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Building the Evidence Base to Update Global Guidance on Early Childhood Nutrition: An Expert Interview with Chessa Lutter

A mother and toddler eat at a table.

Nutrition is one of many critical factors affecting a child’s physical and mental development. It is particularly crucial between 6 and 23 months, when a child’s brain develops rapidly. The specific nutrients that a child receives during this period will have significant long-term implications for the child’s development and wellbeing.

Chessa Lutter, Senior Fellow at RTI and an internationally recognized expert on maternal and child nutrition, recently published a new paper in Nutrition Reviews to build the evidence-base for updating global guidance on complementary feeding. In this interview, Chessa discusses her findings and what they mean for practitioners and policymakers.

What is complementary feeding and why is it important?

Complementary feeding is the introduction of semi-solid and solid foods to complement a milk-based diet, generally between 6 and 23 months of age, a critical period for both physical and cognitive development. During this period, the growth of the brain is one of the highest during the human life span, and consequently, the timing and level of exposure to specific nutrients can have long-lasting positive or negative effects.

Nutritious complementary feeding not only ensures an adequate intake of nutrients, but also avoids excess intakes of calories, salt, sugars, and unhealthy fats. It also introduces young children to meals as cultural and social events where they observe, imitate, learn about foods to like – or dislike – and form lifelong eating habits and practices. Meals are also when a child learns to touch foods and connect food tastes to how foods look and feel.

Ideally, complementary feeding is responsive and promotes child autonomy, but it can also be used to manage behavior problems or overly indulge a child, resulting in long-term consequences for nutrition and health. 

You recently published a new paper on complementary feeding in Nutrition Reviews. What did you learn?

The new paper stems from a background paper I wrote for the World Health Organization as part of its ongoing effort to make recommendations on optimal complementary feeding practices relevant to low-, middle-, and high-income countries. It contains several findings that may be helpful for nutrition and public health practitioners and policymakers, and provides input to national complementary feeding guidelines, policies, and programs,

The paper has several important findings. First, optimal complementary feeding is not only what infants and young children are fed but also how they are fed. Responsive feeding – one manner in which children may be fed – is a critical component of the nurturing care framework endorsed by the World Health Organization and sits at the nexus of early childhood nutrition and child development.

Children fed responsively by a caretaker who pays attention to their cues of hunger and satiety are more likely to receive enough but not too much food, thereby reducing risks of both undernutrition and overweight. Responsive feeding also protects children’s innate ability to self-regulate intake, which over the long term can reduce the risk of consuming too many calories leading to overweight and risk of associated chronic diseases.

The paper also examined where modern complementary feeding often goes wrong – and how to improve. In contrast to evolutionary diets that were comprised largely of animal-source foods, complementary feeding diets now consist largely of cereals that generally do not provide high-quality proteins and contain substances that interfere with micronutrient absorption. These cereal-based diets should be replaced with animal-source foods, including nutrient-rich eggs, fish, and meat, and a variety of fruits, vegetables, legumes, and nuts.  

Additionally, throughout the world infants and young children are consuming increasing amounts of commercially prepared foods rich in added sugars, unhealthy fats, salt, and refined carbohydrates. Intake of sugar-sweetened beverages and sugary fruit-juices is also increasing in many countries, displacing healthy foods that contain essential vitamins, minerals, and other bioactive factors, and increasing the risk of adverse health outcomes associated with their consumption.

Finally, apart from breast milk or another milk source (e.g., infant formula or cow’s milk), infants and young children need only to drink water. Learning to drink water is a very important aspect of infant and young child feeding especially because it is more than about satisfying fluid needs – it also sets the stage for drinking water, instead of unhealthy alternatives, to quench thirst throughout life.

Why has the paper generated so much interest?

I have been overwhelmed by the interest that this paper has generated. There is growing recognition of the importance of appropriate complementary feeding for child nutrition, health, and development of human capital and its importance for economic growth. It also reflects the fact that we still need to learn more about how to improve complementary feeding. As noted by the Chief Nutritionist at USAID, the review article is “perfectly timed as we approach the UN Food Systems Summit. Food systems are failing infants and young children.”

What else are you and your colleagues at RTI working on to increase understanding of early childhood nutrition? How are you using evidence to inform practice?

RTI is currently leading a comprehensive research effort to inform interventions to reduce acute malnutrition in the arid and semi-arid region of Kenya. Understanding complementary feeding practices and how they can be improved in this setting are both critical to this effort. RTI is also leading the USAID-funded Cambodia Integrated Early Child Development Activity, through which we are partnering with Helen Keller International to improve feeding practices of young children with and without delays and disabilities. Finally, Maureen Black and I are working on an internally funded research and development initiative with colleagues in Bangladesh to develop a measurement tool and an indicator to measure responsive feeding.

Based on your new research, what advice do you have for policymakers and practitioners working on child nutrition, development, and well-being?

Early childhood feeding should not be looked at in isolation as only relevant to nutrition, but as an essential component of child health and development. Stakeholders throughout the health and early child development sectors have a large role to play in promoting optimal practices to families, including demonstrating through videos or other techniques how to feed responsively. It’s also important to engage daycare centers and other entities that care for young children to educate them on optimal complementary feeding practices and encourage them to update their menus and practices, when indicated.