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Recommended Feeding

and Dietary Practices to
Improve Infant and
Maternal Nutrition

February 1999

Recommended Feeding and Dietary Practices to Improve Infant and Maternal
Nutrition is a publication of the LINKAGES (Breastfeeding, Complemen-
tary Feeding, and Maternal Nutrition Program) Project. LINKAGES is sup-
ported by the G/PHN/HN, Global, U.S. Agency for International
Development, under Cooperative Agreement No. HRN-A-00-97-00007-00
and managed by the Academy for Educational Development. The opin-
ions expressed herein are those of the author(s) and do not necessarily
reflect the views of the U.S. Agency for International Development.

The LINKAGES Project
Academy for Educational Development
1825 Connecticut Avenue NW
Washington, DC 20009
Tel: 202-884-8000
Fax: 202-884-8977

First Printing, February 1999
Second Printing, December 1999
Table of Contents iii

Table of Contents
Acknowledgments ......................................................................................................... v

Executive Summary ..................................................................................................... vii

Introduction ................................................................................................................... 1

I. Recommended Feeding Practices to Improve the Nutrition of Infants 0 to 6 Months ... 3

II. Recommended Feeding Practices to Improve the Nutrition of Children 6 to 24
Months .......................................................................................................................... 6

III. Recommended Dietary Practices to Improve the Nutrition of Adolescent Girls and
Women of Reproductive Age ........................................................................................ 15

Conclusion ....................................................................................................................24

Summary of Recommended Readings ......................................................................... 25

References ................................................................................................................... 25
Acknowledgments v

This paper benefitted from the contributions and advice of many individuals. Sandra
Huffman and Luann Martin were major contributors. Special thanks are extended to Jay
Ross for his insightful comments, to Roy Miller for presentation of DHS data, and to Ellen
Piwoz of the SARA Project for her contribution to the section on complementary feeding.
LINKAGES and AED staff who participated in review meetings and provided comments
on draft documents included Jean Baker, Rolando Figueroa, Mary Lung’aho, Peggy
Parlato, Maryanne Stone-Jiménez, Vicky Quinn, and Victor Aguayo. Other individuals
who contributed to this document are Stephanie Gabela from Wellstart International who
provided helpful comments on an earlier draft, Erika Lutz for examples of diets for chil-
dren and pregnant women, Soe Lin Post for graphics, and Kimberly Ferguson and Cindy
Arciaga Lauer for layout. The support, technical advice, review, and constructive feed-
back on various drafts by Susan Anthony, Mihira Karra, Miriam Labbok, and Shelley
Snyder are greatly appreciated.
Executive Summary vii

Executive Summary
Malnutrition can start before birth and can persist throughout life. Many babies are
born with low birth weight and micronutrient deficiencies. Poor feeding practices during
the first two years of life have immediate and often long-term negative consequences on
growth and development. Nutritional stress during adolescence and the reproductive
years affects the health of women and, consequently, the next generation. This paper
identifies a set of recommended feeding and dietary practices to break this cycle of poor
health and nutrition that passes from generation to generation. It also provides the scien-
tific evidence to support the recommendations.
Exclusive breastfeeding for about six months ensures that the young infant receives
maximum health and nutritional benefits from breastmilk. Exclusively breastfed infants
are at a much lower risk of infection from diarrhea and acute respiratory infections than
non-breastfed infants. When other foods or fluids are consumed, there is an increased
risk of exposing the young infant to pathogens that cause sickness, leading to decreased
nutrient intake and death.
Children are at greatest risk of nutritional deficiency and growth retardation between
the age of 6 and 24 months. Around six months of age, introduction of complementary
foods, along with sustained breastfeeding, is required. Appropriate complementary feed-
ing helps promote growth, prevent stunting, and increase a child’s chances for a healthy,
productive life as an adult. Improving complementary feeding requires a combination of
strategies. Energy intake can be increased by breastfeeding more frequently, feeding
complementary foods more often, providing energy-dense foods, practicing active feed-
ing, and increasing food portion sizes. If locally available foods are inadequate, micronu-
trient supplementation may be needed.
Another period of nutritional stress is adolescence and the reproductive years. Addi-
tional energy is needed to support adolescent growth, fetal growth during pregnancy,
and milk production during lactation. While pregnancy represents an important opportu-
nity for health and nutrition interventions, nutritional problems must also be addressed
at other times in a woman’s life. Adequate energy and micronutrient intake is critical at
all stages. For adolescents and women of reproductive age, improved energy intake, a
diversified diet, and increased micronutrient intake through food fortification can help to
improve their health and nutrition, as well as birth outcomes. When appropriate foods
are not available, micronutrient supplements can improve nutritional status.
The recommendations presented in this paper and listed on the following pages fo-
cus on feeding and dietary practices and not on other important determinants of nutri-
tional status such as household food security, health services, and environmental factors.
They are grouped into several categories: children 0 to 6 months, children 6 to 24
months, and adolescent girls and women of reproductive age. The goal is for healthy
women to give birth to healthy babies who receive optimal nutrition, first through their
mothers’ breastmilk and then, from around 6 months to 24 months and beyond, through
breastmilk and appropriate complementary foods.
These recommendations can serve as guidelines for program planners and
policymakers to use in setting policies and designing communication, service delivery,
and training activities. LINKAGES suggests that program planners collaborate with com-
munication specialists in determining how to present this advice in a culturally appropri-
ate way to different groups that influence feeding and dietary practices. Local
assessments will help determine the emphasis to give each practice. LINKAGES also rec-
ommends that program planners collaborate with local nutrition specialists to “translate”
caloric requirements into local foods and measurements.
viii Executive Summary

Summary of Recommended Feeding and Dietary Practices

Infants ΠInitiate breastfeeding within about one hour of birth.
0 to 6
ΠEstablish good breastfeeding skills (good positioning and attach-
Months ment).
- Baby should be held close to mother, facing the breast, with the
baby’s ear, shoulder, and hip in a straight line.
- Infant’s mouth should open wide just before attaching so the
nipple, and as much of the areola as possible, are in the mouth. If
properly attached, the lips are rolled outward, with the tongue
over the lower gum.
- Signs of effective feeding include visible jaw movement drawing
milk out, rhythmical suckling with an audible swallow, and no
drawing in of cheeks.

ΠBreastfeed exclusively (no prelacteal feeds, no other foods, no
water or other liquids) for about the first six months.

Œ Practice frequent, on-demand feeding, including night feeds (8–
12 breastfeeds per 24 hours, every 2–3 hours, or more frequently if

ΠIn areas where vitamin A deficiency occurs, mothers should take
a high-dose vitamin A supplement (200,000 IU) as soon as pos-
sible after delivery, but no later than eight weeks postpartum, to
ensure adequate vitamin A content in breastmilk.

Breastfed ΠContinue frequent, on-demand breastfeeding, to 24 months and
6 to 24 ΠIntroduce complementary foods beginning around six months of
Months age.
- Breastfeed before each feeding of complementary food.

ΠIncrease food quantity as the child ages while maintaining fre-
quent breastfeeding.
- Provide 6- to 8-month-old infants approximately 280 kcal per day
from complementary foods.
- Provide 9- to 11-month-old infants approximately 450 kcal per day
from complementary foods.
- Provide 12- to 24-month-old children approximately 750 kcal per
day from complementary foods.

ΠIncrease complementary feeding frequency as the child ages, us-
ing a combination of meals and snacks.
- Feed complementary foods to 6- to 8-month-old infants 2–3 times
per day.
- Feed complementary foods to 9- to 11-month-old infants 3–4 times
per day.
- Feed complementary foods to 12- to 24-month-old children 4–5
times per day.
Executive Summary ix

Summary of Recommended Feeding and Dietary Practices

Breastfed ΠGradually increase food thickness and add variety as the child ages,
Children adapting the diet to the child’s requirements and abilities.
- Feed mashed and semi-solid foods to infants, starting around 6
6 to 24 months of age.
Months - Feed energy-dense combinations of foods to 6- to 11-month-olds.
(con't.) - Introduce “finger foods” (snacks that can be eaten by children alone)
at about 8 months of age.
- Make the transition to the family diet at about 12 months of age.

ΠDiversify the diet of both the breastfeeding mother and the child by
including fruits, vegetables, fortified foods, and/or animal products
to improve quality.
- Feed fruits and vegetables daily, especially those rich in vitamin A
and other vitamins.
- Feed meat, poultry, fish, or other animal products daily or as often as
possible (if feasible and acceptable).
- Use fortified foods, such as iodized salt, vitamin A-enriched sugar,
iron-enriched flour, or other staples, when available.
- Give vitamin-mineral supplements when animal products and/or forti-
fied foods are not available.

ΠPractice active feeding.
- Feed infants directly and assist older children when they feed them-
- Offer favorite foods and encourage children to eat when they lose in-
terest or have depressed appetites.
- If children refuse many foods, experiment with different food combi-
nations, tastes, textures, and methods for encouragement.
- Talk to children during feeding.
- Feed slowly and patiently and minimize distractions during meals.
- Do not force children to eat.

ΠPractice frequent and active feeding during and after illness.
- During illness, increase fluid intake by more frequent breastfeeding,
and patiently encourage children to eat favorite foods.
- After illness, breastfeed and give food more often than usual, and en-
courage children to eat more food at each sitting.

ΠPractice good hygiene and proper food handling.
- Wash caregivers’ and children’s hands before food preparation and
- Keep all food preparation surfaces clean; use clean utensils to pre-
pare and serve foods.
- Cook food thoroughly.
- Avoid contact between raw foodstuffs and cooked foods.
- Serve foods immediately after preparation; avoid storing cooked
- Wash fruits and vegetables.
- Use safe water.
- Use clean cups and bowls; never use feeding bottles.
- Protect foods from insects, rodents, and other animals.
- Store non-perishable foodstuffs in a safe place (separate from pesti-
cides, disinfecting agents, or other toxic chemicals).
x Executive Summary

Summary of Recommended Feeding and Dietary Practices

Adolescent Recommended at all times
girls (10–19 Œ Increase food intake, if underweight, to protect adolescent
Years) and girls’ and women’s health and establish reserves for preg-
Women of nancy and lactation.
Reproductive ΠDiversify the diet to improve the quality and micronutrient in-
Age take.
- Increase daily consumption of fruits and vegetables.
- Consume animal products, if feasible and acceptable.
- Use fortified foods, such as vitamin A-enriched sugar and
other products and iron-enriched and vitamin-enriched flour
or other staples, when available.

ΠUse iodized salt.

ΠIf micronutrient requirements cannot be met through available
food sources, supplements containing iron, vitamin A, zinc,
and other nutrients may be needed to build stores and im-
prove women’s nutritional status.

Recommended during periods of special needs:
At certain times, girls and women have heightened nutritional re-
quirements. During these times, they should follow the above rec-
ommendations plus those listed below.

During adolescence (between 10 and 19 years of age)
Œ Increase food intake to accommodate the adolescent “growth
spurt” and to establish energy reserves for pregnancy and lac-

During pregnancy
ΠIncrease food intake to support fetal growth and future lacta-
ΠTake iron/folic acid tablets daily.

During lactation
ΠEat the equivalent of an extra meal per day.
ΠIn high-risk areas, take a high dose vitamin A capsule
(200,000 IU) as soon after delivery as possible, but no later
than 8 weeks postpartum, to build stores, improve breastmilk
quality and reduce maternal morbidity.

During the interval between the cessation of lactation and the
next pregnancy
ΠAllow adequate time (at least six months) between the cessa-
tion of lactation and the next pregnancy to replace and build
up energy and micronutrient reserves.
Introduction 1

Introduction for developing messages and programs
appropriate to prevailing local conditions.
The overall objective of the LINKAGES When viewed within a larger concep-
Project is to improve breastfeeding and re- tual framework (Figure 1), LINKAGES’ rec-
lated complementary feeding and mater- ommendations are part of maternal and
nal dietary practices. The Project cuts child care, one of three major underlying
across traditional boundaries between determinants of nutritional status. Feeding
health/nutrition and population programs, practices affect both dietary intake and
emphasizing the overlapping benefits of health status, which are the immediate de-
four health-related practices: optimal terminants of nutritional status. The impact
breastfeeding, timely introduction of family of LINKAGES’ activities on improving feed-
planning, including the Lactational Amenor- ing and dietary practices will be greater if
rhea Method (LAM), timely and appropri- they are supported by determinants of nu-
ate complementary feeding, and better tritional status that are outside LINKAGES’
maternal nutrition. scope of work. These determinants include
Together, these practices contribute to household food security, health services,
fertility reduction, improved reproductive environmental factors, and other care is-
health, and child survival. Listed below are sues such as physical workloads. A few
examples of the overlapping benefits of examples illustrate the importance of food
the four health-related practices. security, health services, reduced physical
ΠA well-nourished mother provides opti- workloads, and family planning.
mal nutrition to her fetus and is less ΠAccess to food: Poor-quality diets may
likely to give birth to a premature in- be due to poverty, the unavailability of
fant or to a low birth weight, full-term nutrient-rich foods, and inequitable dis-
baby. She is also able to provide opti- tribution of food within a household.
mal nutrition to her exclusively ΠAccess to preventive and curative health
breastfed infant. services:
ΠThe Lactational Amenorrhea Method - Hookworm infection contributes to
(LAM) and improved breastfeeding anemia and anorexia.
practices extend birth spacing. - Malaria tends to worsen nutritional
ΠOptimal breastfeeding and comple- status by destroying red blood cells,
mentary feeding behaviors promote resulting in anemia.
health, growth, and development and - Illness often suppresses appetite and
increase a child’s chances for a predisposes children to malnutrition.
healthy, productive life as an adult. For example, diarrhea causes de-
ΠGood feeding practices during the first creased nutrient absorption and de-
two years greatly reduce the risk that creased dietary intake.
a girl will reach maturity stunted and ΠReduced physical workloads: Heavy
at risk of obstetric complications and physical labor and high levels of en-
the delivery of a low birth weight ergy expenditure that are not compen-
baby. sated for by increased food intake
undermine nutritional status. In a
The LINKAGES Project, in consultation study in Ethiopia, the caloric intakes of
with technical experts and program man- pregnant women participating in high
agers, identified a set of recommended and low levels of physical activity
feeding and dietary practices to improve were compared. Both groups con-
nutritional status at various points in the sumed approximately the same num-
life cycle: birth to about six months, six ber of calories. Women who engaged
months to 24 months, and adolescence in low levels of physical activity
and the reproductive years. This paper gained, on average, nearly three kilo-
presents the technical justification for the grams more than women involved in
recommendations. Policymakers and pro- heavy labor. Their infants weighed
gram planners can use them as guidelines
2 Introduction

about 200 grams more than the other The remainder of this paper focuses
group (Tafari et al., 1980). on feeding and dietary practices as under-
ΠDelay of first pregnancy: Teenage preg- lying determinants of nutritional status.
nancy increases the risk that a baby The paper does not address issues sur-
will be born with low birth weight. In a rounding infant feeding and HIV/AIDS.
study in urban areas of Mali and These issues are discussed in a separate
Burkina Faso, teen mothers were al- LINKAGES publication, Frequently Asked
most twice as likely to give birth to Questions on Breastfeeding and HIV/AIDS.
low birth weight babies as older moth- For a discussion of interventions to pro-
ers (LeGrand and Mbacké, 1993). mote and support LINKAGES’ recom-
ΠBirth spacing: Frequent childbearing in- mended practices, the reader is referred
creases a woman’s risk of malnutrition to two papers developed for LINKAGES:
because of the nutritional demands of ΠImproving breastfeeding behaviors: Evi-
pregnancy and lactation. Extended birth dence from two decades of intervention
intervals also benefit the child. A child research (Green, Forthcoming) and
born less than two years after the pre- ΠInterventions to improve complementary
vious child is two times more likely to food intakes of 6–12 month old infants in
die before the age of five than a child developing countries: What have we been
born after an interval of two years or able to accomplish? (Caulfield, 1998).
more (Hobcraft, 1991).

Figure 1. Causes of Malnutrition
Malnutrition Manifestations

Inadequate Immediate
Disease Causes
Dietary Intake

Insufficient Inadequate Insufficient Health Underlying
Household Maternal & Services & Unhealthy Causes
Food Security Child Care Environment


Resources & Control
Human, Economic &

Political and Ideological Superstructure

Economic Structure

Potential Resources
UNICEF, 1992.
Nutrition of Infants 0 to 6 Months 3

I. Recommended Feeding provides the infant the enhanced anti-bac-
Practices to Improve the terial, anti-viral, and nutritional properties
of colostrum (the first milk).
Nutrition of Infants 0 to 6
Months Establish good breastfeeding skills
(proper positioning and attachment)
The benefits of breastfeeding for infant
health and survival, child growth and de- A key factor to initiating successful
velopment, and maternal health are well breastfeeding is the establishment of good
documented. These benefits are summa- breastfeeding skills during the first days.
rized in a LINKAGES publication, Quantify- Proper positioning and attachment in-
ing the Benefits of Breastfeeding: An crease the infant’s suckling efficiency, fa-
Annotated Bibliography (Lutter, 1998). This cilitating effective removal of milk from
chapter discusses six key practices, listed the breast, adequate milk intake, and the
in Box 1, that support optimal nutrition production of breastmilk. Proper position-
during the first six months of life. Exclusive ing and latch-on also reduce friction on the
breastfeeding, with frequent, on-demand mother’s nipples that can cause pain and
feedings, also contributes to child spacing result in sore or cracked nipples (Shrago
and lower total fertility rates. A woman and Bocar, 1990).
who is amenorrheic, less than six months Signs of proper positioning and attach-
postpartum, and fully or nearly fully ment include:
breastfeeding1 is more than 98 percent ΠBaby should be held close to mother,
protected against pregnancy, as demon- facing the breast, with the baby’s ear,
strated in clinical trials of the effectiveness shoulder, and hip in a straight line.
of the Lactational Amenorrhea Method Œ Infant’s mouth should open wide just
(LAM) for birth spacing (Labbok et al., before attaching so the nipple, and as
1997). much of the areola as possible, are in
the mouth. Once attached, the lips
Initiate breastfeeding within about one should be rolled outward, with the
hour of birth tongue over the lower gum.
The first step to optimal breastfeeding ΠSigns of effective feeding are: visible
is to put the baby to the breast within the jaw movement drawing milk out,
Note 1 first hour of birth. Initiation during the first rhythmical suckling with an audible
Full or nearly full
hour takes advantage of the newborn’s in- swallow, and no drawing in of cheeks.
breastfeeding in-
cludes exclusive tense suckling reflex and alert state
breastfeeding, “al- (Righard, 1990). Early initiation also stimu- Suckling at the breast differs from
most exclusive” (vi- lates breastmilk production; fosters sucking from a bottle. Use of a bottle to
tamins, mineral
mother-child bonding; and immediately feed expressed breastmilk can result in
water, juice, or ritual-
istic feeds given in-
frequently in
addition to
breastfeeds), and
Box 1. Recommended Feeding Practices to Improve the
“high” levels of Nutrition of Infants 0 to 6 Months
breastfeeding (the
vast majority of ΠInitiate breastfeeding within about one hour of birth.
feeds are ΠEstablish good breastfeeding skills (proper positioning and attachment).
breastfeeds). Inter-
vals should not ex-
ΠBreastfeed exclusively (no prelacteal feeds, no other foods, no water or other
ceed four hours liquids) for about the first six months.
during the day and Œ Practice frequent, on-demand feeding, including night feeds (8–12 breastfeeds
six hours at night. per 24 hours, every 2–3 hours, or more frequently if needed).
should represent no ΠIn areas where vitamin A deficiency occurs, mothers should take a high-dose
more than 5–15 per- vitamin A supplement (200,000 IU) as soon as possible after delivery, but no
cent of all feeding later than eight weeks postpartum, to ensure adequate vitamin A content in
episodes. (Labbok et breastmilk.
al., 1994)
4 Nutrition of Infants 0 to 6 Months

less effective suckling at the breast, who received complementary foods was 6–
“nipple confusion,” the introduction of 13 times greater than for exclusively
pathogens through unsterile feeding breastfed infants (Popkin et al., 1990). Even
bottles, and, in the most extreme cases, the addition of water or other non-nutritive
refusal of the breast (Newman, 1990). To liquids doubled the risk of diarrhea com-
avoid these problems, expressed breast- pared with exclusively breastfed infants.
milk should be fed by cup. Water supplementation is both unnec-
Pacifiers (dummies) and other artificial essary and dangerous because it can intro-
teats can also interfere with breastfeeding duce contaminants and reduce nutrient
and serve as a vehicle for contaminants. intake. In India use of non-nutritive liquids
One study in Brazil reported that the pro- was associated with a decline in breast-
portion of children who were no longer milk consumption (Sachdev et al., 1991).
breastfed at six months of age was signifi- Six studies that examined the water re-
cantly higher among babies who used quirements of exclusively breastfed infants
pacifiers at one month of age than among in diverse climates reported that healthy
those who did not use pacifiers (Victora et infants who consumed enough breastmilk
al., 1993). to meet their energy needs also satisfied
their fluid requirements, even in hot and
Breastfeed exclusively (no prelacteal
dry climates (WHO, 1991). The studies
feeds2, no other foods, no water or other
were conducted in Argentina, Israel, India,
liquids) for about the first six months
Jamaica, and Peru.
A randomized trial conducted in Hon-
Practice frequent, on-demand feedings,
duras suggests that babies who are exclu-
including night feeds (8–12 breastfeeds
sively breastfed for six months grow as
per 24 hours, every 2–3 hours, or more
well as those who receive complementary
frequently if needed)
foods from the age of four months (Cohen
et al., 1994). Given the risks of infection Frequent feedings increase breastmilk
due to food-borne pathogens, most ex- production and maintain supply. They help
perts now recommend exclusive breast- to prevent problems, such as breast en-
feeding for about the first six months. gorgement, that might discourage a
Exclusive breastfeeding ensures that the woman from breastfeeding. Newborns
young infant receives the maximum health who are breastfed on demand generally
and nutritional benefits from breastmilk. A regain their birth weight sooner than those
study (Duncan et al., 1993) in Tucson, Ari- fed on a schedule (de Carvalho et al.,
zona, of more than 1,000 babies found 1983). Indicators of infant hunger are in-
that babies who were exclusively breast- creased alertness, mouthing, and rooting
fed for four months or more had 40 per- for the nipple. Crying is a late sign of hun-
cent fewer episodes of acute ear infections ger (Anderson, 1989).
than breastfed babies who received other Some babies, such as passive, sleepy
foods before four months. babies, may seldom cry or “demand” to
There is also clear evidence that the be fed. Mothers should be informed that
exclusively breastfed child is at a much for optimal nutrition, babies need to be
lower risk of infection from diarrhea and breastfed 8–12 times per 24 hours, every
acute respiratory infections than infants 2–3 hours, or more frequently as needed
who receive other foods (Brown et al., during the first months. During the first
1998; Popkin et al., 1990; Lutter, 1997). For few days after birth, many babies
example, in the Philippines, the risk of diar- breastfeed more frequently and often for
Note 2
rhea among infants four months of age longer periods than when breastfeeding is Prelacteal feeds in-
fully established. clude water, other
liquids, or ritual
foods given to a baby
before breast-
feeding is initiated.
Nutrition of Children 0 to 6 Months 5

In areas where vitamin A deficiency cause they have virtually no reserves of
occurs, mothers should take a high-dose retinol in their livers (Greene, 1991). Pro-
vitamin A supplement (200,000 IU) as viding a high-dose vitamin A supplement
soon as possible after delivery, but no to the mothers of at-risk infants soon after
later than eight weeks postpartum, to delivery will improve their vitamin A status
ensure adequate vitamin A content in and, in turn, the vitamin A content of their
breastmilk milk. In a study in Bangladesh (Roy et al.,
1997), a group of mothers of breastfed in-
The concentration of vitamin A in
fants received a single oral high-dose
breastmilk depends on a woman’s vitamin
supplement of vitamin A soon after birth.
A status and the changing needs of her
Their infants had significantly fewer days
growing infant. Preterm milk is higher in
of illness from respiratory infections during
vitamin A concentration than term milk.
the first six months of life than infants of
During the first two weeks of lactation, the
mothers from the same socio-economic
vitamin A concentration in breastmilk is
group who were not given the supplement.
nearly double the concentration at one
The earlier the single dose (200,000 IU
month. The mature breastmilk of women
orally) is given to a lactating woman, the
with relatively good maternal health and
sooner the vitamin A status of her breast-
nutritional status provides enough vitamin
fed child will be improved (WHO, 1997). A
A for at least the first six months and pos-
high-dose vitamin A supplement can be
sibly the first year (Newman, 1993).
harmful to a fetus (WHO/MI, 1997). There-
In areas where vitamin A deficiency is
fore, it should not be given during preg-
endemic, women may have low vitamin A
nancy or anytime beginning around eight
concentration in their breastmilk, increas-
weeks after childbirth when women are at
ing a child’s risk of becoming clinically de-
heightened risk of pregnancy (especially if
ficient during illness. Preterm infants are at
they are not fully breastfeeding).
particular risk of vitamin A deficiency be-
6 Nutrition of Children 6 to 24 Months

II. Recommended Feeding children’s weights may become appropri-
Practices to Improve the ate for their lower heights, but little can be
done to bring these children up to the stat-
Nutrition of Children 6 to 24 ure of well-nourished children. For girls,
Months the consequences of stunting are height-
Children are at highest risk of nutri- ened risks of obstructed labor during child-
tional deficiency and growth retardation birth since stunting affects the size of the
between the ages of 6 and 24 months. The birth canal (pelvic size). In addition, a
prevalence of malnutrition within a popula- stunted woman is more likely to give birth
tion, as measured by growth retardation, to a low birth weight baby.
usually peaks in children 12 to 24 months Underwood (1985) describes the pe-
of age. As illustrated in Figure 2, the riod between 6 and 24 months as a critical
prevalence of stunting (low height-for-age) transition period when the “exposure to
approaches 40 percent among children in environmental pathogens is most intense,
this age group and is only slightly higher in the likelihood of inadequate nutrient intake
older groups of children. most probable, and the emotional trauma
Short-term nutritional deficiencies, as of less intimate maternal infant contact
evidenced by wasting (low weight-for- most stressful.” The recommended prac-
height), are also most prevalent in the 12- tices to improve the nutrition of children
to 24-month age group. Although wasting between 6 and 24 months address these
drops off sharply in the third year, children risks. These practices, listed in Box 2, fo-
are unable to compensate for their early cus on optimal feeding behaviors, ad-
poor feeding and continue to be stunted for equate dietary intake, hygienic food
the rest of their lives. By age 2–3 years, preparation, and the caregiver’s attentive-
ness to a child’s needs.

Figure 2. Malnutrition Prevalence in 15 Countries by Age
(average prevalence)
42 42
% Deficient

31 Underweight (low weight-for-age)
30 29
24 Stunting (low height-for-age)
20 21
20 Wasting (low weight-for-height)

9 10
10 7
4 5 4 4
<6 6–11 12–23 24–35 36–47 48–59
Age in Months

% Deficient refers to the percentage of malnourished children below -2 Standard Deviations.
Source: Demographic and Health Surveys, 1991–1995.
Note: All DHS countries with anthropometric data in the 1991–1995 surveys were included: Cameroon, Colombia, Dominican
Republic, Egypt, Guatemala, Jordan, Madagascar, Malawi, Namibia, Niger, Nigeria, Pakistan, Peru, Tanzania, and Zambia.
Nutrition of Children 6 to 24 Months 7

Box 2. Recommended Feeding Practices to Improve the
Nutrition of Breastfed Children 6 to 24 Months
ΠContinue frequent, on-demand breastfeeding, to 24 months and beyond.
ΠIntroduce complementary foods beginning around six months of age.
ΠIncrease food quantity as the child ages while maintaining frequent
ΠIncrease complementary feeding frequency as the child ages, using a combi-
nation of meals and snacks.
ΠGradually increase food thickness and add variety as the child ages, adapting
the diet to the child’s requirements and abilities.
ΠDiversify the diet of both the breastfeeding mother and the child by including
fruits, vegetables, fortified staple foods, and/or animal products to improve
ΠPractice active feeding.
ΠPractice frequent and active feeding during and after illness.
ΠPractice good hygiene and proper food handling.

Many of the recommendations are view existing studies and conduct local as-
aimed at increasing energy intake. This sessments to understand the multiple fac-
can be done by: tors that affect feeding practices. These
Πbreastfeeding more frequently, assessments will determine the appropri-
Πfeeding children complementary foods ate emphasis to give to each of the recom-
more often and/or providing more en- mended practices. Local studies should
ergy-dense foods, identify local diets and current good prac-
Πmaking portion sizes larger (up to the tices to be supported, test options for im-
limit of a child’s hunger and stomach proving the traditional diet and changing
capacity), and related feeding practices, and identify tar-
Πpracticing active feeding (adapting the get audiences and effective strategies for
feeding method to the child’s changing reaching them.
psychomotor abilities, actively encour- A discussion of each of the recom-
aging the child to eat, and providing a mended feeding practices to improve the
supervised environment). nutrition of breastfed children 6 to 24
Micronutrient intake can be increased months of age follows.
by diversifying the diet to include fruits,
Continue frequent, on-demand
vegetables, and animal products; using
breastfeeding, including night feeding
fortified foods; and/or giving micronutrient
for infants
supplements. Choosing food combinations
that enhance micronutrient absorption is There are several reasons for recom-
also important. Improving the micronutri- mending frequent, on-demand breastfeed-
ent content of the maternal diet will im- ing of older infants and toddlers.
prove the quality of a woman’s Œ Breastmilk remains an important
breastmilk. source of energy and fat. Breastmilk
In many areas, local, cultural, and en- is relatively high in fat compared with
vironmental constraints make it difficult to most complementary foods. Based on
practice all of the recommended practices. estimates, breastfed infants need only
Adaptations will need to be made; how- 25 percent of their calories from fat in
ever, a child’s nutritional status is likely to complementary foods compared with
be compromised unless most of these 35–45 percent for non-breastfed in-
practices are adopted. Programs to im- fants (Brown et al., 1998). When
prove complementary feeding should re- complementary foods are low in fat,
8 Nutrition of Children 6 to 24 Months

the fat in breastmilk may be essential breastmilk. Complementary foods are any
for the utilization of vitamin A. non-breastmilk foods given to young chil-
Œ Breastmilk’s contribution to the sup- dren during this period.
ply of vitamins and high-quality pro- In many countries, nutrition guidelines
tein may be substantial, depending continue to recommend introducing
on the levels in complementary complementary foods between four and
foods. Studies in Bangladesh reported six months based on the assumption that
that breastmilk contributed nearly half breastmilk alone may not be adequate to
of the protein intake and 60 percent of support the growth of some infants during
daily energy and vitamin A intake in this period. Some have suggested that
the diet of children over two years of complementary feeding should begin be-
age (Brown et al., 1982). In a study of fore six months to get infants used to eat-
rural West African children over one ing other foods. However, a study in
year of age, Prentice and Paul (1990) Honduras (Cohen et al., 1995) showed that
reported that breastmilk was the most early initiation does not result in improved
important source of vitamin A and fat. growth velocities or food acceptance. The
ΠBreastfeeding is extremely important study compared food consumption pat-
during illness. Children often continue terns and growth of infants who were
breastfeeding even when they are started on foods at four months to the con-
anorexic and refuse other foods. sumption patterns and growth of those
ΠBreastmilk continues to reduce the who began eating complementary foods at
risk of infection. Besides providing six months. There were no differences in
young children with an important, food acceptability or food consumption at
high-quality food, breastfeeding contin- 9–12 months between the two groups. In-
ues to reduce the risk of infection (es- fants consumed similar amounts and vari-
pecially diarrhea, including shigellosis), eties of foods whether or not they had
even in the older infant and young solids prior to six months of age.3
child (Ahmed et al., 1992; Mobak et Several studies in Thailand, Peru, Hon-
al., 1994; Clemens et al., 1986). Sus- duras, and the United States have docu-
tained breastfeeding also reduces the mented that early initiation (<6 months)
risk of childhood cancer (Davis, et al., of complementary foods replaces breast-
1988). milk and does not increase caloric intake
ΠBreastfeeding helps to suppress fer- (Brown et al., 1998). None of these studies
tility. Breastfeeding can significantly reported any benefits for the child’s
reduce fertility beyond the first six growth of early complementary feeding.
months among populations where con- Because breastmilk is generally higher in
traceptive use is limited. Women who nutritional value than the complementary
breastfeed their infants at frequent in- foods and liquids fed to children in devel-
tervals over prolonged periods of time oping countries, replacing it can negatively
have lower fertility than women who affect the fat, energy, and micronutrient in-
breastfeed infrequently and for shorter take of young infants.
durations (VanLandingham et al., Even when breastfeeding frequency Note 3
1991). remains high, the total amount obtained Frongillo and
Habicht (1997) raise
from each breastfeed decreases when some concerns
Introduce complementary foods
other foods are fed. The implications are about the study, par-
beginning around six months of age
twofold: (1) maintain high levels of ticularly the high
By about six months of age, breastfeeding when introducing comple- non-random drop-
out rate among the
breastmilk alone cannot meet most ba- mentary foods, and (2) ensure that exclusive breast-
bies’ total energy and vitamin/mineral re- complementary foods are as high in nutri- feeding group and
quirements. At this time complementary ents as possible. an inadequate
feeding should begin. Complementary Many breastfeeding counselors recom- sample size to show
significant differ-
feeding refers to the period when other mend that women breastfeed before feed- ences in weight and
foods or liquids are provided along with ing complementary foods, especially until length.
Nutrition of Children 6 to 24 Months 9

the child is 10 to 12 months of age. This Increase food quantity as the child ages
recommendation is intended to maximize while maintaining frequent
breastmilk consumption and stimulate breastfeeding
breastmilk production. A review by Arm-
Adequate energy intake can be en-
strong (1993) indicated that there is no sci-
sured through age-appropriate, energy-
entific evidence showing that breastfeeding
dense foods, frequent feedings, and
prior to complementary feeding negatively
continued breastfeeding. Table 1 illustrates
affects infant growth. Armstrong terms the
that the energy needed from complemen-
recommendation to breastfeed first
tary foods depends on the child’s age and
“speculative,” a “common-sense position”
the level of breastmilk intake. As the child
that communicates the importance of
ages and breastmilk intake decreases,
breastmilk for infant health and nutrition.
complementary foods must meet a
Breastfeeding before each comple-
greater proportion of the energy require-
mentary feeding is also promoted for its
role in fertility reduction. This practice is
Listed below are estimates of the rec-
one of the criteria for extended use (nine
ommended daily energy intake from
months rather than six months) of the Lac-
complementary foods for various age
tational Amenorrhea Method. Breastfeed-
groups. They represent average require-
ing before complementary feeding helps to
ments for breastfed children. Local re-
maintain the frequency and intensity of
search is needed to determine the best
breastfeeding necessary for the effective-
combinations of foods and feeding prac-
ness of the Lactational Amenorrhea
tices to achieve these levels of energy in-
Method (Cooney et al., 1996). The other
take. Individual children may require more
criterion for extended LAM is amenorrhea.
or fewer additional calories and nutrients
If these criteria are not met, the chance of
depending on their nutrient stores, activity
pregnancy is increased.
levels, and growth requirements.

Table 1. Energy Needed from Complementary Foods to
Meet Daily Requirements by Level of Breastmilk Intake
Level of Breastmilk Intakea
Age in months Daily energy High breast- Average breast- Low breastmilk
requirement milk intakec milk intakec intakec
(kcal)b (Mean +2 S.D.) (Mean - 2 S.D.)
Kilocalories needed from complementary foods
6–8 680 75 270 465
9–11 830 230 450 675
12–23 1090 490 750 1000

Source: Brown et al., 1998.
Figures have been rounded.
Estimates of average breastmilk intake are: 410 kcal for a 6- to 8-month-old, 380 kcal for a 9- to
11-month-old, and 340 kcal for a 12- to 23-month-old. These estimates need to be adjusted for the
size of the infant.
10 Nutrition of Children 6 to 24 Months

General feeding guidelines for breast- takes suggest the following complemen-
fed children with average breastmilk in- tary feeding frequencies, using a combina-
take (defined in the footnote to Table 1), tion of meals and snacks:
and sample daily diets are shown below. ΠFeed complementary foods to 6 to 8-
Œ Provide 6 to 8-month-old infants ap- month-old infants 2–3 times per day.
proximately 280 kcal per day4 from ΠFeed complementary foods to 9 to 11-
complementary foods. month-old infants 3–4 times per day.
(Example: ½ cup rice, 1½ tablespoons Œ Feed complementary foods to 12 to 24-
mung dal [lentils], 3 tablespoons dark month-old children 4–5 times per day.
green leafy vegetables, and 1 tea-
spoon groundnut oil)5 Differences in local foods and recipes
ΠProvide 9 to 11-month-old infants ap- and variations in breastfeeding practices un-
proximately 450 kcal per day from derscore the need to develop local guide-
complementary foods. lines on the types and quantity of food
(Example: 1½ cups plain maize pap, children should consume at different ages
½ banana, ½ cup rice and beans, l as well as the feeding frequency needed to
ladle palm oil/tomato/pepper stew, 1½ meet their energy requirements. Local diets
tablespoons chopped chicken, and 1 will also need to be assessed for their mi-
fried bean cake)6 cronutrient content. Tools such as Designing
ΠProvide 12 to 24-month-old children by Dialogue (Dickin et al., 1997) can help in
approximately 750 kcal per day from the development of recommendations for
complementary foods. feeding practices and appropriate local
(Example: 1 cup rice, 3 tablespoons foods for young children.
dal [lentils], 1 teaspoon oil, a small
Gradually increase food thickness and
piece of fish, ½ cup boiled potato, 1
variety as the child gets older, adapting
tablespoon coconut, 2 tablespoons mo-
the diet to the child’s requirements and
lasses, and 1 small mango)7
All three of these diets provide, in ad- As the gastrointestinal tract and im-
dition to breastmilk, sufficient calories, mune system mature and other develop-
protein, and vitamin A for the specific age mental changes occur, a child is ready to
group. However, because these diets are ingest a variety of foods. The foods con-
low in animal products, their iron and zinc sumed should change in consistency and
content is inadequate. For children 6 to 24 composition, becoming thicker and more
months, it is difficult to obtain sufficient energy dense. Initially, porridge and other
amounts of these nutrients without fortified semi-solid foods are suitable first foods be-
foods or micronutrient supplements. cause infants are physiologically ready to
accept them. They are also more calori-
Increase feeding frequency as the child
cally dense than liquids, such as soups.
gets older, using a combination of meals
When infants are capable of eating
and snacks
thicker semi-solid foods, such as mashed
Guidelines on feeding frequencies bananas, these foods should be introduced
Note 4
should take into account the energy den- because they tend to be more calorically The difference from
sity and the amount of various foods dense than purées. One disadvantage, the number shown
served to a child. The continuation of fre- however, is that thicker semi-solid foods in Table 1 is due to
quent, on-demand breastfeeding is impor- usually take longer to feed than purées, rounding.
tant to ensure that complementary foods until the child reaches about 10 months of Note 5
do not displace breastmilk. Breastmilk age (Gisel, 1991). By 10–12 months of age, Adapted from
Cameron and
should be the sole source of nutrition in the most infants can pick food up by hand and Hofvander, 1983.
first six months and the primary source in are ready to eat solid foods, such as Note 6
the second six months. bread. At this age, the variety of foods Dickin et al., 1997.
Recent estimates (Brown et al., 1998) should be increased by feeding mashed Note 7
of energy requirements and breastmilk in- family foods and various fruits and Wollinka et al., 1997.
Nutrition of Children 6 to 24 Months 11

vegetables (Dickin et al., 1997). At about (Sommer and West, 1996). Provitamin A
12 months, most children are ready to carotenoids are found in fruits and veg-
make the transition to the family diet. etables. Dark green leafy vegetables are a
Guidelines for the introduction of good source of provitamin A carotenoids,
various foods are summarized below. but orange/yellow fruits and vegetables
ΠFeed mashed and semi-solid foods are an even better source. Provitamin A
(softened with breastmilk, if possible) carotenoids in orange/yellow fruits
to infants, beginning around six (mango, papaya) and yellow/red veg-
months of age. etables (pumpkin, sweet potatoes) are
ΠFeed energy-dense combinations of twice as effective in enhancing serum vita-
soft foods to 6–11 month olds. min A levels as those found in dark green
Œ Introduce “finger foods” (snacks that leafy vegetables (Bloem et al., in press).
can be eaten by children alone, such Because vitamin A and its precursors
as grated vegetables and bread strips) are fat soluble, vitamin A can be more
at about eight months of age. fully utilized when fruits and vegetables
ΠMake the transition to the family diet are mixed or eaten with a fat source, thus
Note 8 at about 12 months of age. enhancing their absorption and increasing
Micronutrients are the energy density of the foods without
frequently classified Diversify the diet to improve quality
sacrificing nutrient density. For the same
as Type I and Type II
nutrients (Golden, Optimal feeding of children 6 to 24 reason, breastmilk, which is a major
1995). Although months and older requires adequate pro- source of fat in the diet, may help to im-
growth continues in tein and micronutrient intake8 as well as prove vitamin A status. As noted earlier,
the early stages of energy intake to ensure growth and proper breastmilk is also a good source of vitamin
Type I nutrient defi-
ciencies, characteris- metabolic functions of the body. This can A. For example, a breastfed child who is
tic clinical signs and be done in the following ways: 9–11 months old could meet all of the daily
symptoms develop. ΠFeed fruits and vegetables daily, espe- vitamin A requirements by eating a quar-
Health workers are
cially those rich in vitamin A and other ter of a mango. A non-breastfed child, on
trained to recognize,
diagnose, and treat vitamins. the other hand, would require a whole
such Type I deficien- ΠFeed meat, poultry, or fish daily or as mango (USDA, 1997).
cies as anemia (iron), often as possible (even small quanti-
beri-beri (thiamin),
scurvy (vitamin C), xe-
ties help). Feed meat, poultry
poultry,, fish, or other
rophthalmia (vitamin ΠUse fortified foods, such as iodized animal products daily or as often as
A), and iodine defi- salt, vitamin A-fortified sugar or other possible, if feasible and acceptable
ciency disorders. Defi- vitamin A-fortified products, and iron- In developing countries, where most
ciencies in Type II
nutrients, on the
enriched flour or other staples, when diets are based on staple grains and le-
other hand, exhibit available. gumes, micronutrient deficiencies are very
no specific clinical common. The vitamin A, iron, and zinc
signs but can result in When animal products, fortified foods, found in grains and vegetable sources are
growth failure and
anorexia. When and/or vitamin A-rich foods are not avail- less available and less efficiently stored
growth failure occurs, able, vitamin-mineral supplements, contain- than those found in animal products. Daily
it is difficult to deter- ing appropriate levels of micronutrients, or frequent consumption of animal prod-
mine which nutrients should be given to children to prevent ane- ucts helps to avert deficiencies of these es-
might be responsible.
Zinc, magnesium, mia, zinc deficiency, vitamin A deficiency, sential micronutrients.
phosphorus, and po- and other micronutrient deficiencies. Retinol, a vitamin A compound, is
tassium are among found only in animal sources (eggs, milk,
the Type II nutrients. Feed fruits and v eget
veget ables daily
egetables daily,, cheese, liver, and fish oils). To replace 1 µg
In addition to these
minerals, protein is especially those rich in vitamin A of retinol available in animal products, 6
classified as a Type II The ability of food sources to prevent µg of beta-carotene (in orange and yellow
nutrient. (Note: Addi- vitamin A deficiency depends on the con- fruits and vegetables) and 12 µg of other
tional micronutrients
tent of vitamin A compounds in different provitamin carotenoids (such as in dark
such as riboflavin, nia-
cin, B6, and B12, may foods, the amount of vitamin A that can be green leafy vegetables) are needed
also be deficient in absorbed and utilized, and the vitamin A (Olson, 1995). Only 1.4 percent of the iron
some populations.) status of the person consuming the food in spinach and 7 percent in soybeans can
12 Nutrition of Children 6 to 24 Months

be absorbed, compared with 20 percent of ciency in the population (de Pee et al.,
iron from red meat (Scrimshaw, 1991). 1995).
ΠIodine: If the soil is low in iodine and
Use fortified foods, when available; give seafood sources are lacking, iodine
vitamin-mineral supplements when must be obtained through fortification
animal products, fortified foods, and/or or supplements. Consumption of salt
vitamin A rich foods are not available fortified with iodine will prevent iodine
Although animal products are excellent deficiency in pregnant women, chil-
sources of micronutrients, they are often dren, and other vulnerable groups.
unavailable, unaffordable, or unacceptable Breastfeeding mothers who consume
(such as to a vegetarian population). More- iodized salt will have sufficient iodine
over, it is difficult to meet the iron require- in their breastmilk.
ments of a rapidly growing child even ΠOther micronutrients: Depending on
when animal products (flesh meats) are the local diet and health status, other
consumed regularly. supplements or multiple vitamin-min-
If young children are unable to meet eral tablets may be necessary. For ex-
all of their micronutrient requirements ample, some young children are B6
through the consumption of animal prod- and B12 deficient because of malab-
ucts and vitamin A-rich fruits and veg- sorption in the gut or a deficiency in
etables, they should eat fortified foods, the child’s diet or the diet of the lactat-
such as iodized salt, vitamin A-fortified ing mother. Riboflavin is low in diets
sugar or other vitamin A-fortified products, that contain few animal products, and
and iron-enriched flour or other staples, vitamin C is often only seasonally
when available. If fortified foods are not available. Zinc intake is generally low
available, the following supplements may when iron intake is low. Zinc has been
be needed: shown to enhance growth and reduce
ΠIron: UNICEF recommends oral iron infection in young children.
supplements daily (12.5 mg per day)
Practice active feeding
to infants 6 months to 1 year of age. A
solution of 25 mg/ml of iron can be Active feeding refers to caregiver be-
given to an infant by dropper with 10 haviors that may help to increase a child’s
drops (0.5 ml) per dose. It would be food intake. These behaviors are listed be-
feasible to add 10 mg of zinc to this low.
preparation (Nestel and Alnwick, ΠFeed infants directly and assist older
1997).9 If the prevalence of anemia is children when they feed themselves.
known to be very high (40 percent or ΠOffer favorite foods and encourage
more), supplements should be contin- children to eat when they lose interest
ued until 24 months of age. Low birth or have depressed appetites.
weight infants are at particular risk of ΠIf children refuse many foods, experi-
iron deficiency and may need to take ment with different food combinations,
oral iron supplements (12.5 mg/day) tastes, textures, and methods for en-
starting from three months of age and couragement.
continuing for at least nine months ΠTalk to children during feeding.
(UNICEF/WHO, 1995). ΠFeed slowly and patiently and mini-
ΠVitamin A: Bi-annual dosing with high- mize distractions during meals.
dose vitamin A as retinol (100,000 IU ΠDo not force children to eat.
for children 6–11 months and 200,000
IU for those 12–60 months of age) can Positive reinforcement, persistence,
enhance vitamin A stores in areas and supervised feedings are characteristics
where vitamin A deficiency occurs of active feeding. Children of caregivers Note 9
(WHO, 1997). Consumption of dietary who are passive and non-responsive to The impact of such a
preparation on iron
sources of vitamin A is often inad- their needs are more likely to be malnour- and zinc status is only
equate to eliminate marginal defi- ished than children of attentive caregivers. now being tested.
Nutrition of Children 6 to 24 Months 13

In addition to nutritional benefits, active tious, easily digestible food, reduces pro-
feeding stimulates a child’s verbal and tein and caloric loss at a time when chil-
cognitive development (Engle et al., 1997). dren frequently lose their appetite for
A major problem that can be ad- other foods and liquids. For example, stud-
dressed by active feeding is the high ies in rural Peru found that during diarrheal
prevalence of anorexia observed among episodes, breastfed children maintained
young children. Depressed appetites are their breastmilk intake; however, total ca-
often associated with diarrhea and fever loric intake from other foods decreased by
but are also prevalent in children who are 10–20 percent (Brown et al., 1990). Be-
not ill. Many caregivers only encourage sides helping to maintain energy intake,
children to eat when they are sick, but not breastfeeding helps prevent dehydration
at other times. Encouragement is needed, and comforts the sick child.
even when children do not appear hungry Practice good hygiene and proper food
or refuse new foods. This can be done by handling
offering additional food or second helpings,
showing children how to eat, and talking to To ensure that foods given to children
them while they eat. are safe and transfer nutrients, not patho-
Adequate time for feeding, the gens, caregivers should:
caregiver’s knowledge of the amounts of Œ Wash caregivers’ and children’s hands
different foods that a child needs to eat, before food preparation and eating.
and self-confidence contribute to active ΠKeep all food preparation surfaces
feeding. If a child refuses food, a self-confi- clean; use clean utensils to prepare
dent caregiver does not assume that the and serve foods.
child “knows best” but realizes that the Œ Cook food thoroughly.
food should be offered numerous times ΠAvoid contact between raw foodstuffs
until the child becomes accustomed to eat- and cooked foods.
ing it. Some caregivers may feel that ac- ΠServe foods immediately after prepa-
tive feeding is too time-intensive. They ration; avoid storing cooked food.
need to be assured that this time-intensive ΠWash fruits and vegetables.
period is normal and relatively brief. ΠUse safe water.
ΠUse clean cups and bowls; never use
Practice frequent and active feeding feeding bottles.
during and after illness ΠProtect foods from insects, rodents,
Illness affects both dietary intake and and other animals.
nutrient utilization. Due to loss of appetite, ΠStore non-perishable foodstuffs in a
sick children frequently reject food or con- safe place (separate from pesticides,
sume only small quantities. Even when disinfecting agents, or other toxic
they eat food, nutrients are often lost be- chemicals).
cause the illness inhibits their absorption or ΠKeep all food preparation premises
drains them away through diarrhea and clean.
vomiting. The following advice is offered to
caregivers of children 6 to 24 months of These optimal practices are based on
age. principles set forth by the World Health Or-
ΠDuring illness, increase breastfeeding, ganization (1996). Program planners and
increase fluid intake, and patiently en- communicators will need to determine
courage children to eat their favorite which of these recommended practices de-
foods. serve emphasis within a specific socioeco-
ΠAfter illness, feed children more often nomic and environmental context.
than usual and encourage children to One of the causes of high rates of
eat more food at each sitting. malnutrition among children 6 to 24
months is the introduction of pathogens in
Breastfeeding is particularly critical contaminated feeding bottles and foods.
during illness because breastmilk, a nutri- Contamination is also the result of poor ba-
14 Nutrition of Children 6 to 24 Months

sic hygiene, sanitation, and methods of to be cooked, such as a banana peeled im-
food preparation. Food is often prepared mediately prior to consumption, are an-
several hours before it is consumed and other way of providing foods free from
then stored at temperatures that promote contamination. Fruits and vegetables
the growth of pathogens. Insufficient cook- should be washed and peeled if possible.
ing or reheating of food can also result in Those that cannot be peeled should be
food-borne illnesses. Foods should be cooked to kill bacteria.
cooked thoroughly and fed as soon as they Hand washing can help reduce con-
are cool enough to eat. Foods for infants tamination and the risk of diarrhea. Keep-
should not be stored, unless they can be ing children’s hands clean is important
kept cold (below 10o C) or hot (above 60o because children put their hands in their
C) and in clean, covered containers (WHO, mouths many times when feeding them-
1993). Because bottles are particularly selves. Caregivers need to wash their own
hard to clean, they should not be used for hands with soap before feeding children, a
infant feeding. practice requiring substantial behavior
Acidified foods (such as yoghurt) or changes in places where hand washing
fermented foods are less subject to con- with soap is infrequent. Providing a clean
tamination since the acid helps prevent the surface for the child to feed him/herself is
growth of bacteria. Foods that do not need also important.
Nutrition of Adolescent Girls and Women of Reproductive Age 15

III. Recommended Dietary nant and lactating. McGuire and Popkin
Practices to Improve the (1990) estimate that on average, women
in Africa and Asia between the ages of 15
Nutrition of Adolescent Girls and 45 are pregnant or lactating 30–48
and Women of Reproductive percent of their time. The cumulative ef-
Age fect of frequent, closely spaced pregnan-
cies, negative energy balance, and
As noted in the previous chapter, nutri-
micronutrient deficiencies can lead to a
tional neglect during the first two years of
condition known as “maternal depletion
life has immediate and often long-term
syndrome” (Winkvist et al., 1992).
negative consequences on growth and de-
Recommendations for improving the
velopment. This chapter examines the im-
nutrition of adolescent girls and women of
pact of nutritional stress during
reproductive age, set forth in Box 3, focus
adolescence and the reproductive years in
on dietary practices that affect energy and
women and the next generation. As illus-
micronutrient intake at different points in
trated in Figure 3, the following risks to nu-
the life cycle: adolescence, the non-preg-
tritional status are present throughout life:
nant/non-lactating period, pregnancy, and
food insecurity, micronutrient deficiencies,
lactation. At all stages, energy is needed
infections and parasites, gender inequities,
for body maintenance. Additional energy is
and heavy physical labor. The outer circle
needed to support adolescent growth, fetal
shows additional risks during different
growth during pregnancy, and milk produc-
stages of the life cycle.
tion during lactation. Energy demands are
In most developing countries, women
at a maximum level when an adolescent
spend a larger proportion of their repro-
girl is pregnant and lactating.
ductive years pregnant, lactating, or preg-

Figure 3. Risks to Female Nutritional Status during
Different Periods of Life

Infancy and Early Childhood (0–24 months)
ΠSuboptimal breastfeeding practices
ΠInadequate quality and quantity of weaning diet
ΠInfrequent feedings

Lifetime Risks
ΠFood insecurity
Œ Higher caloric and Childhood (2–9 years)
ΠMicronutrient deficiencies
micronutirent ΠInfections and parasites ΠPoor diets
requirements ΠGender inequities
ΠHeavy physical labor

Adolescence (10–19 years)
ΠHigher caloric, protein, iron,
ΠIncreased nutritional demands
vitamin A and other micro-
during growth period
nutrient requirements
ΠGreater iron needs with onset
of menstruation
ΠEarly childbearing

Source: Baker et al., 1996
16 Nutrition of Adolescent Girls and Women of Reproductive Age

Box 3. Recommended Dietary Practices to Improve the
Nutrition of Adolescent Girls and Women of Reproductive
Recommended at all times
Œ Increase food intake, if underweight, to protect adolescent girls’ and women’s
own health and establish reserves for pregnancy and lactation.
ΠDiversify the diet to improve the quality and micronutrient intake.
- Increase daily consumption of fruits and vegetables.
- Consume animal products, if feasible and acceptable.
- Use fortified foods, such as vitamin A-enriched sugar and other products and
iron-enriched and vitamin-enriched flour or other staples, when available.
ΠUse iodized salt.
ΠIf micronutrient requirements cannot be met through available food sources,
supplements containing iron, vitamin A, zinc, and other nutrients may be
needed to build stores and improve women’s nutritional status.

Recommended during periods of special needs
At certain times, girls and women have heightened nutritional requirements.
During these times, they should follow the above recommendations plus those
listed below.
During adolescence (between 10–19 years of age)
Œ Increase food intake to accommodate the adolescent “growth spurt” and to
establish energy reserves for pregnancy and lactation.
During pregnancy
ΠIncrease food intake to support fetal growth and future lactation.
ΠTake iron/folic acid tablets daily.
During lactation
ΠEat the equivalent of an extra meal per day.
ΠIn high risk areas, take a high-dose vitamin A capsule (200,000 IU) as soon af-
ter delivery as possible but no later than 8 weeks postpartum to build stores,
improve breastmilk quality, and reduce maternal morbidity.
During the interval between the cessation of lactation and the next pregnancy
ΠAllow adequate time (at least six months) between the cessation of lactation
and the next pregnancy to replace and build up energy and micronutrient re-

Micronutrient requirements also time of lowest iron loss for women of re-
change at various points in the life cycle. productive age.
Adolescent growth, menstruation, preg- LINKAGES’ recommended dietary
nancy, and lactation can exacerbate micro- practices address women’s changing nutri-
nutrient deficiencies. For some ent requirements. While pregnancy repre-
micronutrients, such as vitamin A, lacta- sents an important opportunity for health
tion puts greater demands on maternal re- and nutrition interventions, nutritional
serves than pregnancy. In the case of iron, problems must also be addressed at other
the period of lactational amenorrhea is the times in a woman’s life, for the sake of
Nutrition of Adolescent Girls and Women of Reproductive Age 17

both the woman and her children. As than at any other time, with the exception
shown in Box 3, some of the recommen- of the first year of life. Nutritional status
dations apply to all women; others apply can be undermined if adolescent girls’ in-
to periods of special needs. creased nutritional demands are unmet.
Adolescent girls’ “growth spurt” occurs
Increasing Food Intake
about 12–18 months before their first
Women of reproductive age, if menstrual period, usually between 10 and
underweight, should increase food 14 years of age. They continue to grow in
intake to protect their own health and height for up to seven years after the on-
establish reserves for pregnancy and set of menstruation (menarche). A well-
lactation nourished adolescent girl may reach full
In developing countries chronic energy height as early as 16 years, whereas a
deficiency is very common among women malnourished girl, whose menarche has
of reproductive age. Many women are too been delayed, may achieve full height as
thin (Body Mass Index10 less than 18.5) or late as 23 years (Roche and Davila, 1972).
underweight (weight less than 45 kg). Adolescent girls are capable of con-
Over 60 percent of women are under- ceiving before their body is fully devel-
weight in South Asia, over 40 percent in oped. Completion of the development of
South East Asia, and about 20 percent in the birth canal occurs two to three years
sub-Saharan Africa (Gillespie, 1997). Func- after full height is reached (Moerman,
tional consequences of chronic energy defi- 1982). Pelvic bone immaturity increases
ciency include heightened susceptibility to the risks of prolonged labor, pre-eclamp-
infection, reduced activity levels, and sia, and cephalopelvic disproportion. Preg-
lower productivity (Shetty and James, nancy puts adolescent girls at high risk of
1994). malnutrition, complications of pregnancy,
There is a strong association between and poor birth outcomes, including death.
low pre-pregnancy weight and intrauterine For adolescent girls under the age of 18,
growth retardation,11 as shown in a meta- the risk of dying in childbirth is three times
analysis of 25 studies of maternal anthro- greater than for women between the ages
pometry and pregnancy outcome from 20 of 20 and 29 (UNICEF, 1995). A key strat-
countries (WHO, 1995). Most low birth egy for maintaining or improving the nutri-
weight in developing countries is due to in- tional status and survival of adolescent
trauterine growth retardation, which is pri- girls is, therefore, to delay the first preg-
marily the result of maternal malnutrition nancy.
either before conception or during preg-
nancy. Achieving the weight gain neces- Pregnant women should increase food
sary in pregnancy to ensure adequate fetal intake to support fetal growth and
growth and favorable birth outcomes may future lactation
Note 10 be difficult for women who enter preg- The nutritional demands during preg-
The Body Mass Index nancy underweight and continue to engage nancy are multiple. Maternal fat stores are
(BMI) is an expression in heavy physical labor. Increased energy needed to support fetal growth and future
of the height in intake by underweight women between re- lactation. The amount of weight that
meters divided by
weight in kilograms productive cycles can improve birth weight should be gained during pregnancy de-
squared. and maternal health. pends on several factors, such as pre-
Note 11 pregnancy weight, activity level, and body
Adolescent girls should increase food
Intrauterine growth size.
retardation is evident intake to accommodate the adolescent
The average woman should gain about
in full-term babies “growth spurt” and to establish energy
who are born small-
10 kilograms during pregnancy, but many
reserves for pregnancy and lactation
for-date. Low birth women in developing countries, particu-
weight is also com- During adolescence (the period be- larly in South Asia, gain barely half this
mon among infants tween 10 and 19 years), girls experience amount (McGuire and Popkin, 1990). For
who are premature
(born before 37
rapid physical growth and sexual matura- women who enter pregnancy with good
weeks). tion. Growth occurs faster in adolescence nutritional status, the additional food intake
18 Nutrition of Adolescent Girls and Women of Reproductive Age

required is the equivalent of about 200 sen, 1998), as recently demonstrated in a
kilocalories per day (Institute of Medicine, study in the Gambia (Ceesay et al., 1997).
1990). Examples of a 200 kilocalorie snack In the Gambian study, the number of low
are listed below. birth weight babies declined by almost 40
Π1 medium tortilla, 2 tablespoons percent among pregnant women who re-
refried beans, and ½ tablespoon oil = ceived high-energy biscuits which provided
194 kilocalories or around 1,000 kcal/day after 20 weeks of
Œ 1 small orange, ¼ cup split peas, and pregnancy. Still birth and perinatal mortal-
½ cup rice = 206 kilocalories or ity rates were almost cut in half when
Π1 piece of boiled cassava and 12 supplements were targeted at at-risk preg-
ground nuts = 197 kilocalories nant women.

For women who enter pregnancy un- Lactating women should eat the
derweight, more calories than shown in equivalent of an extra meal per day
the above examples are needed to The National Academy of Sciences’ Sub-
achieve adequate weight gain. committee on Nutrition during Lactation (In-
Inadequate weight gain during preg- stitute of Medicine, 1991) recommends that
nancy is often the result of excessive de- breastfeeding mothers consume around
mands on women’s time and energy. Some 2700 kcal per day (about 500 kcal per day
women are unaware of the need for addi- more than a non-pregnant, non-lactating
tional food during pregnancy. Others delib- woman). The recommendation assumes
erately restrict their diet because they fear that women can draw from fat stores accu-
that a large baby will increase obstetric mulated during pregnancy. Malnourished
risks. Low caloric intake or weight gain dur- women with few fat stores and a poor diet
ing pregnancy is a major factor influencing need more calories than the recommended
birth weight, the single most important de- level to meet their energy requirements dur-
terminant of a child’s chances for survival. ing lactation. For underweight women and
Low birth weight, in turn, is an indirect indi- women with low weight gain during preg-
cator of women’s nutritional status. nancy, the National Academy of Sciences
Trials in a number of countries have recommends a 650 kcal/day increase in en-
examined the effects of food supplements ergy intake during the first six months of lac-
on weight gain and birth outcomes. Al- tation. This is about the equivalent of an
though differences in study designs make extra meal and more than triple the esti-
it difficult to generalize, a recent review by mated 200 kcal/day additional requirement
LINKAGES of the evidence from these stud- during pregnancy. In transitional societies
ies concludes that increased caloric intake where obesity is a problem among certain
among severely (<45 kg and BMI <18.5) populations, women may need fewer addi-
and moderately malnourished women tional calories; however, they still require the
(<50 kg and BMI <23) may lead to in- same high levels of micronutrients.
creases in birth weight. In moderately Mothers with adequate fat stores pro-
malnourished women, food supplements duce milk higher in fat content; conse-
may not result in further improvements in quently, their infants need to suckle less to
birth weight because a larger proportion of obtain sufficient energy. Both well-nour-
weight gain is directed to the mother than ished and mildly malnourished women
to the fetus. For better-nourished women produce breastmilk of adequate quantity
(>50 kg and BMI >23), food supplements and high energy and protein quality. Defi-
are unlikely to affect maternal weight ciencies of some vitamins and minerals
change or infant birth weight. Hence, the will result in lower levels of these nutrients
benefits of food supplements for maternal in breastmilk (Prentice et al., 1994). Only
nutritional status and infant birth weight under extreme conditions, such as famine,
are greatest for undernourished women, are the protein and energy composition of
particularly at times of the year when food breastmilk significantly affected (Perez-
is scarce and/or workload is high (Rasmus- Escamilla, 1995). While most malnour-
Nutrition of Adolescent Girls and Women of Reproductive Age 19

ished women can breastfeed successfully, proving variety in the family diet. Dietary
their own health and nutritional status can approaches for improving micronutrient in-
be compromised if their nutritional stores take include the following:
are depleted to nourish their infants. ΠIncrease daily consumption of fruits
Breastfeeding and maternal nutrition is the and vegetables. Increased daily con-
subject of a separate LINKAGES publication sumption of fruits and vegetables will
(forthcoming). improve micronutrient status of vita-
mins A, C, and B6, as well as calcium
Non-pregnant/non-lactating mothers (National Research Council, 1989). In-
should allow an adequate period (at creased vitamin C consumption from
least six months) between the cessation fruits and vegetables will enhance the
of lactation and the next pregnancy to iron bioavailability from other foods.
replace and build up energy and ΠConsume animal products, if feasible.
micronutrient reserves As noted earlier, animal products are
Overlap of lactation and pregnancy is excellent sources of protein, fat, and
common. Nearly half of the women stud- micronutrients. Many micronutrients
ied in the Philippines experienced overlap are more easily absorbed and/or uti-
(Siega-Riz and Adair, 1993). In a study in lized by the body than those found in
Guatemala, more than 50 percent of fruits and vegetables. The cost of ani-
women breastfed during pregnancy, with a mal products, however, may limit
substantial number (44 percent) breast- their consumption.
feeding into the second trimester (Mer- ΠUse fortified foods, such as vitamin A-
chant et al., 1991). Increasing birth fortified sugar, other vitamin A-fortified
intervals and allowing at least six months products, iron-enriched flour, vitamin-
between the cessation of lactation and the enriched flour, or other fortified
next pregnancy can help to replace and staples, when available.12 As stated in
build up energy and micronutrient re- a World Bank publication (1994), “Suc-
serves. Besides improving women’s im- cessful fortification of a staple food
mediate nutritional and health status, may be one of the most equitable
building up micronutrient and fat reserves health interventions available—espe-
between pregnancies can affect pregnancy cially if the slight cost of the additional
outcomes, as discussed earlier. nutrients is absorbed by the govern-
Note 12
Data from the ment—because it reaches everyone,
Improving Micronutrient Intake
United States illus- including the poor, pregnant women
trate the impor- At all times, adolescent girls and women and young children, populations that
tance of fortification of reproductive age should diversify social services can never cover com-
even for an industri-
alized country. In their diet to improve quality and pletely.”
1977 only 5 percent micronutrient intake ΠUse iodized salt. In some areas of the
of women 19–51 Micronutrient deficiencies contribute to world, nearly everyone is at risk of a
years of age met the women’s undernutrition. They also account
Recommended Di-
micronutrient deficiency. This is the
etary Allowance for maternal and childhood deaths, blind- case in areas where iodine is absent
(RDA) for iron. When ness, and mental retardation. Less severe from the soil. Around 250 million
the additional iron deficiencies impair intelligence and reduce women suffer from iodine deficiency,
in fortified foods was
working capacity and productivity. The two increasing the chances of miscarriage,
included, 12 percent
met the RDA (Popkin primary factors contributing to micronutri- stillbirth, and prematurity. During the
et al., 1996). The dif- ent deficiencies are inadequate intake of early months of pregnancy, iodine de-
ferences were even micronutrient-rich foods and inadequate ficiency can result in cretinism and
greater for thiamin,
riboflavin, and niacin
utilization due to disease or some other mental retardation. Iodine deficiency is
(12 percent vs. 35 factor in the diet. Inadequate consumption the single most common cause of
percent, 27 percent may be a result of cost, limited or sea- mental retardation in the world. In
vs. 43 percent, and sonal availability of food, and inequitable Bangladesh, infants of women with
34 percent vs. 52
percent, respec-
intra-household distribution of food. goiter suffer twice as many neonatal
tively). LINKAGES’ efforts are concentrated on im- deaths as infants of normal women.
20 Nutrition of Adolescent Girls and Women of Reproductive Age

(PROFILES, 1993). The irreversible recommends that women of reproduc-
damage resulting from iodine defi- tive age in the United States who are
ciency can be prevented by the intake capable of becoming pregnant take
of minuscule amounts of iodine in io- 400 µg (0.4 mg) of folic acid daily
dized salt. through fortified foods and supple-
If micronutrient requirements cannot Iron: As mentioned earlier, in develop-
be met through available food sources, ing countries iron deficiency is the
adolescent girls and women of most common micronutrient defi-
reproductive age may need to take ciency among women, resulting in a
supplements containing iron, vitamin A, high prevalence of anemia. During
zinc, and other nutrients to build stores early adolescence, iron requirements
and improve women’s nutritional status increase as girls experience a growth
spurt and the onset of menses. An es-
Some micronutrients are concentrated timated 50 million pregnant and 320
in a few foods. If a woman does not have million non-pregnant women in devel-
access to these foods, cannot afford them, oping countries are anemic (Stoltzfus,
or does not have a taste for them, micro- 1995). Anemia causes extreme fatigue
nutrient deficiencies are likely to occur un- and reduces physical activity, produc-
less she eats fortified foods or takes tivity, and possibly a woman’s capac-
micronutrient supplements. Because of ity to care for her children. While
low caloric intake and the limited number anemia can be cured by daily iron
of fortified foods, fortification may not re- supplementation throughout preg-
sult in substantial increase in the propor- nancy, building iron stores to reduce
tion of women with adequate dietary the less severe but important levels of
intakes. iron deficiency is difficult when supple-
Although pregnant women and, in mentation is provided only during
some programs, postpartum women are pregnancy. Pre-pregnancy supplemen-
generally the target populations for supple- tation, in addition to improving iron
mentation, these efforts are often too late, stores, can prevent poor birth out-
too short, or too limited to bring about the comes (Klebanoff et al., 1991).
desired improvements. ΠThe period of supplementation is of-
ΠMicronutrient supplementation that ten too short. In endemic areas, vita-
begins during pregnancy is often too min A is another micronutrient that
late. Folic acid and iron illustrate the may require longer-term approaches
problem of supplementation that be- to improving micronutrient status and
gins in pregnancy. building stores. The Nepal Nutrition In-
Folic Acid: Some defects in fetal devel- tervention Project-Surlahi II study
opment begin within the first few (NNIPS-II) found that provision of vita-
weeks of pregnancy, before most min A for at least three months prior
women start taking supplements to pregnancy and throughout preg-
(Perez-Escamilla, 1995). Recent evi- nancy was still associated with low
dence indicates that improving folate levels of vitamin A in infants at six
status prior to pregnancy reduces neu- months of age (West et al., 1997).
ral tube defects (such as spina bifida). A study in Bangladesh showed that
Defects must be prevented by the while supplementation of postpartum
27th day of gestation when the poste- women with high-dose vitamin A was
rior neural tube closes. This means associated with improved breastmilk
that neural tube defects will occur be- content at three months, high propor-
fore a woman knows she is pregnant tions of infants still had low vitamin A
and begins taking prenatal supple- levels. The increased vitamin A in the
ments (Molinari, 1993). For this reason breastmilk was unable to reverse vita-
the United States Public Health Service min A deficiency in many infants.
Nutrition of Adolescent Girls and Women of Reproductive Age 21

These infants probably were born with time, LINKAGES is encouraging dialogue on
low vitamin A stores because their the potential for an appropriate multiple vi-
mothers were vitamin A-deficient dur- tamin-mineral supplement for women and
ing pregnancy (Rice et al., 1997). the development of international standards
ΠLimiting supplementation to one or for such a supplement.
two micronutrients diminishes effec- The reader is referred to a separate
tiveness. Many women consume low paper developed by LINKAGES, titled The
levels of micronutrients and experi- Case for Promoting Multiple Vitamin/Mineral
ence multiple micronutrient deficien- Supplements for Women in Developing Coun-
cies throughout their reproductive tries (Huffman et al., 1998), for an exten-
years. Treating only one micronutrient sive discussion of the role of multiple
deficiency may be less effective in im- vitamin/mineral supplements.13
proving overall nutrient status because
of the interactions among nutrients. Pregnant women should take iron/folic
Addressing multiple deficiencies prior acid tablets daily
to pregnancy and lactation will im- The need for additional iron during
prove women’s current health and es- pregnancy is widely recognized. Iron re-
tablish reserves to draw on during quirements increase significantly during
pregnancy and lactation. the second and third trimester of preg-
nancy because of the growth of the fetus
The promotion of micronutrient and placenta and expansion of the
supplements first requires an understand- mother’s blood volume. In the third tri-
ing of the levels of nutrients that should be mester, about 300 mg of iron are trans-
included in the supplement and then an as- ferred from mother to fetus (WHO, 1994).
sessment of the quality control of appropri- In developing countries, approximately
ate supplements. In some places multiple 40 percent of women of reproductive age
micronutrient supplements, although avail- are anemic. During pregnancy the rate of
able, are not suitable. For that reason, it is anemia rises to 50 percent in many coun-
not yet appropriate to promote their wide- tries and much higher in some Asian coun-
spread use unless adequacy and quality tries, as shown in Figure 4. Severe anemia
can be assured. increases the risk of hemorrhage during
LINKAGES supports programs that pro- childbirth, with an estimated 20 percent of
vide women with iron/folic acid tablets dur- maternal deaths attributed to anemia
ing pregnancy and a high-dose vitamin A (Ross and Thomas, 1996).
Note 13 capsule soon after childbirth. At the same
Project believes that
it is important to
test delivery strate-
gies for micronutri-
100 Figure 4.
ent supplements.
Along with Popula- 83
tion Services Inter-
national (PSI),
80 74 Anemia Rates
LINKAGES is testing 65
(hemoglobin <11
the social marketing 60 mg/dl) in

of a multiple-micro-
nutrient supple- 42
Countries with
ment in Bolivia. At
the same time,
40 37 over 3 Million
LINKAGES is promot- Births a Year
ing long-term solu- 20 17
tions to improving
micronutrient status,
including dietary di- 0
India Pakistan Nigeria China
versity and con- Indonesia Bangladesh Brazil United States
sumption of fortified
foods. Source: WHO, unpublished data (from surveys 1985–1990) reported in The Progress of Nations 1994.
22 Nutrition of Adolescent Girls and Women of Reproductive Age

The recommended dosage for iron/ Recent and current studies are helping
folic acid during pregnancy is as follows: to define the impact of improving the sta-
ΠPregnant women should take a daily tus of other micronutrients on pregnant
supplement of iron/folic acid (60 mg of women and their infants. Box 4 illustrates
iron and 250–400 µg folic acid) for six the potential impact of maternal deficien-
months of pregnancy (or 120 mg of cies in folic acid and iron, as well as iodine,
iron/folic acid for three months if vitamin A, and zinc on health outcomes of
women are not reached earlier) mother and child.
(Stoltzfus and Dreyfuss, 1998). Folic Recent evidence suggests that in areas
acid is included in the supplement be- where iron deficiency exists, zinc defi-
cause it helps to prevent anemia and ciency is also common because zinc and
reduces the risk of obstetric complica- iron are found in similar foods (animal
tions. Folic acid deficiency is known to products). Zinc deficiency during preg-
contribute to anemia in some parts of nancy has been associated with an in-
India, western Africa, and Burma creased incidence of low birth weight,
(Sloan et al., 1992). preterm delivery, prolonged labor, prema-

Box 4. Potential Impact of Micronutrient Deficiencies
during Pregnancy on Health Outcomes of Mother and Child
Deficiency Impact on pregnant woman Impact on fetus/infant
Folic acid ΠIncreases risk of anemia ΠIncreases risk of pre-term delivery,
low birth weight, and neurological
Iodine ΠReduces physical capacity by ΠIncreases risk of spontaneous abor-
causing lethargy and fatigue tions, stillbirths, impaired fetal brain
ΠCauses goiter development, infant deaths, cretin-
ΠReduces mental capacity ism, and congenital abnormalities
Iron ΠIncreases risk of death from ΠIncreases chance of prematurity, low
hemorrhage, spontaneous abor- birth weight, and infant mortality
tion, stress of labor, and other ΠPossibly lowers iron status in newborns
delivery complications
ΠReduces work capacity and
economic productivity
ΠHeightens fatigue and apathy
ΠDiminishes ability to fight infection
Vitamin A ΠImpairs immune system; in- ΠMay increase risk of infant vitamin A
creases severity of illness deficiency and reduce birth weight
ΠIncreases risk of maternal death ΠIncreases risk of anemia in infants
ΠIncreases risk of anemia
ΠInhibits normal iron utilization
ΠIncreases risks for some kinds of
ΠCauses corneal disease, dry eyes,
and night blindness
Zinc ΠIncreases risk of prolonged labor, ΠIncreases risk of spontaneous abortion,
intra- and postpartum hemor- low birth weight, intrauterine growth
rhage,and hypertension retardation, prematurity, and deformities
Nutrition of Adolescent Girls and Women of Reproductive Age 23

ture rupture of the membranes, and ma- (1993) estimate that about one-third of the
ternal lacerations (Caulfield, 1996). In a hemoglobin decline during pregnancy in
study in Peru, 60 percent of women exhib- the study population could be attributed to
ited low zinc levels (Zavaleta et al., 1997). vitamin A deficiency. They estimate that
Studies in Guatemala, Nigeria, and Nepal daily low-level supplementation of vitamin
also report low intakes of zinc (less than A could eliminate anemia in one-fourth of
two-thirds of the Recommended Dietary anemic women.
Allowances) (Gibson, 1994). As in the case
of iron, it is difficult to meet zinc require- Lactating women should take a high-
ments during pregnancy through dietary dose vitamin A capsule (200,000 IU) as
sources, unless animal products are con- soon after delivery as possible but no
sumed or foods are fortified. This problem later than eight weeks postpartum to
may be addressed through a multiple vita- build stores, improve breastmilk
min-mineral supplement during pregnancy. quality,, and rreduce
quality educe maternal morbidity
Pregnant women and their infants Vitamin A supplementation of lactating
may also benefit from low-dosage vitamin women was discussed in Chapter II as a
A supplementation. High rates of vitamin A way of improving the vitamin A status of
deficiency during pregnancy have been re- infants. A high-dose vitamin A capsule is
ported in many developing countries. In safe during the first eight weeks postpar-
some areas, night blindness (an inability to tum and can help to improve breastmilk
see in dim light or at dusk) is considered a concentrations and maternal stores. In a
normal condition of pregnancy, often de- rural low-lying area in Nepal, a study con-
veloping during the third trimester. Around ducted in 1991 found that night blindness
10–20 percent of pregnant women in rural occurred in twice as many breastfeeding
South and Southeast Asia are estimated to women as pregnant women (16 percent
experience night blindness during preg- vs. 8 percent) (Katz et al., 1995).
nancy. The extent of night blindness in Af- In addition to vitamin A, maternal defi-
rica and Latin America is unknown (IVACG, ciencies in Group 1 nutrients (thiamin, ribo-
1997). flavin, iodine, selenium, B6, and B12) result
In the Nepal Nutrition Intervention in lower concentrations in breastmilk and
Project, women suffering from night blind- can negatively affect infant health (Allen,
ness were more likely to be anemic and 1994). The micronutrient status of a
underweight and at increased risk of infec- breastfeeding woman and the concentra-
tions and death than those without symp- tion of Group 1 micronutrients in her
toms of night blindness (UNICEF, 1998). breastmilk can be improved if she eats
The results of the Nepal Nutrition Interven- more fruits, vegetables, and animal prod-
tion Project showed that low-dose (23,300 ucts; consumes fortified foods; and/or
IU) weekly supplementation of vitamin A takes a micronutrient supplement.
or beta-carotene for at least three months For Group 2 micronutrients (folic acid,
prior to and during pregnancy lowered ma- vitamin D, calcium, iron, copper, and zinc),
ternal mortality by an average of 44 per- micronutrient supplementation has little ef-
cent (West et al., 1997), reduced night fect on breastmilk concentrations. These
blindness by 38 percent in the vitamin A micronutrients are maintained in the
group and 16 percent in the beta-carotene breastmilk at the expense of the mother’s
group (UNICEF, 1998), and improved iron own stores. Improving the intake of Group
status among both pregnant and postpar- 2 micronutrients is more likely to benefit
tum women (Stoltzfus et al., 1997). Based the mother than the infant.
on a study in Indonesia, Suharno et al.
24 Conclusion

The premise of this paper is that nutri- ΠPoor maternal nutrition perpetuates a
tional status reflects a cumulative process. cycle of malnutrition. Approximately
In the case of severe malnutrition, the con- 19 percent of infants in developing
sequences are often immediate and obvi- countries are born with low birth
ous. But in many cases, the consequences weight (WHO, 1992). As a result of io-
of nutritional neglect may not be readily dine deficiency in the maternal diet,
apparent until they appear in the next gen- around 28 million children are born
eration. each year at some risk of mental im-
Nutritional deficiencies often begin be- pairment (UNICEF, 1997).
fore birth and persist throughout life. For ΠMicronutrient deficiencies persist be-
that reason, this paper recommends prac- cause of inadequate intake of micronu-
tices from conception through the repro- trient-rich foods and inadequate
ductive years. To some, the utilization due to disease or some
recommendations may seem simplistic: other factor in the diet. WHO esti-
breastfeed, eat more, and eat better. How- mates that 183 million children (ex-
ever, the following statistics testify to the cluding those in China) under four
challenge of converting these recommen- years of age are anemic. Between the
dations into practices. ages of 6 and 18 months, iron defi-
ΠExclusive breastfeeding rates in most ciency tends to peak (Lozoff, 1990).
countries are very low. It is estimated
that approximately 1–2 million infant Improving infant and maternal nutri-
deaths from diarrhea and acute respi- tion will require personal behavior
ratory diseases could be averted annu- changes, increased community recognition
ally if more women breastfed and support for interventions to improve
exclusively for about six months and maternal nutrition, strategies for reaching
continued breastfeeding through the young people and involving men, and
first year or more (Huffman et al., greater availability of quality health ser-
1991). vices.
Summary List of Recommended Readings 25

Summary List of Armstrong H. Breastfeed first or give soft foods
first? A review of current recommenda-
Recommended Readings tions: A discussion paper prepared for
UNICEF. New York: UNICEF, July 1993.
Caulfield L, Huffman SL, Piwoz E. Interventions
to improve complementary food intakes of Baker J, Martin L, Piwoz E. A time to act:
Women’s nutrition and its consequences
6–12 month old infants in developing
for child survival and reproductive health
countries: What have we been able to ac-
complish? Paper prepared for the in Africa. Washington, DC: Academy for
Educational Development, 1996.
LINKAGES Project. Washington, DC, 1998.
Bloem MW, dePee S, Darnton-Hill I. New issues
Dickin K, Griffiths M, Piwoz E. Designing by dia-
logue: A program planner’s guide to consul- in developing effective approaches for the
prevention and control of vitamin A defi-
tative research to improve young child
ciency. Food and Nutrition Bulletin. In press.
feeding. Washington DC: Academy for Edu-
cational Development, 1997. Brown K, Dewey KG, Allen LH. Complementary
feeding of young children in developing
Green CP. Improving breastfeeding behaviors:
countries: A review of current scientific
Evidence from two decades of intervention
research. Paper prepared for the LINKAGES knowledge. WHO/UNICEF forthcoming.
Brown KH, Black RE, Becker S, Nahar S, Sawyer
Project. Washington, DC: Academy for Edu-
J. Consumption of foods and nutrients by
cational Development, Forthcoming.
Huffman SL, Baker J, Shumann J, Zehner ER. weanlings in rural Bangladesh. American
Journal of Clinical Nutrition 1982; 36:878–
The case for promoting multiple vitamin/
mineral supplements for women in devel-
oping countries. Paper prepared for the Brown KH, Stallings R, Creed de Kanashiro H,
Lopez de Romaña G, Black RE. Effects of
LINKAGES Project. Washington, DC: Acad-
common illnesses on infants’ energy in-
emy for Educational Development, 1998.
Labbok M, Cooney K, Coly S. Guidelines: takes from breast milk and other foods dur-
ing longitudinal community-based studies
breastfeeding, family planning, and the
in Huascar (Lima) Peru. American Journal of
Lactational Amenorrhea Method—LAM.
Washington, DC: Institute for Reproductive Clinical Nutrition 1990; 852:1005–13.
Cameron M, Hofvander Y. Manual on feeding in-
Health, 1994.
fants and young children. 3rd ed. New York:
LINKAGES. Frequently asked questions on
breastfeeding and HIV/AIDS. Washington, Oxford University Press, 1983.
Ceesay SN, Prentice AM, Cole TJ, Foord F, Poskitt
DC: Academy for Educational Develop-
EME, Weaver LW, Whitehead RG. Effects
ment, 1998.
LINKAGES. Frequently asked questions on on birth weight and perinatal mortality of
maternal dietary supplements in rural
breastfeeding and maternal nutrition.
Gambia: 5 year randomised controlled
Washington, DC. Academy for Educational
Development, forthcoming. trial. British Medical Journal1997; 315:786–
LINKAGES. Facts for feeding on maternal food
Caulfield L. Presentation at Zinc for Child Health
supplementation, forthcoming.
Lutter C. Quantifying the benefits of breastfeed- Meeting. Johns Hopkins University. Decem-
ber 1996.
ing: An annotated bibliography. Prepared
Caulfield L, Huffman SL, Piwoz E. Interventions
for the LINKAGES Project. Washington, DC:
Academy for Educational Development, to improve complementary food intakes of
6–12 month old infants in developing
countries: What have we been able to ac-
complish? Paper prepared for the
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