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We Are What We Eat

The Mission Hospit al

Durgapur

Jump to a Healthy Start

Before this year is over, 10.9 million of the world’s children < 5 years of age will die of conditions that would be largely prevented by Optimal Infant and Young Child Feeding .

Before this day is over 3,500 children will be lost from such causes.

Malnutrition in the Developing World

Malnutrition in the Developing World

Malnutrition in the Developing World Factors that contribute to hunger and malnutrition
Political disruptions and natural disasters War Refugees Sanctions Floods, droughts, mudslides, hurricanes Inequitable food distribution

MOTHE R AND CHILD SURV IVAL
MMR 301/100,000 live births IMR* 58/1000 live births Child Mortality 85/1000 Children Rate(Under 5 years)
A whopping 45.9 per cent of India's under-three kids are underweight, 39 per cent are stunted, 20 per cent severely malnourished, 80 per cent anaemic while infant mortality hovers at 67 per 1,000. More than 6,000 Indian children below five years die everyday due to malnourishment or lack of basic micronutrients like Vitamin A, iron, iodine, zinc or folic acid. Overall, India hosts 57 million or more than a third - of the world's 146 million undernourished children.
Vijayaraghavan

NUTRI TI ON PRO BLEMS IN INDIA
WHO IS AT RISK?? PREGNANT WOMEN LACTATING WOMEN INFANTS . PRESCHOOL CHILDREN ADOLESCENT GIRLS ELDERLY SOCIALLY DEPRIVED (SC & ST Communities)
Vijayaraghavan

WHAT ARE THE COMMON PROBLEMS?
• POO R W T. GA IN LO W BIRT H WE IGH T • GRO WTH DURIN G PR EGN ANCY FALT ERI NG • CE D • PEM • MI CRO NUTR IEN T • MI CRO NUTR IEN T DE FI CI EN CIES DE FI CI EN CIES  FLUOROSIS, LATHYRISM

NUT RITION P ROBLEMS IN INDI A
WO MEN CH ILDREN

 DIET RELATED CHRONIC DISEASES OBESITY, CARDIOVASCULAR DISEASES, DIABETES
Vijayaraghavan

Nutrition in the Life Cycle

Achieving Optimal Infant and Young Child Feeding: A Global Responsibility

Is it really possible to promote Optimal Infant and Young Child Feeding in the 21st Century?

b

Yes!!!

Optimal Infant and Young Child Feeding e n e r g mixe y Matern exclusive d
al Nutriti Gestation on and Health B B
Breastfeeding

Fetal Nutrit ion and Healt h

Infant and Young Child NutritionFamily Special Transition al foods

foods

feed ing Complementary (weaning)
feeding

C

? ?

child’s age

? ?
©Adapted by Wellstart from
WHO, 1998

Optimal Infant and Young Child Feeding e n e r g mixe y Matern exclusive d
al Nutriti Gestation on and Health B B
Breastfeeding

Fetal Nutrit ion and Healt h

Infant and Young Child NutritionFamily Special Transition al foods

foods

feed ing Complementary (weaning)
feeding

C

6?mo

child’s age

? ?
©Adapted by Wellstart from
WHO, 1998

Optimal Infant and Young Child Feeding e n e r g mixe y Matern exclusive d
al Nutriti Gestation on and Health B B
Breastfeeding

Fetal Nutrit ion and Healt h

Infant and Young Child NutritionFamily Special Transition al foods

foods

feed ing Complementary (weaning)
feeding

C

6?mo

child’s age

2-7? you
©Adapted by Wellstart from
WHO, 1998

Characteristics of Infants
 Digestion,

absorption & metabolism is similar to older children except:
– Pancreatic amylase deficient until around 4th

month – Fat absorption is inadequate – Stomach acidity is low

Calories
 Milk

: sole source  110-120 Kcal/kg/day = 0-2 mos.  8.5 Kcal/kg = 2-6 mos.  105 Kcal/kg BW = 6-12 mos.  Cow’s/Human milk = 67 kcal/100ml  Infant formula = 64-72 kcal/100 ml

Calories
Reasons for increased need:  Rapid growth rate  Great heat loss due to large body surface area  Activity of the infant

Protein
 RDA:

6 mos = 2.2 g/kg

12 mos = 2.0 g/kg  Human milk = 1.2 gms/100 ml  Cow’s milk = 3x more CHON Disadvantage:
– increase blood urea – high renal solute load – AA pattern different from human milk

Protein
Deficiency:  Marasmus  Mental retardation
– irreversible – Poor reading/writing skills – Less able to grasp knowledge

Carbohydrate
 Prevent

hypoglycemia & ketosis  Lactose: sole source  Improves CHON, Ca 2+ & Mg 2+ absorption  Provides galactosides: brain & nerve cell formation  Laxative  Human milk = 42% of total caloric value  Cow’s milk = 20%

Fat
 Must

constitute 35-55% of TER  Essential fatty acids: linoleic & alphalinolenic acid (omega 3 series)  EFA: retina & brain  Ratio of lenoleic to alpha-linolenic : 5-15  Breastmilk = 30-40 mg/ml  Cow’s milk = 10-15 mg/ml

Vitamins
 Vit.A
– RDA is 325 g retinol equivalents – Adequate: 850 ml BM w/ 170 IU/100ml – Formulas: 750 IU/100 kcal

 Vit.C
– Gen low content in both CM & BM – BM: 5 mg/ml – Vit. C –rich beverages @ 6 mos to get at least

30 mcg daily

Vitamins
 Vit.

D

– Sunlight exposure

 Thiamine
– RDA: 0.4 mg/day

 Riboflavin
– Same as thiamine

 Niacin
– 0.25/100 kcal

Vitamins
 Vit  Vit.

B12 E

– 0.5 mcg during 1st 5 mos. Of life – 1/3 of adult RDA – 0.7 IU/100kcal for artificially-fed infants

 Vit.

K

– All infants: single IM/oral dose ASAP post-

partum

Minerals
 Iron
– 0.15-0.2 mg/100 ml – 4th month: RDA 15 mg/day – Iron fortification of milk formula after 4-6 mos.

 Calcium
– BM = 33mg/100ml; Ca:P ratio is 2.3 – Milk formula = 1.2 only

 Phosphorus
– Intake of infants is quite low

Water & Electrolytes
 70-75%

of BW  Mostly extracellular: prone to dehydration  Special attention: fever, polyuria, diarrhea & during hot weather  Na+ : K+ not ≥ 1.0  Na+ : K+ = at least 1.5 Cl-

Factors Affecting Nutritional Status
 Mother’s

attributes  State of nutrition during pregnancy  Feeding pattern  Weaning & supplementation  Illness  BM: rich in long-chain polyunsaturated fatty acids  LCPUFA – component of structural lipids in membranes of all organs

Indications of Good Nutrition
 Body  BMI:

weight gain

wt. in kg/ height in m2
 MUAC(mid

upper arm circumference)  Behavioral development  Bowel movements  Sleeping habits

Indications of Good Nutrition
 Developed

motor coordination  Well-formed muscles  Grave’s study
– Vigor in any activity – Establishes interaction w/ mother at a distance – Less irritable

RDA @ 1 year
 Green

leafy = 2 & ½ cups; yellow = 2 tbsp  Vit C-rich foods = 2 tbsp  Other fruits & vege = 2 tbsp each for both  Fat = 2 tsp  Meat, fish, poultry = 1 matchbox size  Milk = 2 cups

RDA @ 1 year
 Eggs

=¼  Dried beans = ¼ cup  Nuts = 2 tbsp  Rice (lugaw) = 2 ½ cups  Rootcrops (mashed) = 2 tbsp  Sugar = 6 tsp *RDA : pls refer to handouts

NUTRITION IN PRESCHOOL AGE

 Early

preschool age

– Toddler – 1-3 years old

 Late

preschool age

– 4-6 years old

RDA by FNRI

1–3 years 4–6 years

Ag e

Body Wt. Kg.
13 18

Cal
1 310 1 640

Protei n

Calciu m

gram s
26 32

grams
0.5 0.5

Iron mg.
6 8

Retinol Equivale nt Act. 250 325

Vit. A I.U.
1800 2300

B1 mg.
0.7 0.8

B2 g.
0.7 0.8

Niaci n mg. Equi 9 v.
11

Vit. C mg.
35 45

ENERGY
 55%

- metabolic activities  25% - physical activities  12% - growth needs  9% - fecal loss (90- 100Kcal/kg) FNRI estimate 1350 Kcal/day – 1-3 yr old children 250 Kcal/day – 4-6 yr old children

Protein Energy Malnutrition

(PEM)
 Marasmus  Kwashiorkor

Protein
 FAO

recommendation - 1.5- 2g/kg body wt.

Deficiency symptoms  Retarded growth  Anemia  Pigmentary changes of hair and skin  Edema (kwashiorkor)

Vitamins
 vitamin

A  vitamin C  vitamin B1  vitamin B2

Minerals
 Calcium

and iron  Trace elements - iodine - fluoride -zinc

Zinc deficiency  Dwarfism  Retarded sexual development

TYPES OF AT- RISK FACTOR
BIOLOGICAL  Mother  Young child ENVIRONMENTAL  Cultural  Socio- economic  Geographic- climactic  Miscellaneous EARLY WARNING SIGNALS  Community  Individual

Reasons for nutritional vulnerability
    

His mother may have another baby to whom she lavishes more attention He gets a small share of whatever food is on the table in proportion to his size He may choose from a common dish at the table foods that are not Nutritionally protective The previous major source of his protein intake in which is breast milk maybe suddenly withdrawn from him because mother is pregnant Mother may go back to work and he is left in the care of others

Food Groups
1. 4. 7.
Vegetables

Food Recommended
Amount
2 servings, one should be leafy or yellow 2 servings, one should be Vit. Crich

Allowed Foods

All except strongly flavored for the younger children; chopped or cut in pieces All; skin, seeds and long fibers, and if any removed All except for whole kernel corn and malagkit

Fruits

Rice or substitute

1 ½ to 2 ½ cups cooked

10. 11. 13. 15. 17.

Milk Meat or substitute Fat Sugar Desserts

At least 2 cups 3-5 servings more if milk is refused; liver twice a week As needed 1 tablespoon As needed or made from food allowance

Chopped or ground lean meat liver, chicken; flaked fish; eggs; mashed beans; mild cheese

Cream, butter or margarine Sucrose, syrup, jams or jellies Plain pudding, gelatin, ice cream, cakes and cookies

SCHOOLCHILD

CHARACTERISTICS
      

Between 7 and 12 years Slow steady growth Increase body proportions Enhanced mental capabilities More motor coordination Body reserves are being laid down in preparation for the increased needs during the adolescent stage Growth rates vary within this period

NUTRIENT ALLOWANCES
 

His nutritional needs differ from that of an adult on the ff. points – He is actively growing (girls at prepuberty stage experiences Spurts of growth) – He is constantly active – He is changeable in his attitudes towards food – He cannot afford to eat foods poor in essential nutrients

RDA classification of Filipino school children
– 7 – 9 years old – 10 – 12 years old / pre-

adolescence

Age 7 -9 10 -12

Energy 80 – 90 Kcal/kg 70 – 80 Kcal/kg

Protein 8% 35 gm 45 – 49 gm

Vitamins and minerals Vitamin C 55mg 600 – 700 mg 65-70 mg 70 – 80 mcg Calcium Iodine

FEEDING THE SCHOOL CHILD
1.

Psychological factors
– – –

Let him feel responsible for his own well-being Make him accountable for his diet Parents should take time out and spend time with the children

“ A HAPPY CHILD IS A HEALTHY CHILD”

2. School environment
Goals of School feeding programs
– To improve the nutrition of school children by furnishing

them wholesome food at the lowest possible cost – To aid in strengthening the nutrition and health education program of the public schools – To foster proper eating habits

3. Food Preference

FEEDING PROBLEMS
Inadequate meals 2. Poor appetite 3. Sweet tooth 4. Fast foods
1.

1.

Clinical examination
– – – –

INDICATIONS OF GOOD NUTRITION
3. Anthropometric examination – Weight-for-age – Height-for-age – Weight-for-height

EENT test SE UA PE

2.

Dietary analysis
– Diet history/food

record – General Eating habits – Nutrient intake

FOODS TO BE INCLUDED DAILY
Food item
Milk, whole Meat, fish, poultry Dried beans and nuts Enriched rice and other cereals Rootcrops Fat- butter, margarine, oil Green and leafy vegetables Vitamin C-rich foods Other fruits and vegetables Eggs Sweets

Serving
One or more cups 3 or more servings 1/3 cup or more, cooked 4 or more cups, cooked 1 or more medium pieces 6 teaspoon ½ cup or more One or more 2 medium fruits or 8 or more tbsp vegetables 2-3 a week 6 teaspoons

Food Allergies
 Result

in immunologic reactions  Caused by common foods
– eggs, milk, peanut, soy, wheat, fish, tree nuts, shellfish

 Lead

to

– diarrhea, vomiting, wheezing, anaphylactic shock,

abdominal pain, gas, hives, skin rashes

 Can

be avoided (at least in part)

– slowly introduce new foods – delay introduction of common food allergens until at

least 1 year of age, longer depending on allergen

Fruit Juice
 Too

much of a good thing?

– Nutrient density and displacement of nutrients – Diarrhea – Dental cavities

 Know

the limits

≤ 8 oz diluted 100% fruit juice (4 oz fruit juice and 4 oz water)

Feeding Infants Cow Milk
 Not

recommended during the first year.  Fluid cow milk consumption can lead to:
– GI bleeding – Iron deficiency – Displacement of nutrients

 Other

dairy products  at 8 months

– Yogurt and cheese

Benefits of Healthy Gut Flora

Infants with a healthy gut flora (i.e. one dominated by beneficial bacteria, such as Bifidobacterium and/or Lactobaccillus) have reduced risk of infection, disease and later development of food allergy. Decreased prevalence of eczema in high risk infants given probiotics/lactobacillus. Certain species of gut bacteria down regulate inflammation

     

Diarrhea/gastoenteritis Serious Respiratory Infections Recurrent Ear Infections Obesity Type I Diabetes Allergic disorders

Conditions for which nonoptimally fed infants and young children are likely be at an increased risk:
     

Childhood Leukemia and lymphoma SIDS NEC Lowered IQ Chronic GI Tract disorders Mortality between 28 days and 1 year of age

Influences on Food Choices
Cognitive Habits Comfort foods Cravings Advertising Social factors Nutritional value Health beliefs

Influences on Food Choices
Culture

Beliefs and traditions Religion “Indian diet”

Getting off to the right start: infants
 Calorie

needs are highest in infancy; met w/milk  Respect hunger and satiety cues  Delay introduction of complimentary foods (juice, cereal) till 6 months  Juice—≤4 oz/day of 100% juice; work towards mashed whole fruit after 6-9 months; juice in a cup, not in bottle  Cereal: 1 T/2 oz breastmilk or formula; 1-2 times a day; not in bottle  Milk: whole for 1st 2 years; 24 oz a day by 12 months

Baby and table foods:
 Evaluate

infant’s readiness for solids  Begin with vegetables, then fruits, then meats  No more than 1 new food every 3-5 days  1 tsp at first, then move up to 2 and beyond; maximum of 5 T. of any one item  after age of 12 months, 1 tablespoon/year of age of any one food is a serving --ex. 1.5 tablespoon carrots, 1.5 T chicken, 1.5 T green beans for 18 mon old

Table foods:
 Mashed

up and appropriate consistency for baby’s age, abilities and #teeth  Sit at family table, no TV  Respect satiety cues  Know parent’s and child’s jobs (Satter):  “It is the parent’s responsibility to provide a variety of healthy foods. It is the child’s responsibility to decide whether they are going to eat and how much to eat.”

Model the right plate:
 Make

it colorful—eat the rainbow  www.5aday.com  2/3 vegetables, fruit, whole grains, beans  1/3 protein source

Eating out:
 Eat

at home as often as possible  Teach children about correct portion sizes, “Mighty Kids” meals too big for anyone!  Avoid supersizing yourself—model  Avoid “all you can eat” buffets

Eating and behavior:
 Being

a good role model is #1  Do not use food as a reward or withhold treats as a punishment—these elevate the position of food in the child’s mind  Instead, reward with time spent with caregiver  Do not refer to certain foods as good or bad  Do not over-regulate child’s eating

Child’s self-regulation:
Park et al, 1994

Caregivers as providers of opportunities

Caregivers as direct instructors

Caregivers as interactive partners

Caregivers as interactive partners:
 Caregivers

transmit messages and values about eating and food by their interaction with their children  By your words and actions, children will learn what foods are healthy  “Junk” foods—mixed message if you say they’re junk food but then eat them  Caregivers’ attempts to lose weight, preoccupation with food or body may lead to same in child (Thelen, Stice et al, Francis et al)

Caregivers as direct instructors:
 Show

children how to choose healthy foods in grocery store, at restaurant  Reinforce children for making healthy choices  If you overeat or exhibit “out of control” eating, they may, too (Cutting et al)

Caregivers as providers of opportunities:
 Limiting

intake of and/or access to foods of lower nutritional value  Providing healthy food choices  Children have natural preference for sugar, salt and fat  Caregivers may respond with controlling feeding strategies—either to restrict or to pressure child to eat

Parents as direct instructors, cont:
 This

promotes further problems  Disordered eating  Enticement of the “forbidden”  Overweight in child may result, esp. girls  Too much food presented decreases child’s ability to self-regulate, encourages overeating (Birch, Rolls et al)  Appropriate portion size is important

Picky eaters:
 Research

demonstrates that it takes 10-15 times of offering a new food before an infant or toddler makes a decision  Try, try and try again  Make new food the 1st food toddler tries  Eat it yourself, talk positively about it  Allow preschoolers to help choose and prepare new foods

Toddler and preschooler eating habits:
 Growth

rate slows after 12 months, so they do not need as many calories to grow  100-120 cals/kg of body weight in 1st year  ~100 cals/kg of body weight from 2-3 yrs  90 cals/kg of body weight from 4-6 years  They don’t need as many calories as they did when they were infants  Make the calories they do need healthy

Toddler/preschooler diet:
 One

tablespoon/year of age is a serving of any one food item  Switch to lowfat or skim milk at age 2  3 meals and 2 snacks a day  Same diet as is recommended for adults is recommended for kids 2 and older (<30% of calories from fat, <10% from sat. fat)

Eating habits of young children: What do we know?
J Amer Diet Assn 1/04; Vol. 104 Number 1

 Gerber-sponsored

Study or FITS  30% of infants have solid food introduced before the recommended 4-6 months of age  31% of toddlers ages 12-24 months have a mean energy intake exceeding their estimated mean energy requirement  Intake of “adult” high energy density/low nutritional value foods is prevalent among toddlers

“Feeding Infants and Toddlers”

FITS Highlights, cont:
 18-33%

of 7-24 month olds consume no servings of vegetables, and 23-33% consume no fruits  French fries are the most commonly consumed vegetable beginning at 15 months of age

FITS Highlights, cont:
 ~50%

of 7-8 month olds consume some type of dessert, sweet or sweetened beverage  Infants and toddlers in WIC are more likely to consume 100% fruit juice (vs. whole fruit), desserts, sweets and fruit drinks than their non-WIC peers

Eating habits of young children: Why do we care?
 Rapid

infant weight gain is associated with increased risk of being overweight at age 4 (Guo)  Mothers of overweight young children are unlikely to view their child as such (Baughcum et al)  Restrictive parental feeding practices are associated with increased child eating and weight status (Birch, Fisher)

Most children do not “outgrow” extra weight:
 Children

who are at-risk for overweight or overweight at any time during the preschool years are more than 5 times more likely than their peers to be overweight 12 year olds (Nader et al)  >75% of overweight and obese 10-15 year olds will become obese adults (Whitaker et al)

Childhood obesity affects more than looks:
 Many

medical complications --cardiovascular --endocrine --pulmonary --orthopedic --liver

Childhood obesity complications, cont:
 Psychosocial

complications most common --poor self-esteem --decreased quality of life --depression --teasing and bullying  Children prefer normal weight peers to be their friends more often, even at age 5

Role of early child care professionals:
 Child

Care Champions Best Practices  CO Physical Activity and Nutrition/ CO Dept. of Health document  7 “Best Practices” for prevention of childhood overweight  Goals which are attainable, realistic and proven to be effective

#1: Model healthy eating behaviors
 When

you eat the same foods as the children you serve, you are saying, “Do as I do” rather than “Do as I say”  Sit with children at meals, eat same food  Try new foods with children  Start with “adventurous” eaters to model trying new foods to picky peers  Avoid negative facial expressions, body language or words re: food served

#2: Integrate nutrition/PA into curricula
 Provides

repeated exposures to topics  “Normalizes” healthy eating and PA  Emphasizes their importance daily  New PAT curriculum, High Five, Low Fat, preK school wellness resource guide, Movement Exploration  Other ideas listed in CC Champions

#3: Practice division of responsibility (Satter)
 Caregiver’s

job=what to offer child to eat  Child’s job=how much, what and whether to eat  Caregiver provides regularly scheduled meals and snacks at appropriate intervals  Allow children to help in preparation, table setting, serving and clean up if possible  Offer a variety of healthy foods repeatedly  Avoid verbal or nonverbal prompts to eat

#4: Provide the best start for infant feeding:
 Breastfeeding,

developmentally appropriate 1st foods offered at the right time, recognition of hunger and satiety  Promote breastfeeding to all parents

How can you help?
 Be

welcoming to breastfeeding moms  For 1st 6 months, offer only breastmilk to breastfed infants unless mom wishes otherwise  Provide private place to nurse for moms before they leave their infant and when they return  Provide adequate and safe storage space for breastmilk (COPAN resource kit)

Appropriate 1st foods:
 In

addition to delaying solids till 6 months…  Avoid added sugars (desserts, cookies, cakes, fruit drinks, pop) and do not add sugar, molasses, honey, syrup to baby food, cereal, milk or water  Do not allow “grazing” from plate, cup or bottle

#5: Become partners in prevention
 Partner

with the parent to avoid giving children mixed messages about eating and physical activity  Communicate feeding policies to parent  Alert parent to feeding problems quickly and enlist their ideas  Use resources/newsletter to educate parents on common feeding issues

#6: Promote physical activity and free play
 Young

childhood is key time when PA behaviors, preferences are being set  Infants should play interactive games and safely explore their environment  Toddlers need safe opportunities to learn running, jumping, throwing, kicking; refine skills as preschoolers  Toddlers need ≥30 min of structured PA and ≥60 min of free play  Preschoolers need ≥60 min structured PA and ≥60 min of free play

Physical activity, cont:
 No

TV/screens for children ≤2 years old  1-2 hours/day of educational programs for those >2, preferably movement-promoting  Dance or move to music instead of TV  Use Hip Hop to Health, Jr, Movement Exploration, other resources

Examples in Child Care Champions:
 How

to provide activity opportunities for infants  What counts as structured physical activity?  What counts as free play?  How to ensure play spaces are safe  How to create an indoor activity space

#7: Plan meals w/childrens’ nutrition needs in mind
 It

takes time and planning  Use guidance learned during conference  Use Child and Adult Care Food Program Guidelines and 2005 Dietary Guidelines  Provide written menus to parents  Educate parents on balanced meals if they send food  Establish positive eating environment

Positive eating environment:
 Children

should help with food prep and cleanup as developmentally able  Children should sit with caregiver and each other  Chairs, table, utensils suitable for children  Pleasant social and learning experience with no conflict  Food not a reward or punishment  Allow sufficient time to eat (>20 min)

Common Disorders
 Diarrhea  Vomiting  Constipation  Colic  Measures:
– Determine underlying cause – Maintain water & electrolyte balance – Modify milk formula

Summary:
 Young

children are establishing eating and activity patterns for life  You have an important role to play in promoting breastfeeding as best 1st feeding, promoting and providing opportunities for healthy eating and activity for young children, families

There is always more to come!

Thank you

OK135S053

OK135S057

And we know what to do

Optimal Infant Feeding and Maternal Health