WHOs infant and young child

feeding recommendations
(Adapted from the 2002 WHO/UNICEF Global Strategy
for Infant and Young Child Feeding)
Initiate breastfeeding within one hour of birth.
Breastfeed exclusively for the first six months of
age (180 days).
Thereafter give nutritionally adequate and safe
complementary foods to all children.
Continue breastfeeding for up to two years of age
or beyond.
The aim of the Global Strategy is to improve through optimal feeding
the nutritional status, growth and development, health, and thus
the survival of infants and young children. It also supports
maternal nutrition, and social and community support.

Skin to
Skin
Contact and Early

Breastfeeding

No water necessary
Country

Temperature Relative
C
Humidity %

Urine
osmolarity
(mOsm/l)

Argentina

20-39

60-80

105-199

India

27-42

10-60

66-1234

Jamaica

24-28

62-90

103-468

Peru

24-30

45-96

30-544

(Normal osmolarity: 50-1400 mOsm/l)

Breastfeeding on demand:
Breastfeeding whenever the baby or
mother wants, with no restrictions on the
length or frequency of feeds.

Earlier passage of meconium

Lower maximal weight loss
Breast-milk flow established sooner
Larger volume of milk intake on day 3
Less incidence of jaundice

Infant Feeding
Recommendation for
HIV-positive Women
When replacement feeding is acceptable, feasible,
affordable, sustainable and safe (AFASS), avoidance
of all breastfeeding by HIV-infected mothers is
recommended.
Otherwise, exclusive breastfeeding
is recommended during the first months
of life and then should be discontinued
as soon as it is feasible.

Prolactin reflex

Oxytocin reflex

Helping and hindering the oxytocin reflex

Good feelings or
thinking lovingly
of baby and
feeling confident
that her milk is
the best for baby

Help the oxytocin

reflex

Bad feelings,
such as pain,
or worry, or
doubt that she
has enough
milk

Hinder the oxytocin

reflex

Inhibitor in breastmilk

If a lot of milk is left in a

breast, the inhibitor stops cells
from secreting any more.
Inhibito
r

Reflexes in the baby

Rooting reflex
When something touches a babys lips or
cheek, he opens his mouth and may turn
his head to find it. He puts his turns down
and forward.

Sucking reflex
When something
touches a babys
palate, he starts to suck
it.

Swallowing reflex
When babys mouth fills
with milk, he swallows.

Good and poor attachment

Results of poor attachment

Pain and damage to the
nipple

The milk is not removed

effectively

The breasts make less milk

because the milk is not
removed.
The may cry a lot or feed
often or for a very long time
at each feed.

Nipple fissure
The breasts may become
engorged.
The baby may be unsatisfied
because the breastmilk
comes slowly.
The baby may become
frustrated and refuse feeding
The baby may fail to gain
weight.

Breastfeeding Positions
In line, Close, Supported, Facing

Hospital practices assisting BF

Antenatal education

Rooming in

Early initiation of BF

No artificial teats or
pacifiers

On demand, exclusive
BF

Compliance with the

International Code

Acceptable medical reasons for use of breast-milk substitutes/Infant Conditions

WHO 2009

Infants who should not receive breast milk or any other milk except
specialized formula
Infants with classic galactosemia: a special galactose-free formula is needed.
Infants with maple syrup urine disease: a special formula free of leucine,
isoleucine and valine is needed.
Infants with phenylketonuria: a special phenylalanine-free formula is needed
(some breastfeeding is possible, under careful monitoring).
Infants for whom breast milk remains the best feeding option but who
may need other food in addition to breast milk for a limited period
Infants born weighing less than 1500 g (very low birth weight).
Infants born at less than 32 weeks of gestational age (very pre-term).
Newborn infants who are at risk of hypoglycaemia by virtue of impaired
metabolic adaptation or increased glucose demand (such as those who are
preterm, small for gestational age or who have experienced significant
intrapartum hypoxic/ischaemic stress, those who are ill and those whose
mothers are diabetic) (5) if theirblood sugar fails to respond to optimal
breastfeeding or breast-milk feeding.

Acceptable medical reasons for use of breastmilk substitutes/Maternal Conditions WHO 2009
Mothers who are affected by any of the conditions mentioned below should
receive treatment according to standard guidelines.
Maternal conditions that may justify permanent avoidance of
breastfeeding
HIV infection1: if replacement feeding is acceptable, feasible, affordable,
sustainable and safe (AFASS) (6).
Maternal conditions that may justify temporary avoidance of
breastfeeding
Severe illness that prevents a mother from caring for her infant, e.g sepsis.
Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the
mothers breasts and the infants mouth should be avoided until all active
lesions have resolved.
Maternal medication:

Acceptable medical reasons for use of

breast-milk substitutes/Maternal Conditions
WHO 2009

Maternal medication:
o sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and
their combinations may cause side effects such as drowsiness and
respiratory depression and are better avoided if a safer alternative is
available (7);
o radioactive iodine-131 is better avoided given that safer alternatives are
available - a mother can resume breastfeeding about two months after
receiving this substance;
o excessive use of topical iodine or iodophors (e.g., povidone-iodine),
especially on open wounds or mucous membranes, can result in thyroid
suppression or electrolyte abnormalities in the breastfed infant and
should beavoided;
o cytotoxic chemotherapy requires that a mother stops breastfeeding during
therapy.

Acceptable medical reasons for use of breastmilk substitutes/Maternal Conditions WHO 2009
Maternal conditions during which breastfeeding can still continue, although health
problems may be of concern
Breast abscess: breastfeeding should continue on the unaffected breast; feeding from the
affected breast can resume once treatment has started
Hepatitis B: infants should be given hepatitis B vaccine, within the first 48 hours or as soon as
possible thereafter
Hepatitis C
Mastitis: if breastfeeding is very painful, milk must be removed by expression to prevent
progression of the condition
Tuberculosis: mother and baby should be managed according to national tuberculosis guidelines
Substance use
o maternal use of nicotine, alcohol, ecstasy, amphetamines, cocaine and related stimulants has been
demonstrated to have harmful effects on breastfed babies;
o alcohol, opioids, benzodiazepines and cannabis can cause sedation in both the mother and the baby.

Mothers should be encouraged not to use these substances, and given opportunities and support to
abstain.

Replacement (artificial) feeding options

Commercial infant formulas- most of them are based on cows milk and
have been designed to mimic the nutrient composition of human milk The
concentration of protein and electrolytes such as sodium, potassium and
chloride are lower than in cows milk, while the levels of certain minerals,
primarily iron and to a lesser extent zinc are higher.
Formula from cows milk may be processed to be high in whey proteins.
This formula may be easier for the young infant to digest. Formula that is
high in casein protein can be more difficult for the young infant to digest as
it forms thick curds in the infants stomach.
Formula lucks the non-nutritional , bioactive components of human milk
(protective and trophic factors), and the quality of their proteins and lipids
are not optimal for the infant. Nevertheless, it provide satisfactory
alternative sole source of nutrition for infants of up to 6 months of age in
the absence of BF.
Formula is usually available as a milk powder and needs only to be mixed
with the correct amount of water.
Compositional guidelines for formula have been agreed in the Codex
Allimentarius (energy density is 65 kcal/100 ml is typical)

Specialised formula
Soy infant formula uses processed soybeans as the source of
protein. Usually it is lactose-free and has a different sugar added
instead. Infants who are intolerant of cows milk protein may also
be intolerant of soy protein. Soy milk is not a good milk for young
children as it does not include sufficient calcium and other animal
products for good growth and contains excessive amount of
fitoestrogens.
Low birth weight or preterm formula is manufactured with higher
levels of protein and certain minerals and a different mixture of
sugars and fats than ordinary formula for full-term infants. Low
birth weight formula is not recommended for healthy, full term
infants. The nutritional needs of low birth weight infants should be
individually assessed.
Specialised formulas are available to use in conditions such as
reflux, high-energy need, lactose intolerance, allergic conditions
and metabolic diseases like phenylketonuria. These formulas are
altered in one or more nutrients and should only be used for
infants with the specific conditions under medical/nutritional
supervision.

Home-prepared formula
The milk used as the base for home-prepared formula may be:
Fresh milk that is heat-treated at home,
Commercially heat-treated whole milk (such as UHT or sterilized milk),
Powdered full cream milk, or
Non-sweetened evaporated milk.
o The animal milks used may be from cows, buffalo, goat, ewe, camel or other
animal.
o In full strength full cream milk, the level of protein and some minerals is too
high, and it is difficult for an infant's immature kidneys to excrete the extra
waste. These milks require some modification to make the proportions more
appropriate.
o WHO recommends the following recipe for home prepared formula:
Boil 70 ml of water
Add 130 ml of boiled cows milk to make 200 ml of feed
Add 1 level teaspoonful (5g) of sugar
For sheeps milk the milk and water amounts should be 100 ml to100 ml

Products that are not suitable for making infant formula

Skimmed milk fresh or dried powder

Condensed milk
Creamers used for whitening tea or coffee

Unsuitable breast-milk substitutes

Infants should not be given unmodified cows milk as a
drink before the age of 9 months. Cows milk can be
gradually introduced into the diet of formula fed infants
between the ages of 9 and 12 months.
Skimmed, semiskimed, condenced milks
Yogurt, matzuni, Narine
Fruit juices, sugar-water, and dilute cereal gruels

Calculation of breast-milk substitutes daily

requirements
Volumetric method
The daily volume of breastmilk sunstitute for infants from 10
days to 2 months of age makes 1/5 of body weight, 2-4
months -1/6, 4-6 months - 1/7
2-6 old child should get 150 ml of breastmilk suntitute per kg
of body weight

Calorimetric method
Premature infants up to 3-4 months demand about 120-140
kcal per kg of weight per day
Term infants up to 3-4 months demand 110-120 kcal per kg
per day
As the infant grows the demand per body weight decreases
and for the one years old infant is about 100 kcal per kg per
day
The daily volume of the milk (ml) = weight (kg) x caloric
requirment (kcal/kg/day) / 0. 7
The calculated amount should not be more than one litre and
has only orientational meaning.

Recomendations on safe prepatration

of breastmilk substitutes
Check the expiration date on the
formula can. Discard expired
formula.
Follow the instructions on the lable.
Overdilution and underdilution are
dangerous for infant health.
Cup feeding and spoon feeding are
more recomended than bottle
feeding.

Mother should always wash hands with soap before preparing

feed. Feeding utilensis should be carefully cleaned and boiled.
The water for preparing feed should also be boiled and then
cooled to the temperature needed.
Powdered formula may be contaminated with micro-organisms
(such as E. sakazakii and Salmonella) during the
manufacturing process or may become contaminated during
preparation and that it is therefore necessary to discard any
unused formula immediately after every feed.
Artificially fed infant should also be fed on demand.
Artificially fed infant may need extra water.

Complementary Feeding
Complementary feeding means
giving
other foods in addition to breast milk.
After 6 months of age to meet their
evolving nutritional requirements, all
infants should receive nutritionally
adequate and safe complementary
foods while breastfeeding continues
until up to 2 years of age or beyond.

Energy required and the amount

from breast milk

The iron requirment of infant and the

amount received from breastmilk and
the storages

Daily nutritional requirements of infants and the

amounts received from breastmilk in the second year
of life

Risks of starting complementary foods too early

Take the place of breast milk, making it difficult to

meet the childs nutritional needs and result in a
low nutrient diet
Increase risk of illness because less of the
protective factors in breast milk are consumed;
Increase the risk of diarrhoea because the
complementary foods may not be as clean or as
easy to digest as breast milk;
Increase the risk of wheezing and other allergic
conditions because the baby cannot yet digest and
absorb other foods well;
Increase the mothers risk of another pregnancy if
breastfeeding is less frequent.

Risks of starting complementary foods too late

Delaying the introduction of complementary foods

for too long is also not advisable because:
Breast milk alone may not provide enough
energy and nutrients and may lead to growth
faltering and malnutrition.
Breast milk alone may not meet the infants
growing requirements of some micronutrients,
especially iron and zinc.
The optimal development of oral motor skills,
such as the ability to chew, and the infants
ready acceptance of new tastes and textures
may be adversely affected.
Infants should, therefore, be started on
complementary foods at around six

Introducing complementary
foods
Complementary
foods can be subdivided into:
Transitional (pured, mashed, semi-solid) foods,
which are foods specifically selected from the main
food groups and adapted to meet the particular
nutritional and physiological needs of the infant.
Family foods, largely based on a normal wellbalanced varied family diet, with some minor
adaptations.
Between 6-8 months these should be given 2-3 times a
day, increasing to 3-4 times daily after nine months of
age, with additional nutritious snacks offered 1-2 times
per day, as desired, after 12 months.
Breastmilk, however, should remain the primary source
of nutrition for the whole of the first year of life. During
the second year of life, family foods should gradually
become the primary source of nutrition.

Examples of age-appropriate foods for

different ages and stages of development
Ag
e

Reflexes/skills

(mo
.)

Types of food
that can be
consumed

Examples of foods

06 Suckling/sucking Liquids
and swallowing

Breast milk only

4-7

Appearance of
early
munching;
movement of
gag reflex from
mid to posterior
third of tongue

Pured foods
(only if the
individual childs
nutritional
requirements
call for addition
of
complementary
foods)

Breast milk plus

cooked pured meat;
vegetable (e.g.
carrot) or fruit pures
(e.g. banana);
mashed potato;
gluten-free cereals
(e.g. rice)

7
12

Clearing spoon
with lips; biting

Increasing
variety of

Breast milk plus

cooked minced meat;

Daily energy intake of infants

Age of the
infant

Calories
received from
complementary
food

The volume of
food during
each feeding

The amount
of
complementa
ry feeds

6-8 mo.

280 kcaL

160 ml

2-3 feedings

9-10 mo.

450 kcal

180 ml

3-4 feedings

11-12 mo.

500-600 kcal

250 ml

4-5 feedings

Main food groups

1.Milk and diary products

2.Meat and alternatives
3.Wheat and cereals
4.Fruits and vegetables

Feeding practices
The way in which caregivers facilitate feeding and
encourage eating plays a major role in the food intake
of infants and young children. There are four
dimensions of appropriate feeding:
1. Adaptation of the feeding method to the
psychomotor abilities of the child (ability to hold a
spoon, ability to chew).
2. Responsiveness of the caregiver, including
encouragement to eat, by offering additional
foods.
3. Interaction with the caregiver, including the
conveying of affection.
4. The feeding situation, including the organization,
frequency, duration and regularity of feeding