Infant and Young Child Feeding in Egypt

- Recommendations

Table 3. Recommendations
A. Time of introduction of solid food
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
A1	What is the appropriate time to introduce complementary feeding for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2003 ESPAGHN 2017	Exclusive or full breast feeding should be promoted for at least 6 months. Complementary foods (ie, solid foods and Liquids other than breast milk or infant formula) should not be introduced before 17 weeks of age but should not be delayed beyond 26 weeks of age in formula fed infants.	High Low	Strong Weak (Conditional)

Table 4. Recommendations
B. Order of introduction of solid food
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
B1	What is the suggested order of introducing complementary foods to healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2003 ESPAGHN 2017 ESPAGHN 2017	Complementary food should be adequate in nutrition and as long as long as iron-rich foods are included in early complementary feeding, foods can be introduced in any order and at a rate that suits the infant, however it is recommended that complementary foods are initiated in following order Iron fortified cereals Iron rich vegetables and fruits Egg yolk Pureed poultry/meat/fish yogurt. ü Allergenic foods may be introduced when CF is commenced ü Gluten may be introduced into infant’s diet any time between 6 and 12months of age; consumption of large quantities should be avoided during the first weeks of gluten introduction. Neither any breastfeeding nor breast-feeding during gluten introduction has been shown to reduce the risk of CD.	High Low Low	Strong Weak (Conditional) Weak (Conditional)

Table 5. Recommendations
C. Amount of food to be given
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
C1	What is the appropriate amount of complementary food to be served for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2003	Start at six months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding. The energy needs from complementary foods for infants with “average” breast milk intake in developing countries are approximately 200 kcal per day at 6-8 months of age, 300 kcal per dayat 9-11 months of age, and 550 kcal per day at 12-23 months of age	Low	Weak (Conditional)

Table 6. Recommendations
D. Number of meals to be given
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
D1	How frequent complementary food should be served for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2003	The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding. For the average healthy infant, meals of complementary foods should be provided 2-3 times per day at 6-8 months of age and 3-4 times per day at 9-11 and 12-24 months of age, with additional nutritious snack (such as a piece of fruit or bread) offered 1-2 times per day, as desired	Low	Weak (Conditional)

Table 7. Recommendations
E. Food diversity
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
E1	What is the appropriate food diversity in the meals of healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities morbidities	WHO 2003	Infants have high nutrient requirements but the capacity to consume small amounts of food. Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish or eggs should be eaten daily, or as often as possible	Low	Weak (Conditional)

Table 8. Recommendations
F. Dairy products
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
F1	Which type of dairy products and when should be served to healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2003	With the exception of liquid cow milk, which is not recommended before 12 months of age, WHO recommend giving whole cream dairy products as yogurt, cheese & pudding starting after 6m (good source of protein, calcium & DHA).	Low	Weak (Conditional)

Table 9. Recommendations
G. Honey introduction
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
G1	What is the appropriate time to introduce honey for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	-Medically Graded Honey Supplementation Formula to Preterm Infants as a Prebiotic: A Randomized Controlled Trial. Journal of pediatric gastroenterology and nutrition (2017). (19) -Effect of honey on febrile neutropenia in children with acute lymphoblastic leukemia: A randomized crossover open-labeled study. Complementary therapies in medicine (2016). (20) -Effect of honey on gastric emptying of infants with protein energy malnutrition. European journal of clinical investigation (2010). (21) -Multiplex PCR for detection and genotyping of C. botulinum types A, B, E and F neurotoxin genes in some Egyptian food products. J. Am. Sci, (2011). (22)	Honey has a lot of benefits for human, including infants below the age of one year; It has anti-microbial (anti-bacterial, anti-viral, anti- parasitic, anti- fungal); anti-inflammatory; anti-tumor; immune-modulator; prebiotic and probiotic effects. Honey has been prescribed without prior testing, to thousands of infants below the age of one year for almost 20 years (since 1998) without any single occurrence of infant botulism. Assuming that honey may rarely contain the spores of Clostridium Botulinum, the recommendation that we should not give honey to infants below the age of one year should also include other sources of C. botulinum, including many other food items such as fruits, vegetables, mushrooms, garlic cloves...etc. Therefore, it is impossible to prevent infant botulism even if we prevent giving honey to infants below the age of one year. Based on available evidence in Egyptian population the committee suggests honey introduction in small amounts starting 9 month	Very low	Weak (Conditional) Good practice statement

Table 10. Recommendations
H. Fava Beans
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
H1	What is the appropriate time to introduce fava beans for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2003+EO	Fava beans should be introduced in small amounts with other foods Children with family history of G6PD should be screened before introduction	Low	Weak (Conditional)

Table 11. Recommendations
I. Fruit juice
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
I1	When is it appropriate to introduce fruit juices and how much for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	ESPAGHN 2017	Fruit juice (including 100-percent home made fruit juice) generally should not be offered to infants younger than 12 months. For infants between 6 and 12 months, we suggest consumption of mashed or puréed whole fruit rather than 100-percent fruit juice	Low	Weak (Conditional)

Table 12. Recommendations
J. Supplementation
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
J1	What are mandatory supplementations recommended for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2003 WHO 2016 AAP 2014	breastfeeding mothers may also need vitamin-mineral supplements or fortified products, both for their own health and to ensure normal concentrations ofcertain nutrients (particularly vitamins) in their breast milk. Daily iron supplementation is recommended as a public health intervention in infants and young children aged 6–23 months, living in settings where anaemia is highly prevalent, for preventing iron deficiency and anaemia in dose of 10-12.5 mg elemental iron for 3 consecutive months of year All infants should be supplemented with vitamin D (400 IU) since birth	Low Low Low	Weak (Conditional) Weak (Conditional) Weak (Conditional)

Table 13. Recommendations
K. Water
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
K1	When is it appropriate to introduce water and how much for healthy full term infant, both sexes, either breastfed or not breastfed without co-morbidities	WHO 2005	Breast fed infants don’t need extra water as breast milk is 80% water Non-breastfed infan need at least 400-600 mL/d of extra fluids (in addition to the 200-700 mL/d of water that is estimated to come from milk and other foods) in a temperate climate, and 800-1200 mL/d in a hot climate. Plain, clean boiled water should be offered several times per day to ensure that the infant’s thirst is satisfied.	Low	Weak (Conditional)

➡️Evidence to recommendations: Considerations

The GDG/ GAG was guided by the results of the AGREE II appraisals of the eligible CPGs and thoroughly reviewed the recommendations of the original source WHO CPGs in consideration of local contextual factors related to the national Egyptian health system like burden of the disease, equity, acceptability, feasibility, and other relevant factors. The GDG decided through an informal consensus process to adopt mos. Also, GDG/ GAG develops group of good practice statements to improve acceptability and feasibility.

➡️Implementation Tools and Considerations

To improve healthcare provision, quality, safety, and patient outcome, evidence-based recommendations must not only be developed, but also disseminated and implemented at national and local levels and integrated into clinical practice.

Dissemination involves educating related healthcare providers to improve their awareness, knowledge and understanding of the guideline’s recommendations. It is one part of implementation, which involved translation of evidence-based guidelines into real life practice with improvement of health outcomes for the patients.

Implementation requires an evidence-based strategy involving professional groups and stakeholders and should consider the local cultural and socioeconomic conditions. Cost-effectiveness of implementation programs should be assessed.

Specific steps need to be followed before clinical practice recommendations can be integrated into local clinical practice, particularly in low resource settings.

➡️Steps of implementing Infant and Young Child Feeding in Egypt strategies into the Egyptian health system:

1. Develop a multidisciplinary working group.

2. Assess the status of nutritional care delivery, care gaps and current needs.

3. select the material to be implemented, agree on the main goals, identify the key recommendations for diagnosis, treatment and prevention and adapt them to the local context or environment.

4. Identify barriers to, and facilitators of implementation.

5. Select an implementation framework and its component strategies.

6. Develop a step-by-step implementation plan:

· Select the target populations and evaluate the outcome.

· Identify the local resources to support the implementation.

· Set timelines.

· Distribute the tasks to the members.

· Evaluate the outcomes.

7. Continuously review the progress and results to determine if the strategy requires modification.

Guideline implementation strategies will focus on the following: -

1. For Practitioners

· Educational meetings: conferences, lectures, workshops, grand rounds, seminars, and symposia.

· Educational materials: printed or electronic information (software).

· Web-based education: computer-based educational activities.

· A trained person meets with providers in their practice setting to provide information with the intention of changing the provider’s practice. The information may include feedback on the performance of the provider(s).

· Reminders: the provision of information verbally, on papers or on a computer screen to prompt a health professional to recall information or to perform or avoid a particular action related to patient care.

· Optimize professional-patient interactions, through mass media campaigns, reminders, and education materials.

· Practice tools: tools designed to facilitate behavioral/practice changes, e.g., flow charts.

2. For Patients and care givers

· Patient education materials (Arabic booklet): Printed/electronic information aimed at the patient/consumer, family, caregivers, etc.

· Reminders: the provision of information verbally, on papers or electronically to remind a patient/consumer to perform a particular health-related behaviors.

· Mass media campaigns.

3. For Nurses

· Educational meetings: lectures, workshops or traineeships, seminars, and symposia.

· Educational materials: printed.

· A trained person meets with nurses in their practice setting to provide information with the intention of changing the provider’s practice.

· Reminders: the provision of information verbally, on paper or on a computer screen to prompt them to recall information or to perform or avoid a particular action related to patient care.

· Practice tools: tools designed to facilitate behavioral/practice changes.

4. For Stakeholders

Plans have been made to contact with all the health sectors in Egypt including all sectors of the Ministry of Health and Population, National Nutrition Institute, University Hospitals, Ministry of Interior, Ministry of Defense, Non-Governmental Organizations, Private sector, and all Health Care Facilities.

· Information and communication technology: Electronic decision support, order sets, care maps, electronic health records, office-based personal digital assistants, etc.

· Any summary of clinical provision of health care over a specified period may include recommendations for clinical action. The information is obtained from medical records, databases, or observations by patients. Summary may be targeted at the individual practitioner or the organization.

· Administrative policies and procedures.

· Formularies: Drug safety programs, electronic medication administration records.

5. Other activities to assist the implementation of the adapted guideline’s recommendations include:

· International initiative: Dissemination of the presented adapted CPG internationally via sending the final adapted CPG to the Guidelines International Network (GIN) Adaptation Working Group and contacting the CPG developers.

· Gantt chart has been designed to manage the dissemination and implementation stages for the adapted CPG over an accurate time frame (Appendix).

Evidence to Decision Tables: (both ETD and changing strength of recommendation were not done in this guideline)

Guideline Implementation Tools

Educational materials based on this Adapted CPG for national complementaty feeding guidelines are made available in several forms, including

Booklet with executive summary of guidelines for physicians and primary health care professionals
Illustrative booklet in arabic directed to mothers with steps of solid food introduction
Powerpoint presentation for mothers for more illustration of the steps for introduction of complementary feeding.
Powerpoint presentation for training physicians and primary health care professionals illustrating the steps of introducing complementary feeding and how to explain these steps to the mothers
Poster with illustrative diagrams for mothers to help them with the steps of solid food introduction to be placed in the primary care facilities, clinics and pediatric hospitals.

Practice Guidelines for Complementary Feeding

Physicians Guide

When To Start?

Exclusive or full breast feeding should be promoted for at least 6 months

Order of Introduction

Foods can be introduced in any order and at a rate that suits the infant, however it is recommended that complementary foods are initiated in following order

• Iron fortified cereals

• Iron rich vegetables and fruits

• Egg yolk

• Pureed poultry/meat/fish

• Yogurt.

What about Allergic Food

- Allergenic foods may be introduced when Complementary Feeding is commenced any time after 4 months (17 weeks).

- Gluten may be introduced into infant’s diet any time between 4 and 12months of age; consumption of large quantities should be avoided during the first weeks of gluten introduction

Food Amount, and consistency

Start at six months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding.

The appropriate number of feedings also depends on the energy density of the local foods and the usual amounts consumed at each feeding.

Also In practice, caregivers will not be measuring the energy content of foods to be offered. Thus, the amount of food to be offered should be based on the principles of responsive feeding

Practicing responsive feeding, applying the principles of psycho-social care.

a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues.

b) feed slowly and patiently, and encourage children to eat, but do not force them.

c) if children refuse much food, experiment with different food combinations, tastes, textures and methods of encouragement.

d) minimize distractions during meals if the child loses interest easily.

e) Remember that feeding times are periods of learning and love - talk to children during feeding, with eye-to-eye contact.

Food consistency and variety should be increased with the child’s

age.

Practical guidance on the quality, frequency and amount of food to offer children 6-23 months of age besides milk (either breast milk or its substitutes )

Age In months	Energy needed per day in addition to breastmilk	Texture	Frequency	Amount of food an average child will usually eat at each meal
6-8	200 kcal/day	Start by thick porridge,well mashed food Continue with mashed family foods By eight months most infants can also eat “finger foods” (snacks that can be eaten by children alone).	-2-3 meals per day Depending on the child’s appetite,1-2 snacks may be offered	Start with 2-3 tabblespoonfuls per feed,increasing gradually to of a 250 ml cup
9-11	300 kcal/day	Finely chopped or mashed foods, and fods that baby can pick up	-3-4 meals per day Depending on the child’s appetite,1-2 snacks may be offered	to of a 250 ml cup/bowel
12-23	550kcal/day	Family foods, chopped or mashed if necessary	-3-4 meals per day Depending on the child’s appetite,1-2 snacks may be offered	to of a 250 ml cup/bowel

Avoid foods in a form that may cause choking, such as whole nuts, whole grapes or raw carrots, whole or in pieces

Food diversity

Infants have high nutrient requirements but the capacity to consume small amounts of food. Feed a variety of foods to ensure that nutrient needs are met.

The daily diet should include:

Ø Vitamin A-rich foods: (e.g. dark coloured fruits and vegetables; red palm oil; vitamin A-fortified oil or foods);

Ø vitamin C-rich foods: (e.g. many fruits, vegetables and potatoes) consumed with meals to enhance iron absorption.

Ø Vitamin B rich foods: (e.g. liver, egg, dairy products, green leafy vegetables, soybeans), vitamin B6 (e.g. meat, poultry, fish, banana, green leafy vegetables, potato and other tubers, peanuts) and folate (e.g. legumes, green leafy vegetables, orange juice

Meat, poultry, fish or eggs should be eaten daily, or as often as possible

If milk and other animal-source foods are not eaten in adequate amounts, both

grains and legumes should be consumed daily, if possible, within the same meal, to

ensure adequate protein quality.

Dairy products

With the exception of liquid cow milk, which is not recommended before 12 months of age,

WHO recommend giving whole cream dairy products like yogurt, cheese & pudding starting from 6m (good source of protein, calcium & DHA).

Skimmed(non-fat) milk is not recommended as a major food source for children under two

Honey

Honey has a lot of benefits for humans, including infants below the age of one year; It has anti-microbial (anti-bacterial, anti-viral, anti- parasitic, anti- fungal); anti-inflammatory; anti-tumor; immune modulator; prebiotic and probiotic effects.

Based on available evidence in Egyptian population the committee suggests honey introduction in small amounts starting 9 months.

Fava Beans

Fava beans should be introduced in small amounts with other foods

Children with family history of G6PD should be screened before introduction

Fruit juice

Fruit juice (including 100-percent homemade fruit juice) generally should not be offered to infants younger than 12 months. For infants between 6 and 12 months, we suggest consumption of mashed or puréed whole fruit rather than 100-percent fruit juice

Supplementations

Breastfeeding mothers may also need vitamin-mineral supplements

or fortified products, both for their own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast milk.

Daily iron supplementation is recommended as a public health intervention in infants and young children aged 6–23 months, living in settings where anemia is highly prevalent, for preventing iron deficiency and anemia in dose of 10-12.5 mg elemental iron for 3 consecutive months of year

All infants should be supplemented with vitamin D (400 IU) since birth

Water

Breast fed infants don’t need extra water as breast milk is 80% water

Non-breastfed infants need at least 400-600 mL/d of extra fluids (in addition to the 200-700 mL/d of water that is estimated to come from milk and other foods) in a temperate climate, and 800-1200 mL/d in a hot climate.

Plain, clean boiled water should be offered several times per day to ensure that the infant’s thirst is satisfied.

The Five Keys to Safer Food include

1) keep hands, food preparation surfaces and equipment clean,

2) separate raw meat, poultry and seafood from other foods and use separate utensils and cutting boards for their preparation,

3) cook foods thoroughly, especially meat, poultry, eggs and seafood,

4) keep food at safe temperatures

5) use safe water and raw materials