[Updated September 2024]

ISDI and its members are committed to improving nutrition and providing the highest quality products that help meet the nutritional needs of mothers, infants and young children. Furthermore, ISDI supports exclusive breastfeeding up to 6 months followed by the safe introduction of adequate complementary foods.

Whilst we support the purpose of the WHO Guideline for complementary feeding of infants and young children 6–23 months of age (link) to provide evidence-based recommendations on complementary feeding, ISDI is concerned that certain recommendations are neither in line with existing regulatory frameworks nor scientifically substantiated.

In particular, ISDI would like to highlight the following:

• Contradicting accepted science and overlooking health concerns

Recommendation 2.a states that ‘either milk formula or animal milk’ can be fed as of 6 months. This is against generally accepted scientific evidence that (full fat) cow’s milk can be best introduced at the age of 12 months[1]. Introducing cow’s milk before 12 months of age can have detrimental impacts on infants’ health because of excess protein and poor iron intake. These impacts include an increased risk of gastrointestinal bleeding, anaemia and overweight or obesity[2].

In addition, the WHO Guideline states that milk formulas ‘are associated with child morbidity and mortality’. This is contrary to widely accepted scientific literature and medical guidelines that mention formula to be the only safe alternative to breastfeeding[3].

• The importance of a diversified diet with optimal nutrition intake

Young children learn to experience new tastes and textures, gradually increasing food consistency and variety. A diversified diet ensures a balanced diet that meets the nutritional needs of the growing child.

Data shows that the poor and uneven nutritional composition of unfortified complementary foods means that it is difficult to create varied diets that provide toddlers with optimal intakes of important nutrients like DHA (Docosahexaenoic acid), zinc, iron and vitamin D. To illustrate the point, ISDI notes that:

• For young children 12-23 months of age, the Guideline recognises that ‘milk formula provides supplemental sources of iron and other nutrients’ but still doesn’t recommend its use.
• The Guideline similarly acknowledges evidence that iron-fortified infant cereals have a beneficial effect on mental skill development scores and motor development scores. However, it concludes that their consumption should not be encouraged.

Complementary foods formulated and fortified based on scientific research can be helpful, and at times essential, in ensuring there are no nutritional gaps in the diets and support growth of young children.

• Transition to complementary foods

To meet the evolving nutritional needs of infants and young children, the amount and frequency of adequate and safe complementary foods are managed through appropriate serving sizes to avoid undue displacement of breast milk or infant formula. As the older infant grows to a young child, the contribution that complementary food makes to the diet increases as the total energy intake increases.

Recommendation 3 states that infants should be introduced to complementary foods at 6 months (180 days) while continuing to be breastfed. In prior communications, WHO stated that it is around 6 months of age. EFSA (2019) states that there is no cut-off date:  “As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age.”

ESPGHAN concludes that complementary foods can be introduced from 4 to 6 months, depending on each individual child’s growth trajectory[4]. Furthermore, there is high-quality evidence ‘that earlier introduction of allergenic complementary foods before the age of 6 months, along with continued breastfeeding, can markedly reduce the risk of food allergies.’[5]

• Follow-up formula in Codex Alimentarius texts

The Guideline doesn’t recommend the use of follow-up formula. In so doing, WHO undermines the opinion of its own standardisation body, Codex Alimentarius, which recently finalised a review of the Standard on follow-up formula for older infants (6-12 months) and product for young children (12-36 months). The revised Standard integrates the latest available science on safety and composition and recognises follow-up formula for use “as a liquid part of a diet for older infants when progressively diversified complementary feeding is introduced” and product for young children “for use as a liquid part of the diversified diet of young children”[6].

• The Guideline excludes food safety

ISDI regrets that the Guideline’s scope excludes issues of food safety. ISDI is concerned about this development as complementary foods should be prepared, stored and served with great care under safe and hygienic conditions[7]. Attention to food hygiene has enabled significant reductions in infant food contamination and improved complementary feeding practices.

Food safety is a key component of infant and young child nutrition, as recognised by the WHO Code of Marketing of Breast-Milk Substitutes, which was adopted to ‘contribute to the provision of safe and adequate nutrition for infants’.

Conclusion

To conclude, ISDI is concerned about the scientific substantiation of the WHO Guideline and the evidence base for some of the recommendations. This ‘research gap’ is acknowledged in the Guideline, which states that the Guideline Development Group “highlighted the very limited evidence for many of the recommendations”. This undermines the objective of the Guideline to provide evidence-based recommendations.

ISDI is ready to ‎work together with all stakeholders to support optimal health and well-being for infants and young children, and to contribute the expertise of its members to support scientifically robust and evidence-based complementary feeding practices.

Further reading

For more information about complementary feeding, read ISDI’s factsheet or visit the dedicated page on the ISDI website. For information about follow-up formula for older infants and young children, please click here.

• WHO Guideline for complementary feeding of infants and young children 6–23 months of age (link)
• World Health Organization (WHO) guideline on the complementary feeding of infants and young children aged 6−23 months 2023: A multisociety response (link)
• Guidance on paediatric nutrition should follow quality standards and be evidence based: concerns regarding the recent WHO guideline on complementary feeding (2024) (link)
• EFSA (2019) Scientific Opinion on the appropriate age for introduction of complementary feeding of infants. EFSA Journal 2019; 17(9):5780 (link)
• EFSA (2013) Scientific Opinion on nutrient requirements and dietary intakes of infants and young children in the European Union. EFSA Journal 2013; 11: 3408 (link)
• Koletzko et al. Should formula for infants provide arachidonic acid along with DHA? The American Journal of Clinical Nutrition, Volume 111, Issue 1, January 2020, Pages 10–16 (link).

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[1] See, for instance, US Centers for Disease Control and Prevention (CDC) Cow’s Milk and Milk Alternatives. (retrieved 29 November 2023)

[2] See World Health Organization (WHO) guideline on the complementary feeding of infants and young children aged 6−23 months 2023: A multisociety response

[3] EFSA NDA Panel (EFSA Panel on Dietetic Products, Nutrition and Allergies), 2013. Scientific Opinion on nutrient requirements and dietary intakes of infants and young children in the European Union. EFSA Journal 2013;11(10):3408, 103 pp. Doi: 10.2903/j.efsa.2013.3408

[4] See Complementary Feeding, A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition

[5] See World Health Organization (WHO) guideline on the complementary feeding of infants and young children aged 6−23 months 2023: A multisociety response

[6] See Codex Standard for Follow-up Formula for Older Infants and Product for Young Children (CXS 156-1987)

[7] See a recent publication: Infant Food Hygiene and Childcare Practices in Context: Findings from an Urban Informal Settlement in Kenya Am J Trop Med Hyg. 2020 Jan; 102(1): 220–222 (link) retrieved 29 November 2023

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Note to the editors:

ISDI is the leading international expert association on special dietary foods, including foods specifically designed for infants and young children. ISDI members are national and international associations that are active in this sector from more than 20 countries over 6 continents. Our members manufacture and market foods that are formulated, in accordance with applicable Codex Alimentarius standards, to meet the compositional criteria, quality requirement and nutritional needs of infants and young children.

Further Contact:

Jean Christophe Kremer
ISDI Secretary General
M: +32 476 82 03 90
E: secretariat@isdi.org