Introduction to Complementary Feeding

Unit 1: Introduction
Content
● Definition of complementary feeding
● Importance of complementary feeding
● Factors influencing complementary feeding
● Principles of complementary feeding

Unit Learning Outcomes

Upon successful completion of this unit, the learner will be able to:
● know the importance of appropriate complementary feeding for long-term health and
development

Lesson 1 Definition of complementary feeding

Definition of complementary feeding

Authorities such as the European Society for Pediatric Gastroenterology, Hepatology and Nutrition
(ESPGHAN) have suggested that the term complementary food be applied to all solid and liquid foods
other than breast milk or infant formula (ESPGHAN 2008, ESPGHAN 2017).

For this module we will follow the WHO definition whereby:

Complementary feeding is referred to as the process starting when breast milk or infant formula
alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods
and liquids are needed, along with breast milk or a breast-milk substitute (WHO 2013).

The target age range advised for complementary feeding is between 6 to 24 months with a general aim to
prevent malnutrition, as well as to promote optimal growth and development.

Lesson 2 Importance of complementary feeding

Importance of complementary feeding

The infant’s main source of milk is an important determinant of the amount of nutrients that are required
from complementary feeding. Fat intake is an important determinant of energy supply, and energy
requirements remain high throughout the first year of life. Around 4-6 months of age, the infant’s
endogenous iron stores decline and the need for exogenous iron increases rapidly to support the
developing brain and haemopoiesis. The complementary feeding period is when malnutrition starts in
many infants, contributing significantly to the high prevalence of malnutrition in children under-five years
of age world-wide. The period between 6 to 24 months is especially critical in prevention of subsequent
deficiencies (See Figure 6.1).
Deficiencies of vitamins (such as Vitamin A and D), minerals (such as zinc, iodine and iron) and fats (such
as omega-3 fatty acids, alpha-linolenic acid (ALA) and docosahexaenoic acid (DHA)) are still widespread
and are a common cause of morbidity and mortality in infants and young children (Anderson 2012, Poh
2016, Stoltzfus 2004, Wessells 2012, WHO 2009). Poor quality in complementary feeding can be a
contributing factor to this. In addition, poor quality complementary feeding may lead to childhood stunting
(Victora 2010) while high energy intake may lead to high BMI (Pearce 2013, Pluymen 2018). Faltering
growth patterns are predominantly seen between ages 3 to 18-24 months in children from low to middle
income countries (Victora 2010). This highlights the need for timely intervention of appropriate feeding
practices (Figure 6.1). Effects of poor nutrition during this particularly vulnerable period continue
throughout life, contributing to poor school performance, reduced productivity, and impaired intellectual
and social development, and might affect future generations (Victora 2008).

Figure 6.1: Appropriate timely intervention on nutritional practices

Source: Adapted from WHO 2013

Lesson 3 Factors influencing practice of complementary feeding

Factors influencing practice of complementary feeding

Some of the factors that may result in inappropriate complementary feeding include poor maternal
education and low income (Senarath 2012). Inappropriately early weaning has been reported as more
likely to occur in young mothers, and those with one child, residing in urban areas, or with higher
education and higher household income (Manderson 1984). Understanding the reasons for poor
complementary feeding would enable appropriate targeted education to be provided by health care
providers. A Cochrane review affirmed that educational interventions reduced the number of caregivers
who introduced semi-solids to infants before 6 months, improved hygiene practices, increased the
duration of exclusive breastfeeding, and led to an observable improvement in quality and quantity of
complementary foods provided to infants (Arikpo 2018). Factors that could influence complementary
feeding patterns include cultural, socio-economic status, the beliefs of families and, increasingly, social
media (Chalklen 2017, Yamada 2016).
Lesson 4 Principles for complementary feeding

Principles for complementary feeding

In spite of the critical importance of appropriate complementary feeding for optimal child growth and
development, interventions to improve feeding practices in children 6–24 months of age have received
little attention, especially to the quality and quantity of foods given, or whether this period of significant
dietary changes influence later health, development or behavior.

Appropriate complementary feeding principles can be summarised with the acronym “ATAS” below. Click
on each word to see the description of each principle. (Note: Adapted from Complementary feeding:
Report of the global consultation, and summary of guiding principles for complementary feeding of the
breastfed child, WHO 2003):

Adequate
Foods should provide sufficient energy, protein, and micronutrients to meet a growing child’s nutritional
needs.

Timely
Foods should be introduced in a timely manner based on the infant's need for energy and nutrients. Delay
in initiating CF will result in inadequate nutrition while initiating CF too early will lead to problems such as
excessive weight gain.

Appropriate
Foods should be given responsively- consistent with a child's signals of appetite and satiety-, and that
meal frequency and feeding method - actively encouraging the child to consume sufficient food using
fingers, spoon or self-feeding- are suitable for age.

Safe
Foods should be hygienically stored and prepared, and fed with clean hands using clean utensils and not
bottles and teats.

With the above as general guidelines, counselling for optimal complementary feeding should be tailored
to the child based on an understanding of the specific needs of the child such as his/her age, medical
condition, home circumstances and cultural background.

Examples of Thai and Malaysian recommendations for food amounts and types can be accessed at the
following links:
● Malaysia's Ministry of Health Guideline on Baby and Infant Feeding (“Garis Panduan Pemberian
Makanan Bayi dan Kanak-Kanak Kecil”): Click Here.
● Thailand's Ministry of Public Health food-based dietary guideline in Thai language: Click Here.

This module focuses on complementary feeding in the context of the whole diet during the first 2 years of
life in healthy term-born infants living in Southeast Asia. It has the 3 sections covering different aspects of
Complementary Feeding: Under- and Overnutrition; Iron, Iodine and Zinc & Calcium and Vitamins A, B12,
C, and D.

Note: There are variations in complementary feeding recommendation and practices between and within
countries in terms of timing, amount and types of food and feeding practices. The relation between the
introduction of complementary feeding and food allergies will not be covered in this module.

Appropriate complementary feeding principles can be summarised with the acronym “ATAS” (Note:
Adapted from Complementary feeding: Report of the global consultation, and summary of guiding
principles for complementary feeding of the breastfed child, WHO 2012):
Unit 2: Under and Overnutrition
Undernutrition and overnutrition remain a double-burden in many Southeast Asian countries. The Global
Nutrition Report 2018 found that 25.7% of children below 5 years were stunted and 8.7% were wasted.
The report also found that 7.3% were overweight (Global Nutrition Report 2018). Worldwide, WHO
reported that the proportion of children less than 5 years of age who were underweight was 18%, whilst
those who were obese was 11% (WHO 2014).

Inadequate complementary feeding practices – food restrictions due to cultural practices, low frequency of
feeding, insufficient quantities, poor quality and lack of variety of foods – are often associated with
inadequate macro and micro-nutrient intakes, which could result in undernutrition. On the other hand,
inappropriate complementary foods – those high in fat or sugar, sugar-sweetened milk or fruit juices,
unhealthy snack foods, energy-dense and nutrient poor foods – could lead to overweight and obesity.

Source: ENeA SEA own

Content:
● Undernutrition from sub-optimal complementary feeding
● Overnutrition from sub-optimal complementary feeding
● Case studies of undernutrition and overnutrition
● General recommendations for complementary feeding

Unit Learning Outcomes

Upon successful completion of this Unit, the learner will be able to:
● recognize the pattern of sub-optimal complementary feeding leading to undernutrition
● recognize the pattern of sub-optimal complementary feeding leading to overnutrition
● counsel caregivers on appropriate complementary feeding focusing on energy and macronutrient
balance
Lesson 1: Undernutrition

Complementary feeding case study 1: Undernutrition

Adam was born at a term weighing 3.2 kg. He had been a well and happy baby. His mother, Sofia, is a
full-time homemaker. At age 1-year, Sofia is still exclusively breastfeeding Adam and enjoys the bond she
feels every time she nurses him. However, Adam’s grandparents were concerned that their grandson
appears to be rather small for his age. Adam’s weight was 7.2 kg and length 74 cm. Sofia reassured them
that it was familial as both she and her husband were of small stature.

During a routine clinic visit, Adam’s pediatrician expressed similar concerns about his stunted growth and
failure to thrive. Upon plotting his growth on the chart (refer to next page), it was obvious that Adam had
not been growing much in the last 6 months. On examination, Adam was well in himself, but mildly pale,
and had normal developmental milestones. When asked about his dietary intake, Sofia indicated that she
has yet to start Adam on any complementary feeding. She had serious concerns about allergies as atopy
ran in both sides of the family. She and her husband wanted to delay any exposure to possible dietary
allergens for as long as they could. Moreover, she still enjoyed nursing Adam and said that it was what
made her feel like a mother the most.

Sofia consented for some blood investigations to be done for Adam. Results showed that he was anemic
and had low vitamin D levels.

Adam's full blood count;

● Hb 8.2 g/dL (low; normal 11.3-14.1 g/dL)
● MCV 62.1 fl (low; normal 70-85 fl)
● MCH 21 pg (low; normal 23-31 pg)
● MCHC 32.4 g/dL (normal 32-36 g/dL)
● RDW 18.2% (elevated; normal 12.3-14.1%)

His albumin and calcium levels were borderline low-normal.

After explaining those results to Sofia and her husband, the pediatrician proceeded to counsel them about
appropriate complementary feeding and referred them to a nutritionist for further help.
Growth Chart
 Figure 1: Adam's growth charts showing normal height and reduced weight for his age.

Comment:
Adam was born close to the 50th percentile (median) of the WHO 2006 weight-for-age growth standards.
His current weight of 7.2 kg, below the 3rd percentile (-2 Z-score), is 2 standard deviations lower than his
birth weight. This is because Adam is still being exclusively breastfed at 1 year old, and has missed out
on the nutrition from complementary feeding, which should have started from around 6 months of age.
The pediatrician needs to reassure Sofia that the risk to allergies from complementary foods is low, and
could be identified if allergies do occur, and that delaying the introduction of complementary feeds does
not reduce the risk of allergies. The benefits of complementary feeding need to be emphasized, especially
in terms of the insufficiency of breast milk alone for an infant more than 6 months old. Breastfeeding can
be continued but should not be the sole source of nutrition for a child who is more than 6 months of age.

The nutritionist should guide Sofia on how to provide proper complementary foods for Adam, stressing the
importance of food diversity, quantity and quality. However, as Adam has never had any complementary
foods since birth, the nutritionist may need to provide some guidance on how to start complementary
feeding and gradually increase the quantity and frequency of feeding, depending on how Adam takes to
the foods given to him.

Although he will need to progress quickly in terms of complementary feeding, Adam may have feeding
difficulties as he has not tried any food before, and has missed the critical period for flavor acceptance at
age 4 - 7 months. The parents should be advised to immediately start feeding Adam with a variety of
foods (e.g. rice porridge, fruits, vegetables, meats, etc) in order to increase his exposure to different
tastes and texture. Starting with soft and smooth purees may be necessary, but moving on towards more
lumpy textures and then finger foods as soon as possible is recommended so that Adam will learn the
different textures and types of food.

Adam’s anemia is likely due to iron deficiency, considering that he has hardly any source of iron in his
diet. He would require iron supplements at this stage while establishing a healthier diet (refer to Unit 3).
The low vitamin D level is likely to be caused by a combination of nutritional deficiency as well as limited
exposure to sunlight. It is recommended that babies who are exclusively breastfed be supplemented with
400 IU of vitamin D per day. It is important that Sofia understands the importance of both macro-nutrients
and micro-nutrients in Adam’s diet and their effect on his growth and development; and that inappropriate
complementary feeding practices could lead to malnutrition (refer Malnutrition Module).

Lesson 2: Overnutrition

Complementary feeding case study 2: Overnutrition

Zara was born at term weighing 3kg. She was the first child of Diana and her husband, and the first
grandchild on both sides. Zara enjoyed plenty of attention from the day her parents brought her home
from the hospital as both sets of grandparents lived in the same neighbourhood. Both Zara’s parents
worked in their own advertising company and Zara’s mother managed to exclusively breastfeed her till 6
months old. She was being cared for, alternatingly between the grandparents when her parents were at
work.

During a recent routine clinic visit, the pediatrician expressed concern about Zara’s weight. At 1-year-old,
she weighed 15.5kg. She was bright and bubbly but preferred to be carried rather than to crawl or walk
around on her own. She also had some caries in the few teeth that had erupted. Diana reported that Zara
disliked having her teeth cleaned.

When asked about her diet, Diana revealed that Zara had been started on complementary feeds from the
age of 5 months. They felt that milk was not sufficient for her and she was always looking longingly at
their food during mealtimes. Now, Zara takes 3 meals a day with snacks in between. Her grandparents
find that she is happier with food in her hands, and she particularly enjoys sweet cereals and biscuits. Her
favorite drink is blackcurrant juice. She generally dislikes plain water. Most of Zara’s meals are cereals.
She occasionally eats porridge, mostly plain as she dislikes the texture of meat or vegetables.

During the long clinic consult, Zara began throwing tantrums and her parents were quick to offer her
cream biscuits, which immediately cheered her up. Observing all this, Zara’s pediatrician counselled
Diana and her husband about proper complementary feeding, and made an appointment with both sets of
grandparents for similar counselling.
Growth Charts
 Figure 2: Zara's growth charts showing normal height and increased weight for her age.

Comment:
Zara was born of normal weight at 3kg, which is between the 15th and 50th percentile (just slightly below
the median) of the WHO 2006 weight-for-age growth standards. Weighing 15.5kg at 1 year old, Zara was
way above the 97th percentile (or +3 Z-score). This was likely due to her eating habits, which had
developed since she started complementary feeding at 6 months old, whereby it was noted that she ate 3
meals a day with snacks in between. Moreover, she was frequently offered additional tidbits/snacks,
which were often used to pacify her. Zara was also eating non-nutritious plain porridge and sweetened
fruit juices, with carbohydrates being almost the exclusive source of calories.

In counselling about complementary feeding, the pediatrician should stress on the importance of dietary
diversity, and that Zara should be fed with different food groups, including meat, fish, poultry and eggs, as
well as fruits and vegetables. Reducing the amounts of high calorie-dense foods, such as sweet cereals
and biscuits, as well as eliminating sweetened beverages from the diet should also be emphasized.
If the problem persists, gradual changes can be advised during more regular consultations.
Lesson 3: General Recommendations

Recommendations
Energy requirement in early childhood differs by age and gender. Table 1 below shows the
recommendations for energy requirements in early childhood.

Table 1: Recommendations for energy requirements in early childhood.

Source: ENeA-SEA own, adapted from National Coordinating Committee on Food and Nutrition 2017.

The amount of energy needed increases as a child grows older. However, the amount of energy that can
be obtained from breast milk decreases when the baby reaches 6 months of age (Figure 3). Hence, it is
important that the extra energy that the baby needs is obtained from complementary foods.
Complementary foods are vital to fill the energy gap and other nutrients that cannot be provided by breast
milk alone in a breastfed infant for optimal growth after the first six months of life.

Figure 3: Energy required by age and the amount provided for by breastfeeding.
Source: WHO 2009.
In Figure 4, the gap in the amounts of energy, protein, iron and vitamin A in approximately half a litre of
breast milk is as much as 90% for iron, and needs to be filled by complementary feeds. This emphasizes
the importance of complementary foods, which are essential to fill not only the energy gap but also
nutrient gaps from just feeding on breast milk alone.

Figure 4: Gaps to be filled by complementary foods for a breastfed child 12-23 months.
Source: WHO 2009.

Fats are important in the diets of infants and young children because they provide essential fatty acids,
facilitate absorption of fat-soluble vitamins, and enhance dietary energy density and sensory qualities.
Although there is debate about the optimal amount of fat in the diets of infants and young children, the
range of 30-45% of total energy has been suggested. For breastfed children, the percentage of fats from
complementary foods needed to achieve this range depends on the amount of breast milk intake and its
fat content (WHO 2001).

As muscles and tissues grow at a rapid rate after birth, protein requirements are highest. Therefore, the
lack of dietary protein during this period could result in stunting. It has been found that protein deficiency
is one of the main causes of stunting in South East Asian children. Safe levels of protein intake is shown
in Table 2. However, recent studies have shown that there is an association between high protein intake
during the first 2 years of life and obesity later, due to adiposity rebound (Koletzko B. et al 2009 , Lind,
Mads V.; Larnkjær, Anni; Mølgaard, Christian; Michaelsen, Kim F 2017). As such, avoiding high-protein
intake in early life may be a measure that could decrease the incidence of obesity in later life (Table 2).
Table 2: Safe levels of protein intake.

Source: ENeA-SEA own, adapted from National Coordinating Committee on Food and Nutrition 2017.
Table 3: Practical guidance on the quality, frequency and amount of food to offer children 6-23 months of
age who are breastfed on demand.

Source: WHO 2009.

Dietary diversity is also an important factor to consider with regards to complementary feeding. Minimum
dietary diversity should include at least four of the following 7 food groups:
1. Grains, roots and tubers.
2. Legumes and nuts.
3. Dairy products (milk, yoghurt, cheese).
4. Flesh foods (meat, fish, poultry, liver/organ meats).
5. Eggs.
6. Vitamin A-rich fruits and vegetables.
7. Other fruits and vegetables.
Figure 5: Examples of food groups and their relative proportions for complementary feeding.
Source: ENeA-SEA own.
Unit 3: Iron, Iodine, Zinc & Calcium
Content
● Introduction and Case Study
● Requirement of Iron, Iodine, Zinc, and Calcium
● Deficiency of Iron, Iodine, Zinc, and Calcium
● Common Food Sources of Iron, Iodine, Zinc, and Calcium
● Dietary Recommendation
● Rational for Screening and Supplementation

Unit Learning Outcomes

Upon successful completion of this unit, the learner will be able to:
● identify feeding practices associated with risk of developing deficiencies of iron, iodine, zinc, and
calcium
● identify common food sources of iron, iodine, zinc, and calciu
● recognize the clinical presentation of deficiencie
● counsel caregivers to provide an optimal supply of micronutrients from nutritious complementary
foods

Lesson 1 Important Minerals: Introduction and Case Study

Lesson 2 Requirement and Deficiency of Iron, Iodine, Zinc, and Calcium

Nutrient Requirement during Complementary Feeding Period

The table shows the daily requirement of iron, iodine, zinc, and calcium in infants and toddlers.

Table 1: Daily requirement of iron, iodine, zinc, and calcium in infants and toddlers
Source: WHO 2004

Deficiencies of Iron, Iodine, Zinc, and Calcium

Deficiencies of iron, iodine, zinc and calcium have consequences for infants and young children. The
following table summarizes the clinical signs and consequences from deficiency of each micronutrient.
Clinical manifestations of calcium deficiency are not common because of the large skeletal reserve and
homeostatic mechanisms.
Source: Khambalia A, Aimone A, Zlotkin AH. 2016 , Krebs NF, Hambidge KM. 2016, Weaver CM, Heaney
RP. 2014
Lesson 3 Food Sources of Iron, Iodine, Zinc, and Calcium

Common Food Sources of Iron, Iodine, Zinc, and Calcium

Common food sources of iron, zinc and calcium are shown in Figure 1. Marine fish and iodized salt are
important sources of iodine. However, the iodine content may vary.
There are important dietary enhancers and inhibitors which alter nutrient absorption when consumed with
other foods. For example, heme iron is better absorbed than non-heme iron, and iron absorption is
enhanced by vitamin C-containing foods. Phytate is an inhibitor of zinc and calcium absorption. Lactose
increases the absorption of calcium.

Figure 1. Common food sources for iron, zinc, and calcium

Sources: ASEAN Food Composition Database Electronic version 1, February, 2014, Nutrient values of
Thai foods 2001
Lesson 4 Dietary Recommendation and Supplementation of Important Minerals

Dietary Recommendation

Figure 1. Dietary recommendation

Key Statements
Essentials of Unit 3
● After 6 months of age, iron, zinc and iodine levels in breast milk are decreasing. Appropriate
complementary foods are crucial to prevent micronutrient deficiencies.
● Iron deficiency is usually found concomitantly with other micronutrient deficiencies.
● Common micronutrient deficiencies such as iron, zinc, iodine, and calcium can lead to
compromised immune response, impaired growth, and long-term neurodevelopmental outcomes.
● Iron and zinc are usually found in similar food sources such as liver, pork, and beef.
● Marine fish and iodized salt are important sources of iodine.
● Milk, cheese, and yoghurt are rich in calcium.
● It is important to bear in mind dietary enhancers and inhibitors that may alter nutrient
bioavailability.
● Infants aged 6 months or beyond should eat foods rich in iron and zinc every day.
● Iodine fortified foods should be provided in iodine deficient areas.
● Follow-up formula or cow’s milk should be supplemented in children aged 1-2 years to provide
adequate calcium and some micronutrient intakes.
● Proper screening and supplementation are important to prevent micronutrient deficiencies.
Unit 4: Vitamins
Content
● Case studies of vitamin A and C deficiencies
● Current situations of vitamin B1, B12 and D in SEA
● Discussion of important food sources and eating patterns regarding each vitamin
● Dietary requirement of vitamins
● Practical advice for counselling

Unit Learning Outcomes

Upon successful completion of this unit, the learner will be able to:
● identify feeding practices associated with deficiencies of vitamin A, B1, B12, C, D
● identify food sources for common nutrients
● recognize the clinical presentation of deficiencies
● counsel caregivers to provide an optimal supply of vitamins from nutritious complementary foods

Introduction to Vitamins
Background

Introduction graphic: Chaba discusses about feeding fruits to her 6-month-old son with doctor Tawan.
Source: ENeA SEA own

Vitamins are essential for growth, development, and prevention of illness in infants and young children.
Appropriate complementary feeding practices will lead to adequate intakes of vitamins from various
sources of foods.

Lesson 1 Vitamin A

Case study
A 1-year-old Thai girl was brought to the hospital due to weight loss of 1 kg in 1 month. One month prior,
she had had a diagnosis of measles infection. After recovering from measles, she had a poor appetite
and 600-700 kcal/day of caloric intake with 0.5 g/kg/day of protein, preferring potato chips and jelly to
main meals. Weight was 6 kg, height was 69 cm. Physical examination revealed dry and scaly skin. The
conjunctivae of both eyes had keratinized plaques (Bitot spots). Plasma retinol level was 0.5 µmol/L.
This patient presented with second degree protein-energy malnutrition with post-measles infection, which
increases the risk of vitamin A deficiency. She had signs of vitamin A deficiency in both eyes. The
diagnosis was confirmed by low plasma retinol level that was less than 0.7 µmol/L. The patient
management plan involved dietary counselling to reach the RDA for energy and all nutrients, especially
liver, fish liver oil, milk and other dairy products, egg yolk, green vegetables, yellow fruits and vegetables
as well as avoiding snacks and sweets. Moreover, vitamin A should be given at the dose of 200,000 IU
orally at day 1, 2 and 14, followed by 2,000 - 3,000 IU per day, until recovery.

Discussion
Vitamin A is essential for normal vision, reproduction, cell and tissue differentiation, and functions of the
immune system. (Nelson 2015 a).

Sources of vitamin A and eating patterns

Children who usually consume snacks and sweets without any nutritious complementary foods may be at
risk of vitamin A and other nutrient deficiencies.

Figure 1 Food sources of Vitamin A: human milk, liver, fish liver oil, dairy products, egg yolk and
carotenoids (Nelson 2015 a, AAP 2014 a). Carotenoids are organic pigments that are produced by plants,
algae, several bacteria and fungi. They make many fruits and vegetables deeply colored yellow, orange,
or red. Carotenoids from plants are in green vegetables, yellow fruits and vegetables.
Source: ENeA SEA own
Lesson 2 Vitamin B1 and B12

Introduction: Vitamin B1 situation in SEA

● Thiamin deficiency is one of the nutritional problems in SEA.
● People in SEA have been commonly found to be thiamin deficient due to regularly consuming
foods containing tannin (some ferns, teas, and betel nut), which is a thiamin antagonist.
● Thiaminases, which act during food storage or during passage through the gastrointestinal tract,
may contribute to thiamin deficiency. People living in SEA and often consuming raw fish (with or
without fermentation) and raw shellfish containing thiaminases are at risk for thiamin deficiency
(Nelson 2015 b and Modern 2014 b).
● There was a reported outbreak of thiamin deficiency among 15 commercial fishermen in the Gulf
of Thailand. Due to limited resources, they had only seafood and polished rice for almost two
months prior to symptoms (Doung-ngern P 2005).
● In Laos, the practice of postpartum food avoidance is very common. Nearly all mothers (96.6%)
had insufficient thiamin intake from the survey. Infantile thiamin deficiency also occurs mainly in
breastfed infants whose mothers have inadequate thiamin intake. (Barennes H 2015)

Discussion
Sources of vitamin B1 and eating patterns

Figure 1. Food sources of Vitamin B1: meats including poultry, pork (especially lean), fish, rice, oat,
wheat, legumes, and whole-grain cereals.
Source: ENeA SEA own

● One of the major causes of thiamin deficiency is the loss through the rice cooking process (when
rice is repeatedly washed, and the cooking water is discarded). Some children frequently
consume only polished rice without other meat leading to thiamin deficiency.
● Infants and children may be at higher risk of thiamin deficiency when they have inadequate
thiamin intake in complementary food and exclusive breastfeeding from mothers who have
thiamin deficiency.

Introduction: Vitamin B12 (Cobalamin) situation in SEA

● There is limited information on the prevalence of vitamin B12 deficiency because of the lack of
data from national surveys from SEA. However, many studies indicated that the prevalence of
vitamin B12 deficiency in this region was low.
● The study from Myanmar revealed that less than 1% of 391 anaemic adolescent schoolgirls had
low vitamin B12 concentration (Htet et al., 2016). Also, a report from Vietnam showed that there
 were around 3%- 4% of women of reproductive age having plasma B12 and holotranscobalamin
concentrations indicative of deficiency (Vu et al., 2009).

Discussion
Sources of vitamin B12 and eating patterns

Figure 2. Food sources of Vitamin B12: from animal only (meat, fish, poultry, organ meat, egg, seafood
and breastmilk).
Source: ENeA SEA own

● Since the level of vitamin B12 in breastmilk usually correlates with maternal diet and maternal
serum B12 concentration, an infant and young child receiving only breast milk from a strict
vegetarian mother without any supplementation, a malnourished mother and a mother with
untreated pernicious anemia are at risk of vitamin B12 deficiency.
● Additionally, infants who exclude animal products from their diet or the vegans also have a higher
risk of deficiency (Carmel R 2014, Shah D 2016).
Lesson 3 Vitamin C

Introduction: Case study-scurvy

A 2-year-old Thai girl, namely “Kaew”, was brought to the hospital because she refused to walk for a
month. She also had a low-grade fever and gingival bleeding. Kaew’s mother said that her child usually
had rice, boiled egg, soy bean sauce and UHT milk 4-5 boxes/day but refused to eat any fruits and
vegetables. The attending pediatrician examined Kaew and found she was irritable. Anthropometry
showed weight 8.7 kg, height 81 cm. Follicular hyperkeratosis, perifollicular hemorrhage, gingival swelling
and swelling of both knees were found. Her clinical manifestations were illustrated below.

Figure 1 Clinical manifestations of scurvy

Source: ENeA SEA own
Comment:
In this case, Kaew suffered from scurvy that was induced by inappropriate complementary feeding due to
consuming only overcooked food and UHT milk. All clinical signs were a result of abnormal collagen
causing bleeding in the skin, mucous membranes, joints and muscles. Xrays of both legs showed the
classic presentation of scurvy including Wimberger ring sign (osteopenia of the epiphysis which is
surrounded by a white line of calcification) and white line of Frankel (transverse metaphyseal line of
increased density). These signs correlate with low plasma vitamin C level.
After Kaew received the treatment with vitamin C, there was a drastic improvement of her general state
including her gait.

Discussion
Sources of vitamin C and eating patterns

Figure 2 Food Sources of Vitamin C: fresh fruits and leafy vegetables

Source: ENeA SEA own

● Ascorbic acid is easily destroyed by oxygen and heat, contact with iron and copper, and exposure
to light. These lead to infants who consume predominantly heat-treated (ultrahigh-temperature or
pasteurized) milk or unfortified formulas and not receiving any fruits being at significant risk of
vitamin C deficiency.
● Even though vitamin C is not recognized as a problem nutrient among people living in developed
countries, some infants and young children in Thailand and other Southeast Asia countries are
still faced with scurvy.
● Ratanachu-Ek S reported 28 cases of scurvy in pediatric patients aged 10 months to 9 years
(median age of 29 months), presenting with inability to walk and tenderness of lower limbs. All
were fed with well-cooked food without supplementation of fruits or vegetables, and the vast
majority of them drank 5 boxes/day of UHT milk (Ratanachu-Ek S 2003).
● It is well known that prolonged storage, processing and overcooking of foods can destroy vitamin
C. Infant and young children who consume these food groups and do not receive any fresh fruits
and vegetables as well as supplementation might be at risk of scurvy. These include (WHO
1999):
➔ Infants fed unsupplemented cow's milk in the first year of life
➔ Children fed predominantly heat-treated (ultrahigh-temperature or pasteurized) milk or
unfortified formulas and not receiving fruits and fruit juices

Source: WHO (1999) . Scurvy and its prevention and control in major emergencies.
Available from: http://www.who.int/nutrition/publications/emergencies/WHO_NHD_99.11/en/.
Lesson 4 Vitamin D

Introduction: Vitamin D Status in SEA

● Vitamin D has recently received attention in Southeast Asia. It has been assumed that sufficient
sunlight in the region would ensure adequate vitamin D levels for most people. However, limiting
sun exposure are increasingly caused by lifestyle changes, cultural and religious reasons.
● Children at higher risk of vitamin D deficiency include exclusively breastfed infants and children
with dark skin pigmentation. Infants are born with low vitamin D stores and are dependent on
breast milk as the source of vitamin D in the first few months of life. As the vitamin D content of
breast milk is dependent on maternal vitamin D status and is often low, and sun exposure may be
restricted, infants are particularly vulnerable to vitamin D deficiency.
● The South East Asian Nutrition Surveys (SEANUTS) were conducted in 2010-2011 in Indonesia,
Malaysia, Thailand and Vietnam in country-representative samples of 16,744 children, aged 0.5
to 12 years (Poh BK et al. 2016). Serum 25-hydroxy-vitamin D (25(OH)D) was measured in a
subgroup of 2,016 children. In Malaysia and Thailand, urban children had lower 25(OH)D than
those in rural areas. Regional differences after adjusting for age and sex were demonstrated in all
countries. The percentage of children with adequate 25(OH)D (≥75 nmol/L) ranged from as low
as 5% (Indonesia) to 20% (Vietnam). Vitamin D insufficiency (<50 nmol/L) was as high as 40 to
50% of children in all countries.
● The high prevalence of vitamin D insufficiency in the tropical SEA countries suggests a call for a
systematic approach to successfully combat this problem.
● For more information regarding vitamin D studies in Malaysia, please refer to “Update on Vitamin
D in Human Nutrition” (ILSI SEAR Malaysia 7th Scientific Seminar, 12 November 2013) by the
provided link: http://ilsisea-region.org/event/update-on-vitamin-d-in-human-health/

Discussion
Sources of Vitamin D and Eating Patterns

Figure 1 Sources of vitamin D

Source: ENeA SEA own
Food
● Very few foods in nature contain vitamin D. The flesh of fatty fish (such as mackerel, salmon, and
tuna) and fish liver oils are among the best sources.
● Vitamin D is also found in liver and egg yolk. Liver has been an important complementary food in
SEA, but its popularity is waning among younger parents because of the unconfirmed fear that it
might contain accumulated toxins.
● Some mushrooms (button, oyster, Chinese and wood ear mushrooms) with enhanced levels of
vitamin D2 from being exposed to ultraviolet light are also available but are rarely incorporated in
children’s meals.
● Only 10% to 20% of vitamin D requirement is acquired from the diet. For many whose dietary
diversity is limited, food intake itself rarely provided the Dietary Recommended Intakes (DRIs) for
vitamin D.
● There is no adequate information available for SEA countries on nutritional intake of vitamin D as
most local food composition tables do not contain vitamin D data.

Sun exposure
● Ultraviolet (UV) B radiation with a wavelength of 290-320 nanometers penetrates uncovered skin
and converts cutaneous 7-dehydrocholesterol to pre-vitamin D3, which in turn becomes vitamin
D3. Season, time of day, length of day, cloud cover, skin melanin, and sunscreen are among the
factors that affect vitamin D synthesis.
● For SEA population, dependence on sunlight for vitamin D has become increasingly difficult for
many since aesthetic, skin damage and skin cancer risk have become a concern. Furthermore,
lifestyle changes (fewer outdoor work and activity, more transportation in covered vehicles) are
progressively limiting sun exposure. In addition, some traditions and religions favor the measures
of protection from the sun (long gloves, masks, scarves, and hijabs) and atmospheric pollution
obscures the sun in many urban areas.
Lesson 5 Dietary requirement of vitamins

Dietary requirement of vitamins

Dietary reference intake values for vitamin A, B1, B12, C and D form WHO are provided in Table 1.

Table 1 Dietary reference intake values for vitamin A, B1, B12, C and D in the different age groups

Remark: All dietary reference intake values shown in the table are Recommended Dietary Allowance
(RDA).
Source: FAO/WHO (2004) Vitamin and mineral requirements in human nutrition.
Available from: http://www.who.int/nutrition/publications/micronutrients/9241546123/en/

There are general similarities for the different RDAs in a regional review on RDAs in SEA (Barba anesson

Lesson 6 Practical advice for HCPs to counsel parents

Practical advice for HCPs to counsel parents

● Children should be advised to avoid snacks and sweets to have adequate energy and nutrients
from complementary foods.
● Complementary food high in vitamin A, including liver, dairy products, egg yolk, green vegetables
(e.g. spinach, yellow vegetables e.g. pumpkins and carrots), and fruits (e.g. papayas and
mangoes) should be regularly consumed.
● Adequate thiamin intake can be achieved with a varied diet that includes meat, non-polished rice
and wholegrain cereals. Minimal washing of grains can minimize thiamin losses during
preparation.
● Parents should be advised to provide complementary foods containing meat, eggs, and dairy
product (from animal) to avoid B12 deficiency.
● Providing complementary foods rich in fresh fruit and vegetables daily is the best measure to
prevent scurvy.
● Parents should try to preserve the maximum levels of vitamin C during meal preparation.
➔ Using a small amount of water to prepare foods because vitamin C is usually lost if
vegetables are washed in large amounts of water
➔ Avoid cutting vegetables into small pieces before cooking
➔ Cook at high temperature for a short period to decrease the oxygen exposure time which
causes greater vitamin C losses.
● At-risk populations for vitamin D deficiency should be encouraged to change their lifestyles to
increase sunlight exposure. However, for infants less than 1 year old, 400 U vitamin D
supplementation should be considered instead (AAP 2008 and WHO 2017).
● Fatty fish, liver, egg yolk and foods or dairy products fortified with vitamin D should be
consumed.d Cabrera 2008).