesn’t recommend its use;
• the Guideline similarly acknowledges evidence that iron-fortified infant cereals have a beneficial effect on mental skill development scores and motor development scores. However, it concludes that their consumption should not be encouraged.

Transition to complementary foods

To meet the evolving nutritional needs of infants and young children, the amount and frequency of adequate and safe complementary foods are managed through appropriate serving sizes to avoid undue displacement of breast milk or infant formula. As the older infant grows to a young child, the contribution that complementary food makes to the diet increases as total energy intake increases.

Recommendation 3 states that infants should be introduced to complementary foods at 6 months (180 days) while continuing to be breastfeed. In prior communications WHO stated that it is around 6 months of age. EFSA (2019) states that there is no cut-off date:  “As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age.”

The issue of Food Safety

ISDI regrets that the Guideline’s scope excludes issues of food safety. ISDI is concerned about this development as complementary foods should be prepared, stored and served with great care under safe and hygienic conditions[3]. Attention to food hygiene have shown significant reductions in infant food contamination and improved behaviours of serving complementary foods.

Food safety is a key component of infant and young children nutrition, as recognised by the WHO Code of Marketing of Breast-Milk Substitutes, which was adopted to ‘contribute to the provision of safe and adequate nutrition for infants’.

To conclude, ISDI is concerned about the scientific substantiation of the WHO Guideline. ISDI and its members are ready to ‎work together with all stakeholders to support optimal infant health and well-being.

Further reading

For more information about complementary feeding, read ISDI’s factsheet or visit the dedicated page on the ISDI website. For information about follow-up formula for older infants and young children, please click here.

• WHO Guideline for complementary feeding of infants and young children 6–23 months of age (Link)
• EFSA (2019) Scientific Opinion on the appropriate age for introduction of complementary feeding of infants. EFSA Journal 2019; 17(9):5780 (link)
• EFSA (2013) Scientific Opinion on nutrient requirements and dietary intakes of infants and young children in the European Union. EFSA Journal 2013; 11: 3408 (link)
• Koletzko et al. Should formula for infants provide arachidonic acid along with DHA? The American Journal of Clinical Nutrition, Volume 111, Issue 1, January 2020, Pages 10–16 (link).

Note to the editors:

ISDI is the leading international expert association on special dietary foods, including foods specifically designed for infants and young children. ISDI members are national and international associations that are active in this sector from more than 20 countries over 6 continents. Our members manufacture and market foods that are formulated, in accordance with applicable Codex Alimentarius standards, to meet the compositional criteria, quality requirement and nutritional needs of infants and young children.

Further Contact:

Jean Christophe Kremer
ISDI Secretary General
M: +32 476 82 03 90
E: secretariat@isdi.org

---

[1] See for instance Center for Disease Control (CDC) https://www.cdc.gov/nutrition/infantandtoddlernutrition/foods-and-drinks/cows-milk-and-milk-alternatives.html#:~:text=At%2012%20months%20old%20(but,at%20risk%20for%20intestinal%20bleeding.  (retrieved 29 November 2023)

Also; Paediatr Child Health. 2003 Sep; 8(7): 419–421 (retrieved 29 November 2023)

[2] See https://www.fao.org/fao-who-codexalimentarius/news-and-events/news-details/en/c/1667642/

[3] See a recent publication: Infant Food Hygiene and Childcare Practices in Context: Findings from an Urban Informal Settlement in Kenya Am J Trop Med Hyg. 2020 Jan; 102(1): 220–222 (link) retrieved 29 November 2023