COMPLEMENTARY FEEDING PRACTICES TO CHILDREN DURING THEIR FIRST YEAR OF LIFE

El objetivo fue estudiar las prácticas de alimentación complementaria en el primer año de vida de niños en la región de Botucatu, SP, las cuales fueron descritas según el grupo etáreo y las prácticas de lactancia materna (LM). Fueron entrevistados 1238 acompañantes de niños menores de 1 año vacunados en la Campaña de Vacunación Múltiple. Diferencias asociadas con la situación de LM fueron identificadas a través del test Chi-cuadrado y el test exacto de Fisher. La introducción de alimentos conplementarios fue precoz, lo que produjo una baja frecuencia en la lactancia materna exclusiva (36,9% en < 4 meses). Niños menores de 4 años consumieron mates (30,7%), entre 4 y 6 meses consumieron frutas (54,1%), sopas (39,9%) y comida (19,2%). Los jugos fueron ofrecidos apenas en 15,2% de los niños menores de 4 meses quienes ya no lactaban, y, agua en 60,0% de los casos. Los datos muestran prevalencia en el consumo de preparaciones inadecuadas con relación a su consistencia: oferta de comida por parte de la familia en niños entre 6 y 8 meses (48,8%) y oferta de sopa a niños mayores de 8 meses (71,6%). Se sugiere que el municipio realice intervenciones enfocando la alimentación suplementaria.

This study aimed to investigate complementary feeding practices during children's first year of life in Botucatu, SP, Brazil.Practices were described according to the age range and the breastfeeding (BF) practice.Data were collected during a multi-vaccination campaign through the interview of 1,238 individuals who accompanied children younger than one year old being vaccinated.Differences associated with the BF situation were identified by the chi-square test and Fisher's exact test.The early introduction of complementary food was observed, which led to the low frequency of exclusive breastfeeding (36.9% <4 months).Children younger than 4 months old consumed tea (30.7%); children between 4 and 6 months old consumed fruits (54.1%), soups (39.9%) and home-made food (19.2%).Juice was offered only to 15.2% of children younger than months old who were completed weaned, 60% of the children was offered water.Data show that the consistence of the food consumed was inappropriate: children between 6 and 8 months old were offered the family's regular food (48.8%) and children older than 8 months (71.6%) were offered soup.Therefore, interventions focused on complementary feeding are justified on the city.DESCRIPTORS: breast feeding; Milk, human; supplementary feeding

INTRODUCTION
In the light of current scientific knowledge, there is a consensus about human milk as being the only food product that is capable of adequately attending to all physiological peculiarities of infants' metabolism during the first six months of their lives (1) .
Despite advances in breastfeeding rates in the last decade, the breastfeeding situation in Brazil remains far below WHO (World Health Organization) recommendations: exclusive breastfeeding until the sixth month of life and breastfeeding with complementary foods until the age of two or more (2) .
In Botucatu/SP, the city where this study was carried out, a progressive increase in exclusive breastfeeding has been observed among children younger than 120 days, with prevalence levels of 19.1% in 1995, 22.6% in 1999 and 36.9% in 2004 (3) .Complementary feeding is defined as feeding during the period in which, besides mother's milk, other foods or fluids are offered to the child (4) .As there is no specific term to designate the introduction of food products to children who are not breastfed, in this study, the term complementary feeding will be used independently of the child's breastfeeding situation.
The WHO recommends the offering of complementary foods from the age of six months onwards (1) .However, the current tendency, endorsed by the Brazilian Health Ministry, is to recommend the introduction of complementary foods at the age of six months (5)   .
In to the child's feelings of hunger and satiety (5) .
At first, the food products offered to children must be prepared especially for them, in the form of pulps, vegetable mush, cereals or fruits.These are the so-called transition foods.From the age of eight months onwards, the same foods prepared for the family can be offered, provided that they are mashed, minced, chopped or cut in small pieces.The use of cups is recommended to offer water or other fluids, while semi-solid and solid foods should be given with a plate and spoon (4)   .
In view of the importance of complementary feeding for the child's growth and development, this research was proposed with the aim of studying complementary feeding practices in the first year of life in Botucatu-SP, describing their use according to age range and identifying differences associated with the presence of breastfeeding.

METHOD Study Type and Data Collection
We carried out a cross-sectional study.Data were obtained during the 1 st phase of the 2004 National Multivaccination Campaign in Botucatu-SP, a city of about 110,000 inhabitants, located in the Central-South of the state.We interviewed 1238 companions of children of less than one year old -90.6% of the estimated number of children for this age range -, and obtained information about the consumption (yes, no) of food products during the day before the research.We asked about the consumption of water, teas, juices, fruits, (liquid or powder) milk, beans, meat, porridge, soup, mush and solid food.
We studied children of less than six months to assess the timely introduction or not of complementary foods, children at the age of six months because complementary foods should start in this age range, and children between six and ten months to follow the indicators recommended by the WHO (6) .The age range between eight and twelve months was studied because, at this age, it is indicated that children start to receive the same food prepared for their relatives (4)(5) .

Ethical procedures
This study was assessed and approved by the Research Ethics Committee at Botucatu Medical School and complies with recommendations for research involving human beings.

Data analysis
Questionnaires were checked and coded and a database was created in Epi Info 6.0 software, using resources that only permitted the entry of data established in the coding.File consistency was checked by verifying associated questions in part of the questionnaires and correcting the identified errors.
In order to assess the relation between complementary food consumption and the presence or not of breastfeeding, the chi-square test was used with a 5% significance level.When the number of children in a specific category was lower than five, Fisher's Exact Test was performed, with the same 5% significance level.

RESULTS
Table 1 presents the consumption frequency of complementary foods according to the child's age range.The consumption frequency of any examined food or liquid was proportionally higher among children of less than six months old who were not breastfed.
In the age range under four months old, not receiving breast milk was associated with a higher frequency of porridge consumption (p=0.0000),home-made food (Fisher = 0.0259), fruit juice (p= 0.0007), teas (p= 0.0047) and water (p=0.0000).We also found an association in the age range of four to six months between not being breastfed and greater consumption of some complementary foods, such as porridge (p= 0.0000), fruit juice (p= 0.0576), teas (p= 0.0304) and water (p=0.0000).Among six-month-olds, not being breastfed was only associated with a higher consumption frequency of home-made food (p= 0.0116).We observed some differences in complementary food consumption according to the presence of breastfeeding.In the age range between six and ten months, the absence of breastfeeding was associated with a higher frequency of children receiving home-made food (p= 0.0140).Breastfed children between eight and twelve months old, on the other hand, received significantly more soup (p= 0.0293).
Table 5 shows the presence of meat in soup preparations and meat or beans in homemade food according to breastfeeding in children between four and twelve months old.However, some problems were detected in terms of food consistency, such as the early offering of solid foods and the maintenance of soup for children who should be receiving solid food.
Hence, professionals and health services active in breastfeeding promotion and support now have to work to change this unfavorable picture in terms of complementary food consumption.There is an urgent need to focus food counseling for breastfeeding infants on complementary feeding, besides the already quite disseminated actions implemented in our means to promote and support breastfeeding.
A successful experience was recently developed in the South of Brazil, where undergraduate nutrition students were trained and paid ten home visits to a group of breastfeeding infants and their mothers, during the first life year, giving advice based on guidelines by the Brazilian Health Ministry (5) .In comparison with a group that did not receive the intervention, lower levels of fluid introduction like water and tea were found among the studied children in the first year of life, as well as a 60% increase in the chance of receiving exclusive breastfeeding for at least four months, and a 40 % lower consumption of sweets (candies, soft drinks, snacks and chocolate), among other observed benefits (14).
Another Brazilian study, carried out in the Northeast, also identified a very favorable response to a home intervention aimed at supporting exclusive breastfeeding and avoiding the early introduction of complementary feeding (15) .
Making possible actions as efficient as those described above in public basic health care services is a challenge health professionals have to face without delay.Evidence shows the child's home as the preferential space for their development.
Finally, it should be appointed that this study did not aim to get to know why the detected complementary feeding problems occur.It is known that child care practices, including feeding practices, are influenced by cultural, emotional, socioeconomic and health service problems.Hence, new studies are recommended, both epidemiological and qualitative research, to obtain deeper knowledge about the conditioning factors of maternal behavior related to infant feeding nowadays.

Table 1
Table1shows that 126 children of less than four months old (30.7%) received tea, while other food products were less consumed.Moreover, the proportion of children consuming the different food products we examined increases as age advances,

Table 2 -
Introduction of complementary foods withmeat or beans in children between 4 months and one year old.Botucatu, 2004

Table 5 -
Relation between breastfeeding and introduction of complementary foods with meat or beans in children between four months and one year old.Botucatu, 2004 In this age range, indicators were favorable: high prevalence of children receiving soups with meat and home-made food with meat and beans, which are good sources of iron, a critical nutrient in this age range.