Rev Chil Pediatr.

2018;89(5):612-620
ORIGINAL ARTICLE
DOI: 10.4067/S0370-41062018005000707

Complementary feeding: A practice between two knowledges

La alimentación complementaria: Una práctica entre dos saberes
Yibby Forero T.a,b, María José Acevedo R.a,c, Jenny Alexandra Hernández M.a,d, Gina Emely Morales S.a,d

a
National Institute of Health, Colombia
b
Bacteriologist, Master of Science
c
Anthropologist
d
Nutritionist

Received: 05-04-2018; Approved: 25-6-2018

Abstract Keywords:
Practice;
Introduction. The complementary feeding (CF) comprises a period in the life of the infant that starts Complementary
with the introduction of foods other than breast-milk. It is determined by social and environmental feeding; Infants;
factors which facilitate or limit the appropriate initiation of this practice, directly affecting the nutri- Breastfeeding
tional and health status of children. Objective. To identify barriers and facilities for the follow-up of
nutritional recommendations regarding the early start of CF in children between 0 and 24 months of
age belonging to a comprehensive early childhood care program. Materials and methods. Phenome-
nological, longitudinal, qualitative study in which 43 in-depth interviews and 11 focus-groups were
carried out. Predefined categories were the context of the mother, representations and experiences of
gestation, meanings and experiences of breastfeeding (BF), and CF. The analysis included the rela-
tionships between the units of meaning and predefined and emerging categories. Results. The CF is
a social practice which is the result of medical and popular knowledge mixture, however, the degree
of influence that the latter has on mothers is higher due to the degree of support that they have from
their close circle, especially from mothers, grandmothers, and women of the family. The lack of con-
ceptual and practical knowledge about exclusive breastfeeding (EBF) and CF prevents mothers from
carrying out good practices. Most of them do not know clearly what is involved in the EBF, resulting
in an early start of CF, or do not have objective criteria to assess their milk production. Despite having
received specific training, CF started early in most cases, a fact in which close family influence was
decisive. Conclusions. The CF experience is strongly influenced by sociocultural aspects not only of
the mother but of her immediate circle, and the recommendations they received from health pro-
fessionals are not enough to change their practices. Therefore, it is necessary to improve CF support
interventions.

Correspondence:
Yibby Forero Torres
[email protected]

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Introduction the follow-up of the nutritional recommendations re-

garding the early initiation of CF in children between
Breastfeeding (BF) consists of feeding the infant 0 and 24 months of age in a population belonging to
with human milk and it is recommended to exclusi- a comprehensive early childhood care program in the
vely BF until six months of age, where foods that ac- city of Bogotá, in order to contribute to this knowledge
company breast milk should be introduced without allowing a reorientation of food and nutritional inter-
replacing it since it is advisable to continue BF until 24 vention strategies to take it into account the sociocul-
months of age and beyond1,2. Complementary feeding tural reality where the mothers and/or people respon-
(CF) and exclusive breastfeeding (EBF) are the most sible for feeding children are immersed.
effective means to reduce child morbidity and mor-
tality, therefore, the analysis of these practices should
be addressed together, taking into account that in the Subjects and Method
practice there are some cultural aspects that may affect
the compliance with the recommendation. Phenomenological and longitudinal study based on
The CF should begin when the child is six months the experience of pregnant and nursing women, which
old2 and not before since the infant does not have allowed to approach to their perceptions of the CF and
sufficient maturity and development of his/her orga- to identify aspects that facilitate or hinder an adequate
nic systems3. The early introduction of CF can lead to practice according to the recommendations. This qua-
problems such as the substitution of breast milk for litative method was used with the purpose of searching
less nutritious foods, the inability of the child to di- for units of meanings by explaining the structure of the
gest some foods, early exposure to pathogens, and food lived experiences13, 14.
allergens, among many other problems4. According to The participants in this study were 43 women from
the Pan American Health Organization (PAHO), after their third gestation trimester until their children rea-
six months of age, the potential health benefits are hig- ched 24 months of age, beneficiaries of a comprehensi-
her than the potential risks4, 5. ve early childhood care program in the city of Bogotá.
There is evidence that adequate CF practices have They were selected through a convenience sample13 ta-
resulted in a marked and rapid reduction in stunted king into account criteria such as being beneficiaries of
growth, especially in the most vulnerable populations2, the program, having agreed to participate in the study,
4, 6.
On the other hand, it is estimated that the inade- and in the case of nursing women, having had a full-
quate CF practices, especially the early initiation, cause term pregnancy and have had a healthy baby.
1.4 million deaths and 10% of the number of diseases The sample size was determined through an induc-
among children younger than five years of age2, 7, 8. tive process which ended once it reached the theoreti-
The WHO recommendations were implemented cal saturation13, which means when it is not possible to
by Colombia in its Ten-Year Breastfeeding Plan 2010- find new information in terms of new units of meaning
2020 ‘A public imperative for the protection and adequate in the research. The saturation was reached after 43 in-
nutrition of children younger than two years’9. However, terviews.
in Colombia the BF and CF prevalence do not comply Table 1 shows that the average age of the mothers
with the international recommendations. According was 24 years, with a 6.4 standard deviation, 26% were
to the National Survey on the Nutritional Situation in younger than 18 years. 76.5% had secondary education
Colombia (ENSIN 2010)10, the introduction of the CF and 2% had no schooling at all. 65.2% of the mothers
started at the 2.7 months with liquids other than breast belonged to the second socioeconomic stratum, and
milk, and according to the 2015 survey11, 63.9% of the 91% were insured by the social security health system.
children received foods other than breast milk before The main activity for women was household
the age of six months. tasks(64.3%), working (17.5%) or studying (14.9%).
On the other hand it has been recognized that hu- 50% of the women younger than 18 spent part of their
man feeding is a complex phenomenon that is not only time studying (Table 1).
related to biological and nutritional facts of organisms 53.9% of the mothers were married or in a con-
and food, but it is also determined by social and cultu- sensual union, the rest were single or divorced (Table
ral factors specific to the human species. Feeding is part 1). 42.9% of the participants considered their current
of a family and cultural tradition, in which collective, partner as the head of the household and 79.1% indi-
symbolic, subjective, and material factors converge12. cated that their current partner was the father of the
Considering this, and that Colombia does not com- child. The average number of people per household
ply with the recommendations despite the multiple in- was 5.5, where in addition to the nucleus composed by
terventions that have been implemented, the objective the mother, father, and child, lived in the same hou-
of this study was to identify barriers and facilities for se with other relatives, mainly the grandparents of the

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child, siblings, uncles, and cousins. It worked as a sup- cipants. This codification type and analysis were per-
port network in relation to economic matters and in formed through an individual approach of each mem-
home and care tasks15. ber of the investigation team on the emerging and the
The data collection techniques used were the in- previously proposed analysis categories, therefore their
depth interview16 and focus groups17, which were relevance and theoretical saturation could be verified.
performed at home of the participants and at places This exercise was the result of a qualitative methodolo-
assigned by the program. The participants were called gical triangulation18,19 between the two used informa-
during 2016 and 2017 at six different periods: during tion sources, the interviews, and focal groups, and the
the third trimester of pregnancy, after the birth of the contrast between emerging and previously established
child, at six, 12, 18, and 24 months of age. The team categories (Table 2).
of professionals in charge of the collection, codifica- In order to guarantee the anonymity of the par-
tion, and analysis of the information was made up of ticipants, each one was assigned a code composed of
anthropologists and trained sociologist with experien- the initials of the researcher, followed by the district
ce in the implementation of qualitative methodologies code for each of the localities of the city of Bogotá, the
headed by the lead researcher. Following the contribu- initials of the data collection technique, and finally the
tion of the grounded theory and the phenomenological code assigned by the investigation team for each par-
health studies the codification was performed based on ticipant.
previously established analysis categories, according to The information was collected and recorded on
the investigation purposes and with emerging catego- audio after the sign of the informed consent. It was
ries among the narratives and perception of the parti- transcribed and subsequently systematized through a
codification process that included the identification of
the first work codes, as well as the emerging categories
and then the process of category saturation was veri-
Table 1. Sociodemographical features fied and the information analyzed13, 17,20. The analysis
was performed inductively without forcing data into
Variable Percentage Value (%)
the previously established categories.
≤ 18 19-34 ≥ 35 Total The use of reliable data collection techniques, strict
Age Groups by Year 26 67 7 100 procedures, and controls in order to guarantee the
Etnia quality of the findings31 ensured the scientific rigor of
Afrodescendant 3.7 4.5 11.8 4.8 the study, its credibility, fidelity, confirmability, and
Indigenous 0.9 2.6 2.9 2.2 transferability13. The findings were shared with eight
Without ethnicity 95.4 92.9 85.3 93.13 participants in order to confirm that the study results
Socioeconomic level reflected their experiences. Similarly, the authors re-
1 21.1 19.2 14.7 20 corded every step of the research and analysis process22
2 68.8 64.3 55.9 65.2 (Figure 1).
3 9.2 16.6 29.4 15.8
The research was performed in accordance with
Marital Status the health research studies regulations established
Married or consensual union 4.4 66.6 58.8 53.9
in the Helsinki’s Declaration (1975 and reviewed
Single 8.9 31.7 38.2 45.2
Divorcee 0 0.3 2.9 0.4
in 1983)23 and took into account the Scientific, Te-
Widow 0 0.6 0 0.4 chnical, and Administrative Guidelines for Health
Research established in the Resolution No 008430
Education grade
None 0 0 2.9 2 of 19939 in Colombia24, which defined it as research
Primary 2.2 5.6 14.7 5.6 with minimum risk. No one was forced to participate
Secondary 95.5 71.9 61.8 75.8 in the study if they did not want to and could leave
Higher education (Technician, 2.2 19.5 20.6 16.6 at any time. The study had the approval of the Ethics
technologist, professional) Committee of the National Health Institute (NHI) of
Afiliation with social security in health Colombia.
Subsidized 48.9 48.8 38.2 48.1
Contributory 44.4 41.4 52.9 42.9
Not registered 6.7 9.8 8.8 9
Results
Main activity
Job 4.4 20.1 26.5 17.5
Household activities 41.1 69.5 73.5 64.3
The results address the predefined categories (table
Study 48.9 7.7 0 14.9 2) and are expressed sequentially from the third gesta-
Without activity 5.6 2.7 0 3.2 tion trimester until the child reaches 24 months of age,
and include textual quotes from the participants.

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Table 2. Categories and questions focus group guidelines and interviews

Characteristics of mother’s context We inquired about age, marital status, family structure, educational level, and socioeco-
nomic status

Representations and experiences We investigated the representations and experiences of the participants of the gestation,
facing pregnancy experienced changes, positive or negative aspects perceived, health situation during preg-
nancy, attendance at prenatal check-ups, psychoprophylactic courses, and/or emergency
service

Meanings and experiences of We searched for perceptions and knowledge about breastfeeding and complementary fee-
breastfeeding and complementary ding, access to information on breastfeeding and complementary feeding during and after
feeding pregnancy, sources of information on breastfeeding and complementary feeding, reasons
to breastfeed or stop breastfeeding, social networks of support, family environment/breast-
feeding/complementary feeding, work/breastfeeding/complementary feeding, facilities and
difficulties felt in relation to breastfeeding/complementary feeding, representations of food,
use and access to the health system, and breastfeeding support groups

Figure 1. Information management.

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56.7% of the women were first-time mothers, and as food since they were not solid, therefore they were
although 58.4% of the pregnancies were not planned, considered not to interfere with the EBF.
especially for those younger than 18 years, 90% of The traditional knowledge was a major influence
them stated that they wanted the child later. Until the on the participants; the recommendations from their
second month of age, 93% of the children were un- relatives were more welcomed than those from physi-
der the care of their mothers, the rest were under the cians and/or other health professionals. The internet
care of their grandmothers or others. The participants was an important information source in topics related
were planning to resume their pre-pregnancy activities to the CF, especially for younger participants, while
once their children were six months old. None of the older participants preferred to be informed through
participants had maternity leave since their economic workshops and training. “I followed my aunt’s recom-
activities were informal. mendations, also especially as I have read on the internet,
All deliveries were performed in a hospital, 60% I also have a book where I’ve read about the CF and there
of the cases were natural deliveries and 67% of the are also recipes (…) I haven’t consulted with the pedia-
mothers had immediate skin-to-skin contact with their trician, because, the truth is we haven’t gone, and I know
children. Only 20% of the women had complications, it is a fight” (JV02EN440).
such as high blood pressure, dilation problems, fetal The expected total breastfeeding (TBF) matched
distress or bleeding, and a small number required hos- with what happened in practice, since those women
pitalization after delivery. who said that they intended to breastfeed their chil-
68.8% of newborns received BF during the first dren still did so when they were six months old. Howe-
hour of life and those participants who did not so re- ver, the EBF prevalence was lower compared with the
ported reasons such as the lack of medical advice or expectation that they had during the pregnancy period.
support and weakness. 71.9% received counseling Among the reasons why mothers stopped breastfee-
in BF after the birth, mainly from their Health Care ding their children and therefore started with the CF
Providers (HCP) in breastfeeding techniques. For the was the perception of low milk production, problems
participants the immediate support that they received in breasts and nipples, child or maternal illness, and
in the healthcare institution was essential while breast- rejection from the child.
feeding. 69% of the children in the study had eaten something
The participants had the intentions to start the CF other than breast milk at the second month of life, which
after the children were six months old, however, they was consumed by more than half of them between the
did not care much about the fact of introducing foods two and six months of age. The main reasons for the
like water, formula, and juices before this age. Many mothers to offer formula to their children were the per-
did not know how and when to start the CF, and few ception they were still hungry, the feeling of low breast
believed they would breastfeed for less than six months. milk production, the fact that they had to leave them
Regarding the initiation of the CF, the mothers under the care of another person, and that they consi-
received advice from female relatives, mainly their dered that formula is better than other food, including
mothers, mother-in-law, sisters, grandmothers, and breast milk.” I feed him milk powder as a supplementary
sisters-in-law, who recommended that they start the food, so I can’t feed him a dish of dry food, then I have the
practice before the children were six months old. “My option of the bottle” (AH10EN902). 57% of the mothers
mother told me to give him bean broth that would help used a bottle to feed their children with foods other than
his stomach” (SR01EN03130). In contrast, the recom- breast milk, mainly formula, and in many cases, it was
mendations from health professionals, such as general presented as a substitute of breast milk, since they feed
practitioners, pediatricians, nurses, and nutritionists them with it as frequent as they breastfed.
usually indicated that it was best to maintain the EBF The CF was characterized by the early incorpora-
until the sixth month of age, and therefore start the CF tion of liquids and semisolids, such as water, natural
at this age. However, the mothers did not receive any fruit juices (passion fruit, apple, pear, mango, tange-
indications on how and why to follow these recom- rine, pitaya, orange, plum), fruit or vegetable water
mendations or any information on the consequences (lettuce apple, celery, tomato, among others), and
of early CF initiation. “I started feeding him food after infusions (anise, cinnamon, chamomile, mint). The
six months because let’s say… the pediatrician said so” reasons for fluids initiation were mostly related to the
(SR05EN05). mother’s perception of thirst and constipation.
The milk formula was considered as supplemen- The initiation of feeds with semisolids was varied,
tary food: “What happens is that my milk doesn’t feed not all mothers started at six months, most of them
them well, that’s why I’m reinforcing it with S26®, that started in the fifth month. The participants emphasized
is, it’s like watery milk” (CG08EN011601). Drinks such the influence of female relatives, who advised them to
as water, juices, and milk formula were not perceived start it early “to get the baby used to it” (JV12EN0103).

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Discussion the higher the chances of attending workshops and tra-

ining, the higher the chances of compliance with the
The beginning of the CF depends on socioecono- recommendations. However, according to the findings
mic, cultural, biological, psychosocial, and other fac- of this research this was not enough. Although most
tors, thus the age of feeding the first food to the infant participants reported having received some training
significantly varies from one population to another25. in EBF and CF, almost none followed the recommen-
Occasionally, the socioeconomic conditions may pro- dations. Most of them were not clear on how to use
duce the early introduction of CF, which is mainly the them and why they should use them. This means an
case in the most disadvantaged socioeconomic groups, educational challenge for the different health profes-
since if the mother has to work outdoors and has to sionals who must begin their permanent accompani-
quit the EBF, she has to rely on the CF in order to cover ment of the mother and child from the gestation up to
the dietary needs of the infant. Therefore, more than 24 months of age.
half of the children in this study received CF before re- Matching other authors, in this study no woman
aching six months, coinciding with the results of other indicated disadvantages of the milk formula26, instead,
authors who indicated that the age of quitting EBF is it was positively valued in most cases, which is probably
earlier in families with a lower income26. associated with the advertising of breast milk substitu-
The low education level of the participants is reflec- tes and the high lack of knowledge about the benefits
ted in the informal work relationship, which requires of the BF for the mother and her child, a reason that
little qualification and means low income, a fact that could explain why most of the mothers do not consi-
would partially indicate that large families live in the der the option of expressing and storing their own milk
same home due to economic reasons, which would and decided to buy formula to feed their child.
also explain the great influence that female relatives Although many mothers reported having problems
have in the nutrition of children. For the participants in breasts and nipples, none had major complications
the advice of their mother or grandmother was more such as mastitis and abscesses, which would explain the
truthful than those given by health professionals, cessation of EBF and the consequent start of the CF. In
mainly because they found support, continuous ac- this sense, the physiological barriers were not the main
companiment, and explanations based on experiences reason why EBF and CF recommendations were not
in their families. It is important to note that in Colom- followed34, 35, 36.
bia, until the middle last century, the rural population According to the results of this study, the CF is a
was 60% of the total population27. Most of the mothers social practice that results from the mixture of medi-
and grandmothers of the participants come from the cal and popular knowledge, however, the degree of in-
countryside and base their advice validity on their ex- fluence that the latter has on mothers is higher, mainly
perience, as they raised their children away from bio- because of the degree of closeness and the accompani-
medical knowledge. It should also be considered that ment that they have from their close circle, especially
the gestation as a matter of central public health con- from their mothers, grandmothers, and female relati-
cern is a relatively recent issue, since it is part of the new ves37.
prenatal care model of the WHO8, thus the amount of The lack of conceptual and practical knowled-
contacts that the mother has to have with the health ge about EBF and CF among mothers prevents them
professionals throughout pregnancy increases from from performing good practices 33. Most of them do
four to eight, in order to detect and manage potential not know what the exclusivity of BF implies, which
problems. This model gains relevance in the light of leads to an early beginning of the CF or do not have
the WHO data, which indicate the complications du- objective criteria to evaluate the milk production. The
ring the pregnancy and childbirth are the leading cause inadequate EBF leads to a bad CF practice, therefore,
of death and disability of women in childbearing age in it is necessary to strengthen the EBF support programs
developing countries due to causes which most of the and the CF considering the context of the mothers and
time can be avoided29. their knowledge. The constant support from health
There is evidence that indicates that the early start professionals is necessary to provide mothers with the
of CF is related to a low education level of the parents30, tools to face different barriers that arise throughout the
which can explain why many of the participants stayed CF process34,38,39,40.
home until their children were six months old and did It is essential to inform the close circle of the
not exclusively breastfed them, and why they decided mother and society in general thus they can be a sup-
to buy formula despite its high cost. port for the EBF and therefore the CF since they are
Studies show that the prenatal education contribu- social practices that are directly or indirectly influen-
tes to the extension of the EBF and the adequate start ced by everyone.
of the CF,31, 32, 33 since the higher education level and Throughout the study, there was a tension bet-

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ween the medical and popular knowledge, therefore followed the protocols of their Center and Local regu-
an approach of both pieces of knowledge is essential lations on the publication of patient data.
for them to recognize each other, and the mothers can
take the best of both in order to work for the nutritio- Rights to privacy and informed consent: The authors
nal well-being of their children, thus generating a posi- have obtained the informed consent of the patients
tive impact on the public health of the country thanks and/or subjects referred to in the article. This docu-
to free and informed CF practices. ment is in the possession of the correspondence author.
The revealed results of this study correspond to
the reality of a specific group of women who share Conflicts of Interest
similar sociodemographic characteristics, thus their
conclusions offer a partial view of the issue. However, Authors declare no conflict of interest regarding the
it allows seeing the point of view of these mothers re- present study.
garding the way in which they experience the CF with
their children. Financial Disclosure
The research was funded by Colciencias, National Ins-
Ethical Responsibilities titute of Health, the District Department of Social In-
tegration, and the Colombian Association for the Ad-
Human Beings and animals protection: Disclosure vancement of Science.
the authors state that the procedures were followed ac-
cording to the Declaration of Helsinki and the World Aknowledgments
Medical Association regarding human experimenta-
tion developed for the medical community. We thank the mothers and families who agreed to par-
ticipate in the study and the entities that contributed
Data confidentiality: The authors state that they have to its realization.

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