This analysis highlights differences, and similarities, in food group consumption patterns, according to wealth status and provides insight into complementary feeding behaviours that may drive inequities in nutrient intake in infants and young children in the Philippines.
The prevalence of breastmilk consumption was higher among all infants and young children from poorest households and the contributions of breastmilk to daily energy intakes were higher. In the 2013 National Nutrition Survey, FNRI reported that 52.3% of infants were exclusively breastfed from 0-5.9 months and 60% of 6-11.9 month old infants consumed breastmilk on the day of the survey . Overall, the prevalence of breastfeeding is sub-optimal and does not adhere to the guidelines of continued, on-demand breastfeeding until 2 years of age and beyond . Nonetheless, the situation is better than that reported in national surveys from other geographies e.g. China (44% 0-5.9mo)  and Mexico (15% 0-3.9mo) .
Breast milk makes an important contribution to the nutrient intakes of children between 6–24 months. However, breast milk is low in minerals such as iron and zinc, and infants need complementary foods, in particular, those that provide iron, zinc and calcium, from the age of 6 mo [15, 16]. Given the relatively small amounts of complementary foods consumed between 6-11.9mo, the nutrient density of these foods needs to be high . Indeed, an extensive study examining Filipino infant and child feeding (6–23 months of age) in urban areas reported that children who are breastfed were more likely to be anaemic or iron deficient after 6 months of age than those receiving fortified foods . Fortified young child beverages provide a source of iron among Filipino infants (6-11.9mo) and toddlers (12-23.9mo), respectively . However, consumption of these products was more prevalent in children from higher income households. This may, in part, explain some of the differences we see in nutrient intakes according to household wealth category.
Rice is the most commonly consumed (94.8%) food in the Philippines, and is also the primary source of energy, protein, iron, thiamin and niacin . The percentage contribution of rice to total daily energy, was consistently higher among children from the poorest households in all 3 age groups. However, intakes of protein and B vitamins remain low in Filipino infants and toddlers . Ideally, the mandatory iron fortification of rice in the Philippines could provide a public health opportunity to improve nutrient intakes, particularly in children from poorer households. For example, a study among school kids revealed significant reduction in anaemia after a 120 day supervised fortified lunch feeding program . Unfortified complementary foods that are plant-based generally do not provide sufficient key nutrients such as iron, zinc and calcium in adequate amounts for very young children in developing countries . The current analysis identified low intakes of iron, zinc and calcium in young Filipino children, particularly in those from poor households. Therefore, initiatives to support fortification of commonly consumed foods could help to close this gap in nutrient intakes.
In general, infant cereal consumption is low in the Philippines, with the exception of a sub-population from the rich households. In the current study, iron-fortified infant cereal, as recommended in complementary feeding by several medical and nutrition organisations, was lacking from the diet, with the exception of 6% of 6-11.9 month old infants from the middle and rich households. The lack of dietary diversity, with less than 5 foods making up 80% of the diet in 6-11.9 month olds and 60% of the diet in 18-23.9 month olds. This is further exacerbated in the poor households, and is coupled with a low consumption of iron-containing foods, which is a public health concern. Improving access to fortified foods for breastfed children, such as infant cereal, could help to improve micronutrient intakes. However, even in the U.S., iron and zinc were identified as problem nutrients  despite the widespread availability of fortified foods for infants. Therefore, ensuring adequate nutrient supply in complementary feeding is clearly complex and requires further detailed study in order to examine how young children can meet their nutrient needs in these challenging circumstances.
Nutrient-dense protein foods such as eggs, pork and chicken were more likely to be consumed by children from richest households. Whereas, fish was more likely to be consumed by children from low wealth households. Indeed, fishing is an important source of nutrition, subsistence and income for some of the poorest households in the Philippines. For coastal communities, it is their main source of animal protein, yet, children from houses headed by fisher-folk experience some of the highest rates of malnutrition [20–21]. Recent environmental changes have been discussed as potentially threatening a main source of protein intake in poor households and that marine conservation and food security go hand in hand for these populations . It is estimated that inclusion of animal-source foods may help improve nutrient intakes, however, this may not be affordable or practical for low-income groups, particularly in coastal communities of the Philippines .
In the current study, SSBs were more likely to be consumed by infants and young toddlers from the poorest households. However, SSBs were consumed at approximately equal prevalence across wealth categories by 18-23.9 month olds. Since the nutrient needs, according to body weight, of infants and young children are very high  there is typically no room in the diet for nutrient-poor foods such as SSBs. In the current study, infants were more likely to consume fruit juice and powdered chocolate milk than other types of SSBs. In order to help combat the nutritional inadequacies in the Philippines, fruit juice and chocolate milk are often fortified and have been shown to be among the top sources of micronutrients in the diets of Filipino children . Fortified fruit juice has been effective at reducing the basal level of iron deficient anaemia in Filipino school children from 100–13% . However, large inequities remain in nutrient intakes between children from the poorest and richest households. Adherence to the Pinggang Pinoy recommendation for frequent consumption of fruit and vegetables is poor, this may be due to a number of factors including high cost, limited access to fresh fruit and vegetables, poor nutrition knowledge and family members’ food preferences . The importance of fruit and vegetables, meat, poultry, fish and eggs, should be emphasised in Filipino households. Public health authorities may wish to investigate methods to improve accessibility to such foods, particularly among low-income households.
Finally, household wealth status is significantly related to only a few food groups in infancy however at 12-17.9mo more consumption of diverse food groups was significantly related to household wealth. This may suggest that household wealth starts to play a much bigger role in the food choices (and consumption) from the age of 12 months old.
This study presents a very comprehensive evaluation of complementary feeding patterns of Filipino infants and young children. It relied on nationally representative data from the National Nutrition Survey in 2013. Several limitations are noted. The dietary intake estimates for the infants and young children were based on reports by parents, and may have included inaccuracies leading to over- or under-estimation of food intakes. The data were collected in 2013, and it is possible that new foods on the market in the Philippines, especially fortified foods, could have resulted in subsequent improvements in the nutrient intake estimates of young children. Furthermore, we used a single 24hr recall to assess food group intakes, and this may not fully capture habitual dietary intakes. Dietary supplements were not included in the analysis and, if used, may have also increased nutrient intakes in this population.