Infant and Young Child Feeding in Egypt

Optimal nutrition is critical in the first two years of a child’s life as it improves morbidity and mortality, reduces risk of chronic disease and improves overall development

Complementary feeding is described by the World Health Organization (WHO) as the period from age 6 months onwards where breast milk alone is no longer sufficient to fulfill the nutritional requirements of the infant, therefore requiring complementary feeding to be started

Nutritional deficiencies are common in Egyptian infants, with iron, vitamin D, vitamin A, protein, calories and certain trace elements a key concern

There are currently no detailed guidelines for complementary feeding in Egypt. Consequently, current practice deviates greatly from international guidelines. The Demographic and Health survey also reports that complementary feeding does not follow best practice

This guideline focuses on Introduction of complementary feeding in Egyptian Children through proper introduction of solid food for healthy full term infants of both sexes, either breastfed or non - breastfed without co-morbidities.

➡️ Guideline development process and methods

After reviewing all the inclusion and exclusion criteria and quality appraisal results, the GDG/ GAG recommended using the following source original clinical practice guidelines (CPGs):

1-  WHO guideline ” Guiding Principles For Complementary Feeding of  the  Breastfed  Child”(2003).

2-  ESPGAN position paper “Complementary Feeding: A Position Paper by the European Society for Paediatric   Gastroenterology,Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition (2017).

3-    American Academy of Pediatrics Committee on Nutrition. Complementary feeding. In: Pediatric Nutrition, 7th ed, Kleinman RE, Greer FR (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2014. p.123.

4-    Guideline: Daily iron supplementation in infants and children. Geneva: World Health Organization; 2016.

We conducted Adolopment for these guidelines: (Adoption, Adaptation, and Development)

         -    Adoption for most of the guideline recommendations.

         -   Development of Good Practice Statements

Recommendations and Good Practice Statements (GPS)

This version of the CPG includes recommendations and good practice statements on the following four sub-sections:

A. Achieve Proper physical & neurodevelopmental outcome of infants.

B. Prevent malnutrition, under nutrition and over nutrition.

C. Prevent micronutrient deficiencies and its comorbidities.

The guideline covers healthy full term infants of both sexes, either breastfed or non-breastfed without co-morbidities.

This guideline emphasis on proper introduction of solid food for healthy full term infants of both sexes, either breastfed or non - breastfed without co-morbidities.

We can summarize the guidelines’ recommendations for Infant and Young Child Feeding in Egypt in the following:

▪️  Exclusive or full breast feeding should be promoted for at least 6 months. (strong recommendation).

▪️  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. (Weak (conditional) recommendation).

▪️ Complementary food should be adequate in nutrition and 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. (strong recommendation).

▪️ Allergenic foods may be introduced when CF is commenced. (Weak (conditional) recommendation).

▪️ Gluten may be introduced into the 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 breastfeeding nor non breast-feeding during gluten introduction has been shown to reduce the risk of CD. (Weak (conditional) recommendation).

▪️ 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 day at 9-11 months of age, and 550 kcal per day at 12-23 months of age. (Weak (conditional) recommendation).

▪️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. (Weak (conditional) recommendation).

▪️  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. (Weak (conditional) recommendation).

▪️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). (Weak (conditional) recommendation).

▪️ 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. (Weak (conditional) recommendation).

▪️ Based on available evidence in Egyptian population the committee suggests honey introduction in small amounts starting 9 month. (Good practice statement).

▪️ Fava beans should be introduced in small amounts with other foods.

Children with family history of G6PD should be screened before introduction. (Weak (conditional) recommendation).

▪️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. (Weak (conditional) recommendation).

▪️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. (Weak (conditional) recommendation).

▪️ 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. (Weak (conditional) recommendation).

▪️ All infants should be supplemented with vitamin D (400 IU) since birth. (Weak (conditional) recommendation).

▪️Breast fed infants don’t need extra water as breast milk is 80% water. Non-breastfed infant 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. (Weak (conditional) recommendation).

 Guideline Registration

PREPARE (Practice guideline REgistration for transPAREncy), WHO Collaborating Center for Guideline Implementation and Knowledge Translation, EBM Center, University of Lanzhou, Lanzhou, China. Registration Number: ((submitted and in process)). Link: http://www.guidelines-registry.org/