WHO Guideline for complementary feeding of infants and young children 6–23 months of age (2023)

After the age of 6 months, infants may require more energy and nutrients than can be provided from exclusive breastfeeding and consequently, providing foods in addition to breast milk and milk formula may be required to help meet their needs. Complementary feeding often starts around the age of 6 months until 23 months, though breastfeeding may continue past this point. This period is not only critical for sustaining health growth and development during a particularly decisive stage of growth and development but also for establishing acceptance of a variety of healthy foods. 

To this effect, the World Health Organization (WHO) published their WHO Guideline for complementary feeding of infants and young children 6-23 months of age in 2023, providing public health guidance for both breastfed and non-breastfed full-term children. To inform the development of this guideline, the WHO commissioned a narrative review of the literature published since 2003 on complementary feeding, as well as 10 systematic reviews. 

The following article provides an overview and key messages from the guidelines, destined for health professionals. The recommendations and a summary of the additional remarks are as follows: 

Recommendation 1: Continue breastfeeding. Breastfeeding should continue up to 2 years or beyond (strong, very low certainty evidence).  

Summary of remarks: 

• To continue breastfeeding, women require an enabling environment and supportive services, including workplace accommodations, counselling, and protection from exploitative marketing of breast milk substitutes. 

Recommendation 2:  

1. Milks 6–11 months: for infants 6–11 months of age who are fed milks other than breast milk, either milk formula or animal milk can be fed (conditional, low certainty evidence); 
2. Milks 12–23 months: for young children 12–23 months of age who are fed milks other than breast milk, animal milk should be fed. Follow-up formulas are not recommended (conditional, low certainty evidence).

Summary of remarks:

• Dairy products, such as animal milks, are integral to a varied diet and aid in achieving nutritional adequacy;
  • They are particularly important for non-breastfed children, especially when other animal-source foods are scarce. 
• Acceptable types of animal milks include pasteurized milk, reconstituted evaporated milk (not condensed), fermented milk, or yogurt. Strict adherence to proper handling and storage practices is necessary;
• Flavoured or sweetened milks are not recommended; 
• For infants aged 6–11 months, full-fat milk should be used if animal milks are introduced. 

In this report, the WHO highlights the importance of animal milks, as they are an important source of key nutrients, such as calcium, riboflavin, potassium, phosphorus, magnesium, and zinc, as well as protein; milk proteins stimulate the production of insulin-like growth factor-1, which is important for bone development and growth. It is further specified that milk or other sources of dairy are necessary, especially for children who aren’t consuming other animal-source foods. While cow's milk in infancy has been linked to gastrointestinal blood loss and higher kidney solute load, the WHO advocates cow's milk with complementary foods as safe due to minimal occult blood losses in 6–11-month-old infants that are unlikely to impact iron status. 

Recommendation 3: Infants should be introduced to complementary foods at 6 months (180 days) while continuing to breastfeed (strong, low certainty evidence). 

Summary of remarks: 

• Some infants may benefit from an earlier introduction of complementary foods;
• Lactation support may aid mothers worried about breast milk adequacy; 
• The early introduction of complementary foods, even if they are iron-fortified, may not be sufficient for preventing iron deficiency anemia in high-risk populations. 

Recommendation 4: Infants and young children 6–23 months of age should consume a diverse diet. 

1. Animal-source foods, including meat, fish, or eggs, should be consumed daily (strong, low certainty evidence). 
2. Fruits and vegetables should be consumed daily (strong, low certainty evidence).
3. Pulses, nuts, and seeds should be consumed frequently, particularly when meat, fish, or eggs and vegetables are limited in the diet (conditional, very low certainty evidence). 

Summary of remarks: 

• Animal-source foods, fruits, vegetables, nuts, pulses, and seeds are key foods for their nutrient density, as opposed to cereal grains; 
• Limit starchy staple foods, given their lower-quality protein compared to animal foods, their lower content in many critical nutrients, and the presence of anti-nutrients;
  • When cereal grains are used, whole cereal grains should be prioritized, and refined ones minimized.
• Take precautions to prevent choking when offering pulses, nuts, and seeds. 

To ensure infants and young children meet their nutritional needs and promote healthy growth, a diverse diet is essential. Lack of dietary diversity raises the risk of nutrient deficiencies that cannot be fully addressed by supplements or fortified foods, as they offer only a subset of the essential nutrients and bioactive compounds present in foods. 

Consuming various food combinations can produce synergistic effects that promote the absorption of essential nutrients. The WHO and UNICEF have previously defined dietary diversity as being a minimum of 5 out of the following 8 key food groups: 

1. Breast milk 
2. Flesh foods (meat, fish, poultry, etc.)
3. Dairy (milk, yogurt, cheese)
4. Eggs
5. Legumes and nuts
6. Vitamin A-rich fruits and vegetables
7. Other fruits and vegetables
8. Rains, roots, and tubers 

The importance of consuming a diverse diet extends beyond the fulfillment of nutritional needs: Children benefit from exposure to various food tastes and textures, which are inherent to a diverse diet.  

Despite concerns about the sustainability of animal-source foods, specifically red meat, infants' and young children's unique nutritional requirements warrant careful attention, even in high-income populations. Considering infants' limited gastric capacity, their meat consumption has a minimal environmental impact and thus, ensuring infants and young children receive animal-source foods within the family diet requires nuanced consideration for their needs. 

Recommendation 5: Unhealthy foods and beverages

1. Foods high in sugar, salt, and trans fats should not be consumed (strong, low certainty evidence).
2. Sugar-sweetened beverages should not be consumed (strong, low certainty evidence).
3. Non-sugar sweeteners should not be consumed (strong, very low certainty evidence).
4. Consumption of 100% fruit juice should be limited (conditional, low certainty evidence). 

Summary of remarks: 

• Policy actions required for implementation include addressing nutritional needs in agriculture and regulating food labelling/marketing; 
• Caregivers should be counselled on the harms of foods high in sugar, salt, and/or trans fats, such as sugar-sweetened beverages and non-sugar sweeteners. 

Infants and young children are increasingly consuming highly processed or ultra-processed foods and beverages, containing high amounts of free sugars, salt, and certain fats, including saturated and trans fats. The WHO describes these products as being generally energy-dense but nutrient-poor and are more often consumed than more nutritious options due to palatability, convenience, affordability, widespread availability, and aggressive marketing. 

Recommendation 6:  Nutrient supplements and fortified food products 

In some contexts, where nutrient requirements cannot be met with unfortified foods alone, children 6–23 months of age may benefit from nutrient supplements or fortified food products. 

1. Multiple micronutrient powders can provide additional amounts of selected vitamins and minerals without displacing other foods in the diet (context-specific, moderate certainty evidence). 
2. For populations already consuming commercial cereal grain-based complementary foods and blended flours, fortification of these cereals can improve micronutrient intake, although consumption should not be encouraged (context-specific, moderate certainty evidence). 
3. Small-quantity lipid-based nutrient supplements may be useful in food insecure populations facing significant nutritional deficiencies (context-specific, high-certainty evidence). 

Summary of remarks: 

• WHO guidelines advise on micronutrient supplementation contexts; 
• The three aforementioned products should never be presented as standalone interventions and should always accompany messaging and support for optimal feeding practices; 
• No supplement substitutes a diverse diet of healthy foods. 

Recommendation 7: Responsive feeding 

Children 6–23 months of age should be responsively fed, defined as “feeding practices that encourage the child to eat autonomously and in response to physiological and developmental needs, which may encourage self-regulation in eating and support cognitive, emotional, and social development” (strong, low certainty evidence). 

Summary of remarks: 

• Healthcare workers require training to offer nuanced, personalized guidance on responsive feeding; 
• Caregivers need sufficient time and resources to support effective child-feeding practices, including minimizing food loss during self-feeding. 

Lastly, this report concludes the report with a list of research gaps on topics such as continued breastfeeding, milk for infants and young children, age of introduction of complementary foods, unhealthy foods and beverages, nutrient supplements, and fortified food products, as well as responsive feeding. Questions related to milk include: 

• For infants 6–11 months of age who consume non-fortified animal milk, what other foods need to be added to the diet to avoid iron deficiency? 
• What are the effects of different types of milk (for example, full-fat vs. low-fat animal milks, plant-based vs. animal milks) in young children 12–23 months of age on health and nutrition outcomes? 
• What is the optimal/maximum quantity of milk that children 6–23 months of age should/can consume (that is, should maximum limits be set to avoid displacement of other foods)?