Optimal timing of introduction of complementary feeding: A systematic review and meta-analysis

Context: The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.Objective: This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.Data sources: Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.Data extraction: Two investigators independently extracted data from the included studies on a standardized data-extraction form.Data analysis: Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (\u3c 3 months, \u3c 4 months, \u3c 6 months of age) or late introduction of CF (\u3e 6 months, \u3e 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (\u3c 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at \u3c 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at \u3c 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (\u3e 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (\u3e 8 months) might increase height-for-age z score.Conclusion: Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.Systematic review registration: PROSPERO registration number CRD42020218517