Toward consensus on complementary feeding recommendations: findings from a national evidence-informed modified Delphi study in Türkiye

BACKGROUND: Complementary feeding (CF) recommendations are generally based on international guidelines; however, several clinical issues remain controversial, resulting in variability in professional practice. This study aimed to develop evidence-informed expert consensus on complementary feeding recommendations and to explore the reasons underlying persistent disagreement. METHODS: In this national evidence-informed modified Delphi study in Türkiye, 58 pediatricians working in Social Pediatrics participated in the first round and evaluated 53 statements using a five-point Likert scale. Statements not reaching consensus were revised based on participants' comments and reevaluated in a second round. Thirteen unresolved statements underwent a third round involving evidence presentation and structured online discussion with 23 participants; 22 subsequently completed the final re-rating. Audio-recorded discussions and written comments were analyzed using reflexive thematic analysis in MAXQDA Analytics Pro 24. RESULTS: Consensus was achieved for most recommendations regarding the timing of CF, developmental readiness, responsive feeding, and several feeding practices. Persistent disagreement remained for recommendations concerning formula-fed infants, infants with poor weight gain, preterm infants, baby-led weaning (BLW), vegan CF, bottle use, and selected allergy-related practices. Qualitative analysis generated five overarching themes: (1) individualization beyond fixed age thresholds; (2) balancing nutritional priorities with developmental safety and feasibility; (3) risk-stratified introduction of allergenic foods; (4) conditional rather than universal acceptance of BLW; and (5) ethical and clinical tensions surrounding vegan CF. Experts generally agreed on the underlying scientific principles but emphasized that recommendations should incorporate developmental readiness, clinical judgment, family circumstances, cultural context, and implementation feasibility rather than relying on rigid or universal recommendations. CONCLUSIONS: Integration of quantitative Delphi findings with qualitative thematic analysis revealed that non-consensus primarily stemmed from the practical nuances of clinical execution and contextual adaptation, rather than a fundamental skepticism toward the underlying scientific data. These findings provide an evidence-informed foundation for developing context-sensitive CF recommendations for clinical practice.