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Feeding#kb02 tvm

  1. 1. DEPT. OF KAUMARABHRITYA GOVERNMENT AYURVEDA COLLEGE THIRUVANANTHAPURAM KERALA Certificate This is to certify that Dr. LEKSHMI M.K has worked on ‘’ A STUDY ON THEEFFICACY OF PRIYALAMAJJADI YOGA IN THE GROWTH AND DEVELOPMENT OFCHILDREN DURING COMPLEMENTARY FEEDING’’ for her thesis as a partialfulfillment for the degree of Doctor of medicine (Ayurveda) - Kaumarabhritya of the universityof Kerala, under my supervision and guidance. Under nutrition and under weight is most prevalent among children under fiveyears of age, especially in the weaning and post weaning period. Improper complementaryfeeding is the root cause of the condition even though many interventions are at hand. Thepresent study seeks the evidence for an ideal and palatable complementary food formulation,Priyalamajjadi. The findings are valuable and have contributed substantially to the presentknowledge on the subject. Dr. Lekshmi.M.K is a talented,, active research worker. She is hard working,reliable and good at conduct and character. I strongly recommend this thesis to be forwarded to the adjudicators for acceptance. Dr. S.K. RAM ACHANDRAN MD ( Ay) Professor & Head
  2. 2. Declaration I here by declare that this thesis work entitled ‘A STUDY ON THEEFFICACY OF PRIYALAMAJJADI YOGA IN THE GROWTH AND DEVELOPMENT OFCHILDREN DURING COMPLEMENTARY FEEDING’ is a bonafide record of theresearch work done by me under the guidance of DR. S.K. RAMACHANDRAN,Professor and Head, Department of Kaumarabhritya, Government AyurvedaCollege, Thiruvananthapuram, and that no part there of has been presentedearlier for any Degree or Diploma or similar title of any other university.Thiruvananthapuram Dr. Lekshmi M.K
  3. 3. Acknowledgement I with utmost courteousness and gratitude submit my relentless praises to theAlmighty for having bestowed his grace and blessings over me to accomplish this task ofcompleting the thesis. I express my sincere gratitude to Dr.S.K Ramachandran, Professor and Head, deptof Kaumarabhritya, for the immense ideas shared, which formed the entire basis of thework I express my gratitude to Dr. M.R Vasudevan Nampoodiri, Principal, GovtAyurveda College, Thiruvananthapuram, for providing necessary requirements in time. My sincere thanks to staff members of the Immunization unit, Govt. AyurvedaCollege Hospital for Women and Children, Poojappura for their cooperation and supportto conduct the study smoothly. My thanks to the Faculty and staffs of Pharmacy, Government Ayurveda College,Thiruvananthapuram, for their immense cooperation for preparing the study formulation. I remember with utmost gratefulness my colleagues, family and friends, for theirtimely help and support for completing the thesis in time. Above all, I dispense my love to those fifty-five giggling weeping cute littleparticipants who made the study a reality. Dr. Lekshmi M.K
  4. 4. ContentsList of tables iList of figures iiiList of abbreviations ivAbstract vIntroduction 1a. Need and significance of study 2b. Aim and objectives of the study 3c. Hypothesis 4d. Contents of the thesis 4The literature reviewChapter 1 – Growth and Development 51.1 Infant growth and development during the first two years of life 61.2 Assessment of growth and development 10Chapter 2 – Child nutrition 212.1 Introduction and background 212.2 Nutritional requirements 21Chapter 3 – Breast feeding 303.1 Nutritional considerations in the first year of life 313.2 Human-milk intakes 313.3 Composition of human milk 323.4 Some important approaches in infant feeding 393.5 Contraindications of breast-feeding 413.6 Formula Feeding 42Chapter 4 – Complementary feeding 444.1 Relevant definitions 44
  5. 5. 4.2Ideal time to start complementary feeding 454.3 Research findings on the duration of exclusive breast feeding 474.4 Complementary feeding practices 494.5 Complementary foods 514.6 Improved weaning practices 544.7 First-Year Feeding Problems 594.8 Feeding During the Second Year of Life 64Chapter 5 – Growth and development – Ayurvedic Perspective 695.1 Growth and development 705.2 Factors controlling growth and development in a child 715.3 Factors that enhance strength and immunity 765.4 Assessment of growth and development in Ayurveda 785.5 Classification of children 82Chapter 6 – Infant and young child feeding in Ayurveda 866.1 Importance of Food 866.2 Infant and young child feeding in Ayurveda 886.3 Improved weaning practices in children – Ayurvedic perspective 976.4 The main weaning disorders described in Ayurveda 1036.5 Certain dietetic aspects considered especially for children 104Chapter 7 – Evaluation of the formulation under consideration 1057.1 Ingredients of the formulation 1067.2Therapeutic action of the formulation 118Methodology of researchChapter 8 – Methodology of research 1198.1 Objectives of the study 1198.2 Research approach 1198.3 Research design 1208.4 Reasons for selecting the design 1228.5 Variables 1238.6 Selection criteria 1238.7 Randomization 1248.8 Dropouts 124
  6. 6. 8.9 Duration of study 1248.10 Method of preparation of the study drug 1258.11 Data collection 1268.12 Assessment criteria 1278.13 Intervention schedule 1288.14 Follow up 1298.15 Data analysis 1298.16 Ethical considerations for the study 130Observation, analysis and interpretationsChapter 9 - Observation, analysis and interpretations 1319.1 Data relating to Socio demographic factors 1329.2 Data relating to weaning practices noticed in the sample 1369.3 Analysis and Interpretations 1379.4 Data relating to interventions and its efficacy including analysis and Interpretations 1399.5 Assessment of development in all the groups 1569.6 Assessment of morbidity 158Discussion, summary and conclusionChapter 10 - Discussion, summary and conclusion 16010.1 Discussion and summary 16010.2 Statement of the major findings 16310.3 Mode of action of the formulation 16710.4 Strength and weakness of the study 16910.5 Suggestions for future research 16910.6 Conclusion 170References 171Bibliography 175Annexure – 1 177Annexure – 2 183Annexure – 3 184
  7. 7. List of tablesSerial No Title PageTable 1.1 Developmental milestones in the first two years of life 6Table 1.2 Emerging patterns of behavior during the first year of life 8Table 1.3 Formulas for approximate average height and weight of normal infants and children 12Table 1.4 Dental development 17Table 2.1 Approximate energy values of the body fuels per gram 22Table 2.2 Calorie requirements during the first year of life 23Table 2.3 Protein requirements in children 24Table 3.1 Human milk composition 32Table 3.2 Energy requirements of breast fed infants 33Table 3.3 Iron Requirements of breastfed infants 38Table 5.1 Different ceremonies and their inference 80Table 6.1 Feeding schedule of newborn in Ayurveda 94Table 6.2 Comparison of commonly used animal milks and breast milk 95Table 6.3 Comparison of Nutrient composition in various milks/100ml 95Table 6.4 Dilution of cow’s milk 96Table 6.5 Dilution of buffalo’s milk 96Table 6.6 Opinions regarding the time to start weaning 97Table 7.1 Nutritive value of honey per 100 g 113Table 7.2 Nutritional value of edible portion of rice per 100 gram 116Table 8.1 Study cluster intervention schedule 128Table 8.2 Control cluster intervention schedule 129Table 9.1 Age wise distribution of the participants 132Table 9.2 Sex wise distribution of the participants 133Table 9.3 Domicile wise distribution of the participants 133 i
  8. 8. Table 9.4 Distribution of participants as per educational status of the parent 134Table 9.5 Economic status wise distribution of participants 134Table 9.6 Religion wise distribution of the participants 135Table 9.7 Dietary habits wise distribution of the participants 135Table 9.8 Initial month of complementary feeding 136Table 9.9 First complementary feed given 136Table 9.10 Food with vegetable in the first month of weaning 137Table 9.11 Data relating to length – Group A 139Table 9.12 Data relating to weight – Group A 140Table 9.13 Data relating to head circumference – Group A 141Table 9.14 Data relating to chest circumference – Group A 142Table 9.15 Data relating to mid upper arm circumference – Group A 143Table 9.16 Data relating to length – Group B 146Table 9.17 Data relating to weight – Group B 147Table 9.18 Data relating to head circumference – Group B 148Table 9.19 Data relating to chest circumference – Group B 149Table 9.20 Data relating to Mid Upper Arm Circumference – Group B 150Table 9.21 Data relating to length – Group C 152Table 9.22 Data relating to weight – Group C 153Table 9.23 Data relating to head circumference – Group C 154Table 9.24 Data relating to chest circumference 155Table 9.25 Data relating to mid upper arm circumference 156Table 9.26 Developmental assessment chart for all groups 157Table 9.27 Morbidity conditions prevailed 158 ii
  9. 9. List of figuresSerial No Title PageFigure 9.1 Age wise distribution of the participants 132Figure 9.2 Distribution of participants as per educational status of the parent 134Figure 9.3 Economic status wise distribution of participants 134Figure 9.4 Initial month of complementary feeding 136Figure 9.5 First complementary feed given 136Figure 9.6 Length gain in Group A 144Figure 9.7 Weight gain in Group A 144Figure 9.8 HC gain in Group A 145Figure 9.9 MAC gain in Group A 145Figure 9.10 CC gain in Group A 145Figure 9.11 Length gain – Group B 151Figure 9.12 Weight gain – Group B 151 iii
  10. 10. List of abbreviationsCG Control groupSG Study groupBT Before treatmentAT After treatmentD DifferenceL LengthW WeightHC Head circumferenceCC Chest circumferenceMAC Mid arm circumference iv
  11. 11. Abstract Under nutrition and problems associated with complementary feeding are of greatconcern in the field of pediatrics. The trial was proposed to study the efficacy ofPriyalamajjadi Yoga during complementary feeding by using specific parameters forgrowth and development. The study was conducted at the Immunization unit,Government Ayurveda College Hospital for Women and Children, Poojappura,Thiruvananthapuram. Children between the age of four to 24 months and startedcomplementary feeding were included in the study. Total 55 children of the criteria wereselected and assigned to three groups as per the stage of complementary feeding and rateof growth for the age. Each group is again divided into one study and control clusters.The study cluster in each group received the food formulation Priyalamajjadi in definitedose along with a proper dietary advice suitable for the age to follow. The controlclusters received the dietary advice alone. The responses of both clusters in each groupwere obtained and analyzed statistically. Final assessment of length, weight, headcircumference, chest circumference and mid arm circumference showed that thePriyalamajjadi yoga is effective for the proper growth and development of children duringcomplementary feeding in the first year of life. It is also effective in reducingconstipation associated with complementary feeding during the period. v
  12. 12. Department of Koumarabhritya Introduction The dimensions of health are always changing. In the present era, health isconsidered “not mainly an issue of doctors, social services, and hospitals. It is an issue ofsocial justice”. World Health Organisation broadly defines health as “a state of completephysical, mental, and social well being, not merely an absence of disease or infirmity”.The above concept of health envisages several spiritual, emotional, vocational, andpolitical dimensions. Presently exploring medical requirements are, most of the timeincapable to fulfill these views. Therefore, Ayurveda, popularly known as the Indiansystem of medicine, which is considering the living systems in its physical, mental, andspiritual levels, gains high acceptance in the western scientific world. The medicalsystem is giving equal importance to preventive, curative, and prophylactic aspects ofmedicine, there by maintaining the sensitive homeostasis of the body, which is thefoundation of happy and wholesome existence of every living being. Kaumarabhritya, is the branch of Ayurveda which elaborates pediatrics and evenmore. It covers all aspects from genetics to dietetics in children. It gives a completeguidance for reproductive child health care, infant and young child feeding practices andadolescent care. The science had a very precise way to make out the health and ill healthof the child and the proper growth and development. It also has immunization methodsbased on its principles. Introduction 1
  13. 13. Department of Koumarabhritya a. Need and significance of the study Good health depends on an adequate food supply, which in turn depends on asound agricultural policy, a good food distribution system and proper health education. Ahealthy younger generation with duly developed body, mind and brain is the bedrock fora good future. Every child in every part of the world has the potential to grow anddevelop as long as his and her basic needs are met. Adequate supply of essential nutrientsrequired as per age is the most important factor for the proper growth and development. Infant and young child feeding is the subject of great concern in the field ofnutrition since malnutrition in early childhood has serious, long-term consequencesbecause it I impedes motor, sensory, cognitive, social and emotional development.Malnourished children are less likely to perform well in school and more likely to growinto malnourished adults, at greater risk of disease and early death. One in three of theworlds malnourished children live in India. Where, around 46 per cent of all childrenbelow the age of three are too small for their age, 47 per cent are underweight and at least16 per cent are wasted. WHO Global Strategy for Infant and Young Child Feeding, 2002 advocatesexclusive breastfeeding for the first six month with the introduction of local and highnutrient complementary foods after six months while continuing breastfeeding to twoyears and beyond. After six months of age a child needs high-energy and high nutrientfoods that are rich in vitamin A, vitamin C, iron and other important minerals, in additionto breast milk. Children are more physically active and they continue to grow rapidlyduring the second half of first year. Introduction 2
  14. 14. Department of Koumarabhritya The introduction of complementary foods is a time of transition when childrengradually becomes used to eating semi solid and solid foods. The nutritional role ofmother’s milk in the second year is inversely related to the adequacy of thecomplementary diet. Improper nutrition during weaning and post weaning period is theroot cause of malnutrition in children. This is a period of great dilemma, stress andhumiliation to the child and is associated with many disorders like constipation, diarrhea,colic etc. This physical and mental turmoil along with the need for a highly nutritious dietpoints out the importance of an ideal weaning food. The present study aims to find thesolution for this grave problem. b. Aim and objectives of the study The study intend to find the efficacy of the formulation Priyalamajjadi in thegrowth and development of children during complementary feeding. The study aims notonly to the efficacy of the formulation; as a broad objective, the ideal time for itsadministration is also considered. Nationally accepted international parameters are usedfor the assessment. These standards depict normal growth under optimal environmentalconditions and can be used to assess children everywhere, regardless of ethnicity, socio-economic status and type of feeding Introduction 3
  15. 15. Department of Koumarabhritya c. Hypothesis Null Hypothesis: Priyalamajjadi yoga is not effective in the proper growth anddevelopment of children during complementary feeding. Alternate Hypothesis: Priyalamajjadi yoga is effective in the proper growth anddevelopment of children during complementary feeding. d. Contents of the thesis Title of the thesis is ‘A study on the efficacy of Priyalamajjadi yoga in the growthand development of children during complementary feeding.’ The thesis consists of the following parts. I. Introduction II. Literarature review III. Methodology of research IV. Observation, analysis and interpretation V. Discussion, summary and conclusionIntroduction 4
  16. 16. Department of Koumarabhritya Chapter 1 Growth and Development “Growth is the most commonly used functional outcome measure of nutrientadequacy. This outcome is particularly useful for screening purposes because the normalprogression of growth is dependent on many needs being met and many physiologicalprocesses proceeding normally. However, this strength also betrays this outcome’sprincipal weakness since abnormal growth is highly non-specific. The single or multipleetiologies of abnormal growth are usually difficult to ascertain confidently. This is mostapparent in the differential diagnosis of failure to thrive found in most standard pediatrictexts.”(1) Growth and development is a continuous process which begins at the conceptionand ends at maturity. Growth, in short, may be defined as the increase in the size of anindividual due to increase in number and size of the cells. ‘Development’ is maturation of function. It depends on maturation andmyelination of the nervous system and denotes acquisition of a variety of competenciesfor optimal functioning of the individual. (2). The term growth denotes increase in size orbody mass and development is the emerging and expanding capacities of the individual toprovide progressively greater faculties in function. They are unique characteristic of Literature review 5
  17. 17. Department of Koumarabhrityachildren and any obstacle in this process at any stage can possibly result in aberration ofgrowth and / or development.1.1 Infant growth and development during the first two years of life Physical growth, maturation, acquisition of competence, and psychologicalreorganization occur rapidly during the first year. These changes do not occur smoothlyover time but rather in discontinuous bursts that qualitatively change the childs behavior.Physical growth during this period is rapid; growth parameters and normal ranges forattainable weight, length, and head circumference presents an overview of milestones inthe domains of gross motor, fine motor and cognitive development (3).Table 1.1 Developmental milestones in the first two years of life (4)Milestone Average Age of Developmental Implications Attainment(months) Gross MotorHead steady in sitting 2.0 Allows more visual interactionPull to sit, no head lag 3.0 Muscle toneHands together in 3.0 Self–discoverymidlineAsymmetric tonic neck 4.0 Child can inspect hands in midlinereflex goneSits without support 6.0 Increasing explorationRolls back to stomach 6.5 Truncal flexion, risk of fallsWalks alone Exploration, control of proximity to 12.0 parentsRuns 16.0 Supervision more difficult Fine MotorGrasps rattle 3.5 Object useReaches for objects 4.0 Visuomotor coordinationPalmar grasp gone 4.0 Voluntary releaseTransfers object hand to 5.5 Comparison of objectshandThumb–finger grasp 8.0 Able to explore small objectsTurns pages of book Increasing autonomy during book 12.0 time Literature review 6
  18. 18. Department of KoumarabhrityaScribbles 13.0 Visuomotor coordinationBuilds tower of two 15.0 Uses objects in combinationcubesBuilds tower of six cubes Requires visual, gross, and fine motor 22.0 coordination Communication and LanguageSmiles in response to 1.5 Child more active social participantface, voiceMonosyllabic babble Experimentation with sound, tactile 6.0 senseInhibits to "no" 7.0 Response to tone (nonverbal)Follows one–step 7.0 Nonverbal communicationcommand with gestureFollows one–stepcommand without 10.0 Verbal receptive languagegestureSpeaks first real word 12.0 Beginning of labelingSpeaks 4-6 words Acquisition of object and personal 15.0 namesSpeaks 10–15 words Acquisition of object and personal 18.0 namesSpeaks two–word Beginning grammaticization,sentences 19.0 corresponds with 50+ word vocabulary CognitiveStares momentarily atspot where Lack of object permanence (out of 2.0object disappeared sight, out of mind)(e.g., yarn ball dropped)Stares at own hand 4.0 Self–discovery, cause and effectBangs two cubes 8.0 Active comparison of objectsUncovers toy (after 8.0 Object permanenceseeing it hidden)Egocentric pretend play(e.g., pretends to drink 12.0 Beginning symbolic thoughtfrom cup)Uses stick to reach toy 17.0 Able to link actions to solve problemsPretend play with doll 17.0 Symbolic thought(gives doll bottle) Literature review 7
  19. 19. Department of KoumarabhrityaTable 1.2 Emerging patterns of behavior during the first year of life (4) Neonatal period (first 4 weeks)Prone: Lies in flexed attitude; turns head from side to side; head sags on ventral suspensionSupine: Generally flexed and a little stiffVisual: May fixate face or light in line of vision; "dolls–eye" movement of eyes on turning of the bodyReflex: Moro response active; stepping and placing reflexes; grasp reflex activeSocial: Visual preference for human face At 4 weekProne: Legs more extended; holds chin up; turns head; head lifted momentarily to plane of body on ventral suspensionSupine: Tonic neck posture predominates; supple and relaxed; head lags on pull to sitting positionVisual: Watches person; follows moving objectSocial: Body movements in cadence with voice of other in social contact; beginning to smile At 8 weekProne: Raises head slightly farther; head sustained in plane of body on ventral suspensionSupine: Tonic neck posture predominates; head lags on pull to sitting positionVisual: Follows moving object 180 degreesSocial: Smiles on social contact; listens to voice and coos At 12 weekProne: Lifts head and chest, arms extended; head above plane of body on ventral suspensionSupine: Tonic neck posture predominates; reaches toward and misses objects; waves at toySitting: Head lag partially compensated on pull to sitting position; early head control with bobbing motion; back roundedReflex: Typical Moro response has not persisted; makes defensive movements or selective withdrawal reactionsSocial: Sustained social contact; listens to music; says "aah, ngah" At 16 week Prone: Lifts head and chest, head in approximately vertical axis; legs extended Supine: Symmetric posture predominates, hands in midline; reaches and grasps objects and brings them to mouth Sitting: No head lag on pull to sitting position; head steady, tipped forward; enjoys sitting with full truncal supportStanding: When held erect, pushes with feetAdaptive: Sees pellet, but makes no move to it Social: Laughs out loud; may show displeasure if social contact is broken; excited at sight of food At 28 week Prone: Rolls over; pivots; crawls or creep–crawls Literature review 8
  20. 20. Department of KoumarabhrityaSupine: Lifts head; rolls over; squirming movementsSitting: Sits briefly, with support of pelvis; leans forward on hands; back roundedStanding: May support most of weight; bounces activelyAdaptive: Reaches out for and grasps large object; transfers objects from hand to hand; grasp uses radial palm; rakes at pelletLanguage: Polysyllabic vowel sounds formed Social: Prefers mother; babbles; enjoys mirror; responds to changes in emotional content of social contact At 40 week Sitting: Sits up alone and indefinitely without support, back straight Standing: Pulls to standing position; "cruises" or walks holding on to furniture Motor: Creeps or crawls Grasps objects with thumb and forefinger; pokes at things with forefinger;Adaptive: picks up pellet with assisted pincer movement; uncovers hidden toy; attempts to retrieve dropped object; releases object grasped by other personLanguage: Repetitive consonant sounds (mama, dada) Social: Responds to sound of name; plays peek–a-boo or pat–a-cake; waves bye– bye At 52 week(one year) Motor: Walks with one hand held (48 wk); rises independently, takes several stepsAdaptive: Picks up pellet with unassisted pincer movement of forefinger and thumb; releases object to other person on request or gestureLanguage: A few words besides "mama," "dada" Social: Plays simple ball game; makes postural adjustment to dressing 15 MonthsMotor: Walks alone; crawls up stairsAdaptive: Makes tower of 3 cubes; makes a line with crayon; inserts pellet in bottle Jargon; follows simple commands; may name a familiar object (ball)Language: Social: Indicates some desires or needs by pointing; hugs parents 18 MonthsMotor: Runs stiffly; sits on small chair; walks up stairs with one hand held; explores drawers and waste basketsAdaptive: Makes a tower of 4 cubes; imitates scribbling; imitates vertical stroke; dumps pellet from bottleLanguage: 10 words (average); names pictures; identifies one or more parts of bodySocial: Feeds self; seeks help when in trouble; may complain when wet or soiled; kisses parent with pucker 24 MonthsMotor: Runs well; walks up and down stairs, one step at a time; opens doors; climbs on furniture; jumpsAdaptive: Tower of 7 cubes (6 at 21 mo); circular scribbling; imitates horizontal stroke; folds paper once imitativelyLanguage: Puts 3 words together (subject, verb, object)Social: Handles spoon well; often tells immediate experiences; helps to undress; listens to stories with pictures Literature review 9
  21. 21. Department of Koumarabhritya1.2Assessment of growth and development The standards of growth and development fixed by WHO by evaluating themulticentric growth trials conducted apart. The same is published in two technical reportsin the year 2006 and 2007(5).Growth can be measured in terms of 1. Nutritional anthropometry (weight, height, circumference of head, chest abdomen and pelvis). 2. Assessment of tissue growth (skin fold thickness and measurement of muscle mass). 3. Bone age (radiological by appearance and fusion of the various epiphyseal centers). 4. Dental age. 5. Growth studies and percentilesFor day to day work, anthropometry is the simplest tool.1.2.1 Nutritional anthropometry (6) This is the technique for measuring somatic growth. Literature review 10
  22. 22. Department of Koumarabhritya1.2.1.1 Length Length in recumbence is measured using an infantometer until 24 or 36 months ofage. The length is recorded in centimeters up to one decimal point. After the age of twoyears, standing height is recorded by using a stadiometer. Detecto weighing scales fixedwith anthropometric rods are in common use. For community survey, portable types ofrods are also used. For recording stature, the subject should remove his/her socks andshoes and stand perfectly straight with arms relaxed by his/her sides and ankles and kneestogether. Before measurement starts, a gentle pressure may be applied over the spinewith one hand while other hand holds the anthropometric rod. The subjects head ispositioned in Frankfort plane. Sitting height For recording sitting height, the subject is made to sit on a table or otherconvenient hard surface so that his/ her head lies in Frankfort plane. The back should bestraight, thighs horizontal and comfortably positioned. The feet should be supported onthe foot board and hands should rest comfortably on the subjects lap. To ensure that thesubjects back is fully extended, the observer may run his/her index finger up the spineapplying pressure to the lumbar and sacral regions, causing the subject to sit up by reflexaction. The head board should be lowered and made to touch the head of the subject andreading should be recorded to the nearest completed unit. Body proportions The total body length is divided in two segments. The upper segment is fromhead to pubic symphysis and the lower segment is from pubic symphysis to the toes. TheU/L segment ratio is 1.7:1 at birth. By six to seven years, it reaches 1:1. If the ratio is Literature review 11
  23. 23. Department of Koumarabhrityainfantile after one year of age, it suggests short limb dwarfism due to bone disorders suchas rickets and hypothyroidism. Weight It is the commonest and important anthropometric measurement. The weighingscales best suited are those which are designed on balance arm principle. Accuracy up to0.1 kg is quite acceptable. For smaller babies, machines of more accuracy are required as0.1 kg forms a higher percentage of total body weight. More recently, many electronicweighing scales giving 0.01 kg have been made available.Table 1.3 Formulas for approximate average height and weight of normalinfants and children Weight Kilograms (Pounds) (a) At birth 3.25 (7) (b) 3–12 mo age (mo) + 9 (age [mo] + 11) 2 (c) 1–6 yr age (yr) ´2 + 8 (age [yr] ´5 + 17) (d) 7–12 yr age (yr) ´7 – 5 (age [yr] ´7 + 5) Height Centimeters (Inches) (e) At birth 50 (20) (f) At 1 yr 75 (30) (g) 2–12 yr age (yr) ´6 + 77 (age [yr] ´2½ + 30) Head circumference Head circumference (HC) is measured with a non stretchable tape passing throughthe maximum point of occipital protuberance posteriorly and at a point, just above theglabellum anteriorly. HC increases by 2cm per month for the first three months, one cm Literature review 12
  24. 24. Department of Koumarabhrityaper month for the next three months and 0.5 cm per month for the next 6 months where asHC at birth on an average is 34 cm. HC increases by 2 cm in the second year and one cmin the third year. Midarm circumference The upper arm circumference can be measured both in flexed and extendedpositions and also either at the maximum circumference of biceps muscles or midpoint, asthe difference between the two is negligible. It is measure by a non stretchable tapewhich is passed around the circumference of the arm while the arms hanging by the sides.The measurement is noted at the midpoint of left arm, mid way between acromion andolecranon processes. Shakir’s tape is used for quick monitoring of MAC in communitywhich gives green color, if MAC>13.5 cm, yellow if between 12.5-13.5 cm and red if lessthan 12.5 cm. Chest circumference The chest circumference for boys, prepubertal girls and men can be recorded at thelevel of xiphisternal junction during normal breathing. It is recorded to the nearest 0.1cm. 1. At Birth - about 3 cm less than the Head Circumference 2. Equal to head circumference at 1 year 3. Thereafter it increase than head circumference1.2.1.7 Age independent anthropometry As the Midarm circumference (MAC) is relatively constant between 16.5cm to17.5cm in one to five years of age, this measurement may be considered as an age Literature review 13
  25. 25. Department of Koumarabhrityaindependent variable up to five years of age. Any child whose MAC is less than 12.5 cmup to five years of age, is considered malnourished. Weight for height The degree of wasting can be measured by comparing the child’s weight withexpected weight for a healthy child of the same height. Combinations of thesemeasurements have been used to distinguish different types of malnutrition. Waterlowsuggests that weight for height can be used to distinguish between malnutrition of recentorigin, i.e. wasting and malnutrition due to considerable period of months. In chronicmalnutrition, the child is stunted with the weight for age and height for age being low. Inacute malnutrition, height for age is normal but weight for age is low (wasting). Thus, theweight and height measurements together are useful in understanding the dynamics ofmalnutrition. In nutritional short stature the weight /height is equal; the child may passoff as a normal child of lower age if the chronological age is not known. Quackstick Quacker’s Midarm circumference measuring stick is a height measuring rod,calibrated in MAC than length; values of 80 percent MAC for height are marked on thestick at corresponding height levels. If a child is found taller than his/her armcircumference, level on the stick, he/she may be considered as malnourished. Midarm/head circumference ratio It is a simple and useful criterion for detection of malnutrition. A ratio 0.280 to0.314 indicates early malnutrition, 0.250 to 0.279 moderate, and less than 0,249 denotessevere malnutrition. Literature review 14
  26. 26. Department of Koumarabhritya1.2.1.11 Quetlet’s index It is based on the relationship between weight and height and is expressed asweight (kg)/height (cm) x 100. Normal value varies from 0.14 to 0.16. In grossmalnutrition, it is less than 0.14. It is a quite reliable ratio for assessing malnutrition. Mid-upper arm/height ratio It is also a very good indicator for nutritional status. A ratio of less than 0.29indicates gross malnutrition, while normal value ranges from 0.32 to Body mass index (BMI) BMI = weight (kg) / height 2 in meter. This is similar to Quetlet’s index except that the values are in SI units. BMIvalues can be used to draw standardized percentile curves in children and adolescents. Itis especially useful for defining obesity. BMI values above 95 th percentile for age areusually used to define obesity. Ponderal index (PI) PI = height (cm) / cube root of body weight (kg)This is another index similar to BMI and is often used in defining newborn withintrauterine growth retardation (IUGR).1.2.2 Tissue growth This measurement is done for special purpose and is not used in routine clinicalpractice. It is measured with a special caliper. Triceps skin fold thickness The skin fold picked up over the posterior surface of the triceps muscle, one cmabove the mark on a vertical line passing upward between bony point identified for takingmeasurement, maintaining a pressure of 10g/ mm2 on the caliper and freeing the skin fold Literature review 15
  27. 27. Department of Koumarabhrityafrom the underling muscle with left hand between thumb, index and middle finger andholding caliper with the other hand. The reading is recorded to the nearest 0.1mm. Sub scapular skin fold thickness The subject stands as for the triceps skin fold with shoulder and arm relaxed. Theinferior angle of scapula is located by running finger on medial border of scapuladownward, till inferior angle is reached. The skin is pinched up immediately below theinferior angle either in the vertical line or slightly downward and reading is recorded tothe nearest 0.1mm maintaining the pressure of caliper as before. Biceps skin fold thickness For recording biceps, the child is made to stand erect, facing observer with arm onside and palm facing forward. The skin fold is picked up over the belly of biceps and1cm above the line marked for the upper arm circumference and triceps skin fold on avertical line joining antecubital fossa to the head of humerus. The caliper is applied at themarked level and reading is recorded to 0.1mm.1.2.3 Bone age or skeletal maturity Appearance and fusion of various epiphyseal centers follow a definite sequencerelated to chronologic age from birth to maturity. Radiological examination of left wristand elbow is usually considered for bone age assessment. X-ray of the lower end offemur, and talus is used for the assessment of maturity of newborn babies.1.2.4 Dental development Eruption of teeth follows a definite sequence. Eruption of temporary or deciduousteeth begins at about six months with eruption of upper or lower central incisor, followedby lateral incisor. By one year of age 4 to 8 teeth are present. The permanent teeth beginto erupt at six years. Literature review 16
  28. 28. Department of KoumarabhrityaTable 1.4 Dental development (4) Calcification Age wise eruption Begins at Complete at Maxillary MandibularPrimary TeethCentral incisors 5th fetal mo 18–24 mo 6–8 mo 5–7 moLateral incisors 5th fetal mo 18–24 mo 8–11 mo 7–10 moCuspids (canines) 6th fetal mo 30–36 mo 16–20 mo 16–20 moFirst molars 5th fetal mo 24–30 mo 10–16 mo 10–16 moSecond molars 6th fetal mo 36 mo 20–30 mo 20–30 moSecondary TeethCentral incisors 3–4 mo 9–10 yr 7–8 yr 6–7 yrLateral incisors Max, 10–12 mo 10–11 yr 8–9 yr 7–8 yr Mand, 3–4 moCuspids (canines) 4–5 mo 12–15 yr 11–12 yr 9–11 yrFirst premolars 18–21 mo 12–13 yr 10–11 yr 10–12 yr(bicuspids)Second premolars 24–30 mo 12–14 yr 10–12 yr 11–13 yr(bicuspids)First molars Birth 9–10 yr 6–7 yr 6–7 yrSecond molars 30–36 mo 14–16 yr 12–13 yr 12–13 yrThird molars Max, 7–9 yr 18–25 yr 17–22 yr 17–22 yr Mand, 8–10 yr1.2.5 Growth studies and percentiles While discussing growth, various terms which are used are explained. Cross-sectional study This is a very convenient, easy, less time consuming and economical method tostudy growth. For example, children of each age group in large number collected, theirweights are recorded and an average is found out. These groups of children are studiedjust once. Literature review 17
  29. 29. Department of Koumarabhritya1.2.5.2 Linear or longitudinal study In this type of study, the same child is measured from birth to maturity at yearly orpreviously decided regular intervals. It is difficult to study very large number of childrenin this fashion and hence, the linear studies have comparatively less subjects in number.The longitudinal study helps us to determine the growth velocity. Concept of percentiles While making various calculations, the use of terms like mean or average andstandard deviation (SD) is well known. While expressing growth, the term percentile orcentile is used. Growth charts Growth chart is the most important tool in assessment of growth of an individualchild. A standard chart contains weight for age, height for age and weight for height.The head circumference is included for first three years of age.Growth Chart & their significance –  Introduction – Also called ‘Road to health chart’.  Definition – Growth chart is a visible graphical display of a child’s Growth & Development designed primarily for the longitudinal follow up (growth monitoring) of the child, so that changes over time can be interpreted & progress of Growth interpreted.  Visits to be recorded – Weighing should be done at least once every month for the first year Every 2 months during second year. Every 3 months up to age of 5 -6 years. This is done in a pattern of ‘weight for age’ on the chart. Literature review 18
  30. 30. Department of KoumarabhrityaTypes of Growth Chart –  WHO Growth Chart – it has two reference curves. The upper reference curve represents the median (50th percentile) for boys (slightly higher than that for girls) & the lower reference curve represents the percentile for girls (slightly lower than that for girls). The space in between two growth curves (weight channel) is called ‘Road to Health’. This includes children with +/- 2 SD on each side of standard weight.  Growth chart recommended by Govt. of India & IAP (Indian Academy of Pediatrics). – It has 4 reference curves.  ICDS Chart- 3 reference lines in addition to standard representing 80%, 60% & 50% of the reference standards.Use of Growth charts – 1. Growth monitoring – To detect malnutrition or infections by periodic assessment in progress of weight 2. Diagnostic tool – to identify ‘High risk children’. Malnutrition can bee detected long before signs & symptoms of it become apparent. 3. Planning & Policy making – By grading malnutrition it is possible to evolve an objective basis for planning & policy making in relation to child health care at local & central levels. 4. Education tool – Mothers can be taught care of her own child & encourage her to actively participate in Growth monitoring with the help of visual character of the Growth chart.Literature review 19
  31. 31. Department of Koumarabhritya 5. Tool for action – Helps the health workers to decide type of interventions that is needed, which helps making referrals an easier jobs. 6. Evaluation – growth chart provides a good method to evaluate the effectiveness of corrective measures & impact of a program or of special intervention for improving child Growth & Development.The Growth Chart has been aptly described as ‘A passport to child health care’.Velocity growth charts These charts are developed by long term longitudinal studies and are known asincremental charts. They show the rate of change due to chronic illness or growthhormone deficiency. Literature review 20
  32. 32. Department of Koumarabhritya Chapter 2 Child nutrition2.1 Introduction and background Nutrition may be defined as the science of food and its relation to health. It isconcerned primarily with the part played by the nutrients in body growth developmentand maintenance. Good nutrition means maintaining a nutritional status that enables us togrow well and enjoy food (7). Disturbances of feeding and related nutritional disordersconstitute a major health problem in developing countries.2.2 Nutritional requirements (8)2.2.1 Food and Energy: The chemical energy required for the human body engine is bound in fuels presentin food. The foods which supply energy are carbohydrates, fat, proteins and alcohol.Energy is required for the activities of the child as well as synthetic reaction whichproduce the chemical components of the new cells and tissues during growth. Energy isrequired for the functioning of each and every unit of the body. Literature review 21
  33. 33. Department of KoumarabhrityaTable 2.1 Approximate energy values of the body fuels per gram (9) Kcal kjCarbohydrates 4 16.7Fat 9 37.7Protein 4 16.7Alcohol 7 The nutrient requirementsThe nutrient requirement depends on 1. the rate of growth 2. physical activity 3. climate 4. body temperature 5. body weight and height 6. body surface area 7. genetic and constitutional factors 8. individual variations2.2.3 Calorie requirements A one year old child usually requires about 1000 calories per day. There is somereduction in the need for calories per kilogram as the child grows and the calorierequirement for a child of two year of age is 1100 calories; three years 1200 calories; fouryears 1300 calories; and five years 1400 calories. Literature review 22
  34. 34. Department of KoumarabhrityaTable 2.2 Calorie requirements during the first year of life (10) Age kcal/kg kj/kgLess than three months 120 5003-5 months 115 4806-8 months 110 4609-11 months 112 470 As the rate of growth of children is very variable depending up on the racial,genetic and constitutional factors, the calorie need will vary in different children of thesame age.Physical activity The calorie requirement will also vary greatly with physical activity. Hencechildren who are very active may need 100 to 300 calories more than less active children.2.2.4 Proteins Protein is an essential constituent of living protoplasm and it participates in allimportant processes. There are nine essential amino acids needed for older children andten for infants. They are – leucine, isoleucine, methionine, phynylalanine, threonine,tryptophan, histidine and valine. Histidine is essential for growth of infants. The majorfunctions of proteins are 1. Growth, as amino acids provide building stones for tissue synthesis. 2. Repair of body tissues under going wear and tear. 3. Supply of raw materials essential for the formation of digestive juices, hormones, plasma proteins, immunoglobulin, Haemoglobin, enzymes etc. Literature review 23
  35. 35. Department of Koumarabhritya 4. In case of necessity, proteins can be used for energy purposes as each gram of protein supplies about 4 kcal of energy. 5. Function as buffers to maintain the reaction of various body fluids such as plasma, intestinal secretion, CSF etc.Protein requirements Nutritive value of proteins depends on its amino acid constituents which arerequired for building new tissues and its digestibility. The capacity of proteins to makegood one another’s deficiencies is known as their supplementary value. The protein requirement in children depends mainly upon the rate of growth,degree of tissue repair and the presence or absence of infections or infestations. In theadult as the growth ha ceased, the requirement in terms of milk or egg protein are0.57gms/kg of body weight for a man and 0.42gms/kg body weight for woman per day.The protein requirements in children are much higher than adults because of the necessityof maintaining healthy growth rates.Table 2.3 Protein requirements in childrenAge in months protein requirement in grams (In terms of milk protein)0-3 2.403-6 1.856-9 1.609-11 1.44 Literature review 24
  36. 36. Department of Koumarabhritya The protein requirements also depend upon the calorie intake in children. If thecalorie intake is adequate, proteins are spared for their usual functions of growth andrepair, if calories are not adequate, proteins are diverted to the provision of energy. Abreastfed baby growing normally has a protein intake of 1.87 gms/kg body weight whichis more than adequate compared to the calculated 1.6gm/kg. a baby who gets full creamcows milk will get almost three times the amount of protein than that supplied by thehuman milk.2.2.5 Fat Fat is not only an important constituent of the diet but also an essential one. Itprovides a higher source of energy, nine calories per gram, i.e., double the energyfurnished by protein or carbohydrates. Vegetable oils are particularly rich in essentialfatty acids which play an important role in several metabolic reactions in the body.Animal fats such as butter and ghee contain vitamin A and vitamin D. Cholesterol, aconstituent of fat, may be increased in the blood when the consumption of fat is morethan 30% of the calories in the diet. Young babies absorb fat from human milk much better than cow’s milk becausein human milk fat, 74% of the palmitic acid is esterified while it is only 39% in cow’smilk. To increase the absorption of cow’s milk, butter fat is avoided in practice and amixture of animal as well as vegetable fats is used to mimic the composition of humanmilk. Linoleic acid like unsaturated fatty acids can also be added to increase theassimilation as they are readily absorbed by babies particularly if they are of plant origin.The intake of fat in the diet of a child should be enough to supply 30-35% of the totalcalories, as with a lesser intake of fats babies are likely to get more amounts of protein Literature review 25
  37. 37. Department of Koumarabhrityaand carbohydrates. Both may produce undesirable effect on the body of the child. Inolder children and adolescents the intake of fat could be as low as 15% of total calories,as they are able to tolerate carbohydrate and proteins much better than infants and youngchildren below three years.2.2.6 CarbohydratesCarbohydrates have the following important functions. 1. They provide energy 2. They are used in the synthesis of DNA, RNA and other important chemicals used in building various substances in the baby. 3. They are useful in the detoxification of ammonia. 4. They are useful in counteracting acidosis. Glucose is the main source of cellular energy particularly to brain cells.Carbohydrates are important in the maintenance and improvement of liver functions. Acommon method of detoxification is conjugation with glucoronic acid which is formedfrom glucose and predominantly galactose in the neonatal period. This indicates thespecial need of galactose in the neonatal period apart from glucose in the conjugation ofbilirubin, steroids and drugs like chloremphenicol. The high lactose content of breastmilk is an excellent source of glucose and galactose particularly in the neonatal period,where an adequate amount of lactase in the intestinal mucosa of the newborn is availablefor digestion of lactose. The carbohydrates are utilized for energy purposes and hence the fatty acids fromfat are not necessary when glucose is adequate. In the absence of adequate carbohydrates,particularly glucose, fat will break down for energy which results in ketosis. Also Literature review 26
  38. 38. Department of Koumarabhrityaglucose will prevents acidosis in the neonatal period by proper glycogenesis andglycogenolysis. Essentially no carbohydrate reaches the colon in normal children, and indeedmany of the consequences of carbohydrate malabsorption are the result of carbohydrateentry to colon. Infants can absorb sucrose readily because of sucrase activity in theintestine readily from birth. They can also deal with partial hydrolysis of products ofstarch usually called dextri-maltose, and quite young babies can digest cooked starch forthey have the maltase activity necessary for breaking it down. Carbohydrate in baby’s food includes lactose or sucrose in infants fed on top milk.The carbohydrates should supply 50% or more of the calorie requirements. Though olderchildren can thrive on a diet of carbohydrate which supplies 32% or more of the totalcalories, in infancy and early childhood reduction below 32% are likely to producesymptoms of carbohydrate deficiency. High lactose milk like human milk has a slightlaxative action and hence the breast fed babies stools are semi formed, and 3-4 numberper day.Percentage distribution of calories Just as adequate calories are necessary for maintaining health, proper distribution ofthe calories from protein, fat and carbohydrate is of equal importance particularly inchildren. In an infant, distribution of calories in breast milk is 8% from protein, 42%from carbohydrates, and 50% from fat. This has proved to be highly successful inadequate growth of the baby with excellent nutrition if the quantity of the human milkwas sufficient. A marked disturbance in the distribution calories adversely affects thechild’s health and produce malnutrition in spite of excess calories. Various types of Literature review 27
  39. 39. Department of Koumarabhrityapictures may be produced, depending on the amount of protein intake and adequate or nosugar. This result in various syndromes like 1. carbohydrate malnutrition a. with protein overload b. without protein overload 2. protein overload syndrome Though the human metabolism can adjust to many of the variations in diet, markeddisturbance in the percentage of calories supplied from proteins, carbohydrates and fatscan be deleterious in infancy and early childhood.2.2.6 Vitamins Vitamins are a group of organic accessory food substances which the body needsin small amounts to maintain health. The FAO/WHO expert groups have consideredhuman requirements for 8 vitamins.The vitamins for human requirements can be classified in the following three categories 1. The obligatory vitamins, which must be supplied in the diet to maintain proper health. They are (1) vitamin A (A1 and A2), (2) thiamine, (3) riboflavin, (4) pyridoxine, (5) folic acid, (6) cyanocobalamin,(7) ascorbic acid and (8) cholecalciferol. 2. Conditional vitamins are those which are mainly needed in the presence of deficit of other nutrients. They are nicotinic acid, choline and vitamin K. 3. Questionable vitamins are the substances which have not been proved essential for the normal human subject though recent studies suggest that Vitamin E deficiency can occur if there is a deficiency of the trace element selenium in the diet. Literature review 28
  40. 40. Department of Koumarabhritya2.2.7 Water Water is the most essential fluid for life. Though it is not a nutrient per se it is themost essential vehicle concerned with all cellular and extra cellular metabolisms. Lack ofit will result in death in a matter of days.The requirement for water depends on various factors: 1. the climate 2. the body temperature 3. the protein and mineral content of the diet 4. the solute load presented for renal secretion 5. metabolic and respiratory rates 6. faecal loses and habit The water requirement per kilogram weight varies from 125 – 150 ml in infancy; 100– 115 in the preschool age and 40 – 100 ml in other age groups. However during the hotseason as in tropical countries, requirement increase by 25 – 50 ml per kg per daydepending on the heat. If the child is exposed to direct sunlight as may happen withworking mothers, the requirement may increase up to 60 ml per kg per day. Except in theinfants, in most children, the fluid requirement can be easily decided by the presence ofthirst. Healthy children cry mainly because of hunger or thirst. All personnel concernedwith the health of the baby must realize that all infants should give extra amounts ofboiled water varying from 25 – 50 ml per kg per day during hot weather. Failure torecognize high water requirements and relatively less food requirement in hot weathermay often cause pyrexia, vomiting, diarrhea, dehydration, and heat pyrexia in theseinfants. However, breastfed babies do not need water in the first four months if thequantity is adequate, as judged by weight gain of the body. Literature review 29
  41. 41. Department of Koumarabhritya Chapter 3 Breast feeding Breast feeding, the most natural way of feeding the young infant, satisfies theinstinctive urge and assures the continuity of life and health of the progeny particularly soin a developing country like India. The breast milk is a complete food for the infant asthe lactatory apparatus of the mother is both efficient and specific for the proper growthand development of the baby. However in industrialized cultures and in modern andsophisticated families often the breast milk, the natural food of infant, is being replacedby artificial baby foods and other breast milk substitutes. Breast feeding however stillremains a necessity more so for developing countries and it is now realized more andmore that it is the best milk for babies even in developed societies. The nutrient adequacy of breast milk during the first year of life especially in thefirst six months of life is experimentally proved by multicentric trial conducted by WHO.The data is very useful in highlighting the importance of breast feeding. Although thisstudy aims to attain a natural weaning food, the importance of breast milk is never beingunder estimated. Literature review 30
  42. 42. Department of Koumarabhritya 3.1 Nutritional considerations in the first year of life (11) Estimates of nutrient requirements for the first year of life are based on measuredintakes of human milk during the first 6 months. Estimated needs during the second 6months are sometimes determined by extrapolating from these intake measures. Thereasons for selecting the first 6 months appear arbitrary. One can offer physiologicalmilestones as a reason for selecting this age, e.g. changes in growth velocities, stability innutrient concentrations in human milk, disappearance of the extrusion reflex, teething,and enhanced chewing capabilities. However, the variability in the ages at which thesemilestones are reached is far greater than the specificity that the cut-off suggests. Asnoted above, growth may be used to justify selecting the first 6 months as a basis forestimating nutrient requirements, although its use this way has severe limitations.3.2 Human-milk intakes Studies conducted in presumably well-nourished populations from developedcountries and in under-privileged populations from developing countries in the 1980s–1990s were compiled and showed the following results. Mean human milk intake ofexclusively breastfed infants, reared under favorable environmental conditions, increasesgradually throughout infancy from 699 g/day at 1 month, to 854 g/day at 6 months and to910 g/day at 11 months of age. The mean coefficient of variation across all ages was 16%in exclusively breastfed infants compared to 34% in partially breastfed infants. Milkintakes among the partially breastfed hovered around 675 g/day in the first 6 months oflife and 530 g/ day in the second 6 months. Literature review 31
  43. 43. Department of Koumarabhritya3.3 Composition of human milk The composition of human milk changes dramatically in the postpartum period assecretions evolve from colostrum to mature milk. The stages of lactation correspondroughly to the following times postpartum: colostrum (0–5 days), transitional milk (6–14days), and mature milk (15–30 days). . The first 3 to 4 months of lactation appear to bethe period of most rapid change in the concentrations of most nutrients. After that periodnutrient concentrations appear to be fairly stable as long as mammary gland involutionhas not begun. However, few studies assess the dietary and physiological factors thatdetermine either the rate of change in nutrient concentrations or inter individualvariability.Table 3.1 Human milk composition3.3.1 Energy content of human milk Proteins, carbohydrates and lipids are the major contributors to the energy contentof human milk. Protein and carbohydrate concentrations change with duration oflactation, but they are relatively invariable between women at any given stage oflactation. In contrast, lipid concentrations vary significantly between both individual Literature review 32
  44. 44. Department of Koumarabhrityawomen and populations, which accounts for the variation observed in the energy contentof human milk. Within-day, within-feeding, and between-breast variations in milkcomposition; interference with milk “let-down”; and individual feeding patterns affect theenergy content of human milk. The mean energy content of human milk ranges from0.62 kcalth/g to 0.80 kcalth/g (33). For present purposes, a value of 0.67 kcalth/g hasbeen assumed.Table 3.2 Energy requirements of breast fed infants Literature review 33
  45. 45. Department of Koumarabhritya3.3.2 Protein composition of human milk The protein content of mature human milk is approximately 8–10 g/l . Theconcentration of protein changes as lactation progresses. By the second week postpartum,when the transition from colostrum to mature milk is nearly complete, the concentrationof protein is approximately 12.7 g/l . This value drops to 9 g/l by the second month and to8 g/l by the fourth month where it appears to remain until well into the weaning processwhen milk volumes fall substantially. At this point protein concentrations increase asinvolution of the mammary gland progresses. The interindividual variation of the proteincontent of human milk, whose basis is unknown, is approximately 15%.Protein intake and growth It thus appears that human milk meets the protein needs for growth of infantsbetween 0 and 6 months. Based on factorial and balance studies, infants’ mean proteinrequirements are approximately 1.1 g/kg per day from 3 to 6 months of ageImmune function Protein under nutrition adversely affects immune function. Protein-deficientinfants present impaired immune responses that, in turn, increase their risk of infectiousepisodes.3.3.3 Total nitrogen content of human milk Human milk’s total nitrogen content, which appears to depend on the stage oflactation and dietary intakes, ranges from 1700 to 3700 mg /l. Eighteen to 30% of thetotal nitrogen in milk, is non-protein nitrogen (NPN). Approximately 30% of NPN are Literature review 34
  46. 46. Department of Koumarabhrityaamino acids and thus should be fully available to the infant. As much as 50% of NPNmay be bound to urea and the remaining approximately 20% is found in a wide range ofcompounds such as nitrogen-containing carbohydrates, choline, nucleotides andcreatinine.3.3.4 Vitamin A content of human milk Vitamin A is a generic term for a group of retinoids with similar biologicalactivity. Recent recommendations by the United States Food and Nutrition Board re-evaluated conversion equivalency and recommended use of 1/12 retinol equivalents (RE)from a mixed diet. The vitamin A content of human milk depends on maternal vitamin Astatus. .The mature milk of well-nourished mothers contains approximately 1.7 moles/lvitamin A. The recommended vitamin A intake level for infants 0 to 6 months was set at1.4 μmoles/day and 1.75 μmoles/ day for infants 6 to 12 months based on the intakes ofbreastfed infants of well-nourished women. In populations that are at risk of vitamin Adeficiency, the age at which a deficiency occurs is related to the age of weaning, i.e. theshorter the duration of breastfeeding, the earlier the onset of deficiency. Associations between linear growth retardation and vitamin A deficiency havebeen found in some, but not all, studies. Age-specific paired comparisons showed alower height-for-age, weight-for-height, mid upper arm circumference and triceps skin-fold in children under 3 years of age with xerophthalmia than in controls. Vitamin A-deficient children consumed almost half the amount of vitamin A-containing foods (dark-green leafy vegetables and) than controls (11). Literature review 35
  47. 47. Department of Koumarabhritya3.3.5 Vitamin D content of human milk Vitamin D is a fat-soluble vitamin that is synthesized in the skin and may beobtained from the diet. In postnatal life, the most widely recognized functions of vitaminD are related to calcium and phosphate metabolism. It is widely accepted that human milk contains very low levels of vitamin D.Vitamin D concentrations in human milk depend on maternal vitamin D status. Factorsaffecting vitamin D status include skin pigmentation, season and latitude. Increased skinmelanin concentration reduces the efficiency of vitamin D synthesis in the skin. The United States Food and Nutrition Board recommend 5 g of vitamin D forinfants 0 to 6 months of age, although it also acknowledges that breastfed infants “withhabitual small doses of sunshine” do not require supplemental vitamin D. Two hours isthe required minimum weekly amount of sunlight for infants if only the face is exposed,or 30 minutes if the upper and lower extremities are exposed. Severe vitamin Dinsufficiency results in inadequate mineralization of the skeleton. In growing infantsdeficient mineralization leads to rickets3.3.6 Vitamin B6 content of human milk Vitamin B6 functions as a coenzyme in the metabolism of protein, carbohydrateand fat. Signs and symptoms of vitamin B6 deficiency include dermatitis, microcyticanaemia, seizures, depression and confusion. In infants vitamin B6 deficiency appears toadversely influence growth. The vitamin B6 content of human milk varies with maternal B6 status and intake.The mean B6 concentration in human milk of women with B6 intakes below 2.5 mg/dayis 0.13 mg/l (778 nmol/l). Mean B6 levels in milk of women with B6 intakes between 2.5and 5 mg/day are substantially higher – approximately 0.24 mg/l. Other factors, e.g. Literature review 36
  48. 48. Department of Koumarabhrityalength of gestation, stage of lactation and the use of B6 supplements, influence thevitamin B6 concentration in human milk. The adequate intake for vitamin B6 is 0.1mg/day for infants 0 to 6 months and 0.3 mg/day for infants 6 to 12 months of age.3.3.7 Calcium content of human milk Human milk contains 250–300 mg/l of calcium with no pronounced changesduring lactation . Generally, maternal diet does not appear to influence the concentrationof calcium in milk. Calcium requirements are affected substantially by genetic variabilityand other dietary factors. Pronounced calcium deficiency resulting in tetany rarely occursin the healthy, breastfed infant and therefore is not helpful in determining requirements.Assessment of calcium status is difficult since serum levels are homeostatically regulatedand therefore do not reflect body content. Inadequate calcium intake can result in lower-than-normal bone mineralization. Since bone mineralization did not differ betweenbreastfed and formula-fed infants after weaning, retention of more calcium than thatachieved by breastfed infants does not seem to benefit bone mineralization later in life.3.3.8 Iron content of human milk The concentration of iron in human milk declines from ~0.4–0.8 mg/l incolostrum to ~0.2–0.4 mg/l in mature human milk. The iron content of human milkappears to be homeostatically controlled by up and down-regulation of transferrinreceptors in the mammary gland ; consequently, it is unaffected by maternal iron status ordiet. Major factors determining iron requirements during infancy are iron endowment atbirth, requirements for growth and a need to replace losses. The newborn infant is wellendowed with iron stores and a high concentration of haemoglobin. Between 4 and 6 Literature review 37
  49. 49. Department of Koumarabhrityamonths of age, there is an increased dependence on dietary iron. Dietary iron provides~30% of the requirement for haemoglobin iron turnover, compared to 5% in adultsBecause of the considerable iron requirement for growth and the marginal supply of ironin infant diets, iron deficiency is prevalent among infants between 6 and 12 months ofage.Table 3.3 Iron Requirements of breastfed infants3.3.9 Zinc content of human milk The concentration of zinc in human milk declines precipitously from 4–5 mg/l inearly milk, to 1–2 mg/l at 3 months postpartum, and to ~0.5 mg/l at 6 months. There isconsiderable inter-individual variation in milk zinc concentrations. Severe zincdeficiency results in acrodermatitis enteropathica, impaired immune function, diarrhoeaand growth retardation. Mean serum zinc was stable in breastfed infants from 2 to 9months, but the number of infants in the low range (0.55mg/l) increased from 3% at birthto 30% at between 4 to 9 months. Serum zinc correlated with zinc intake and milk zincconcentrations. Using stable isotope studies, the estimated mean net zinc absorption,which does not include urinary or integumental losses, was 0.26 mg/day at 2 months and0.29 mg/day at 4 to 5 months. Even with very efficient absorption and conservation ofendogenous losses, net zinc absorption did not meet zinc requirements at 2 months or 4 to Literature review 38
  50. 50. Department of Koumarabhritya5 months. Zinc requirements are higher in boys than in girls and are highest in earlyinfancy, at the time of greatest weight gain.3.4 Some important approaches in infant feeding3.4.1 Baby-friendly Hospital Initiative The Baby-friendly Hospital Initiative (BFHI) was launched by WHO andUNICEF in 1991, following the Innocenti Declaration of 1990. The initiative is a globaleffort for improving the role of maternity services to enable mothers to breastfeed babiesfor the best start in life. It aims at improving the care of pregnant women, mothers andnewborns at health facilities that provide maternity services for protecting, promoting andsupporting breastfeeding. Different tools and materials were developed and provided forimplementation of the BFHI, including an 18-hour course, a self-appraisal tool, and anexternal assessment tool. Since its launching BFHI has grown, with more than 20,000designated facilities in 152 countries around the world over the last 15 years. Theinitiative has measurable and proven impact, increasing the likelihood of babies beingexclusively breastfed for the first six months.3.4.2 HIV and infant feeding The HIV pandemic raised concerns and queries in relation to feedingrecommendations for children of HIV-infected mothers. In 2003, as a result ofcollaboration between nine UN agencies, a framework for priority action on HIV andinfant feeding was published, promoting optimal infant and young child feeding for alland including support for BFHI. Additionally, there is new research on breastfeeding andinfant feeding and information on the critical importance of breastfeeding in emergencysituations. The main objective of the guideline is to promote breast feeding by women Literature review 39
  51. 51. Department of Koumarabhrityawho are known not to be infected with HIV, and for women whose infection status isunknown, protect, promote and support exclusive breastfeeding for 6 months, followed bycontinued breastfeeding, together with appropriate complementary feeding, for up to twoyears of age or beyond. 3.4.3 Evidence for the ten steps to successful breastfeeding The “Ten Steps to Successful Breastfeeding” are the foundation of theWHO/UNICEF Baby Friendly Hospital Initiative (BFHI). They summarize the maternitypractices necessary to support breastfeeding. The BFHI addresses a major factor whichhas contributed to the erosion of breastfeeding – that is, health care practices whichinterfere with breastfeeding. Many other factors affect how women feed their infants andthe length of time for which they breastfeed. In the ‘Ten Steps’, policy development andstaff training resulting in appropriate skilled support of mothers before, during and afterdelivery, and ongoing postnatal support in the community, are all necessary to realize theimprovements aimed for by other activities. The Ten Steps to Successful Breastfeeding 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within a half-hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. Literature review 40
  52. 52. Department of Koumarabhritya 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in - allow mothers and infants to remain together - 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breast- feeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.3.5 Contraindications of breast feeding: For the average, healthy, full-term infant there are no disadvantages to breast-feeding, provided that the mothers milk supply is ample and that her diet containssufficient amounts of protein and vitamins. Infrequently, allergens to which the infant issensitized may be conveyed in the milk. In such cases, an attempt should be made to findthe specific allergen and to remove it from the mothers diet; its presence rarely is a validreason for weaning the baby. From the mothers standpoint, there are few contraindications to breast-feeding.Markedly inverted nipples may be troublesome. Fissuring or cracking of the nipples canusually be avoided if engorgement is prevented. Mastitis may be alleviated by continuedand frequent nursing on the affected breast to keep it from becoming engorged, by localheat applications, and by antibiotics. Acute infection in the mother may contraindicatebreast-feeding if the infant does not have the same infection; otherwise, there is no need Literature review 41
  53. 53. Department of Koumarabhrityato stop nursing unless the condition of either necessitates it. When the infant is unaffectedand the mothers condition permits, the breast may be emptied and the milk given to theinfant. Septicemia, nephritis, eclampsia, profuse hemorrhage, active tuberculosis, typhoidfever, breast cancer, and malaria are contraindications to nursing, as are chronic poornutrition, substance abuse, debility, severe neuroses, and postpartum psychoses.3.6 Formula Feeding (12) Whole cows milk or its modified form is the basis for most formulas, althoughother milks and milk substitutes are available for infants who cannot tolerate it.Sterilization and refrigeration of the formula greatly reduce morbidity and mortality fromgastrointestinal infections. Milk processing (ranging from simple home boiling tocommercial pasteurization, homogenization, and evaporation) alters the casein so thatsmall and readily digestible curds form in the stomach, eliminating the principal cause forindigestibility of cows milk protein. Although breast-feeding is considered superior to formula feeding for normalinfants, many infants receive formula from birth. Changing social and cultural patternsmay encourage formula feeding. Because they are employed outside the home, manymothers are reluctant to nurse their infants. Others believe that nursing will limit theiractivities or they fear failure at nursing. Some regard weight gain and loss of breast toneas unattractive and some consider breast-feeding as socially unacceptable. Whatever thereasons, the present popularity of artificial feeding could not have been reached withoutprior improvements in the safety and quality of the substitute milks. Literature review 42
  54. 54. Department of Koumarabhritya Objective nutritional studies of growing infants (e.g., rate of growth in weight andlength, normality of various constituents in blood, performance in metabolic studies, bodycomposition) show relatively small differences between infants fed human milk and thosefed cows milk. Although such techniques may not record small but important variations,these investigations attest to the normal infants ability to thrive by making satisfactoryphysiologic adjustments to wide ranges of ingested protein, fat, carbohydrate, andminerals. Conventional formulas of whole and evaporated cows milk provideapproximately 3–4 g of protein/kg/24 hr ("high protein" intake largely exceeding thebasic need, whereas breast milk and many commercially prepared feedings simulating thecomposition of breast milk supply 1.5–2.5 g/kg/24 hr ("low-protein" intake supplying asmaller degree of excess). Commercial formulas are modified from a cows milk base, and their protein andash levels are reduced nearer to those of human milk, thus decreasing osmolality andrenal excretory load. The saturated fat of cows milk is replaced with some unsaturatedvegetable fatty acids, and vitamins are added. The concentration of lactose is lower incows milk than in human milk. Some formulas include higher whey protein and lowercasein, such as in breast milk. Low-birth weight infants in particular may benefit from theincreased cystine of whey proteins. Until more information is available, breast-feeding forall infants appears prudent, but if this is impossible, then a formula as compositionallyclose to breast milk as possible is desirable. Literature review 43
  55. 55. Department of Koumarabhritya Chapter 4 Complementary feeding 4.1 Relevant definitions(13) Complementary food means any food whether manufactured or locally prepared,suitable as a complement to breast milk or to infant formula, when either becomeinsufficient to satisfy the nutritional requirements of the infant Such food is alsocommonly called weaning food or breast-milk supplement. Breast-milk substitute means any food being marketed or otherwise presented as apartial or total replacement for breast milk, whether or not suitable for that purpose. Infant formula means a breast-milk substitute formulated industrially inaccordance with applicable Codex Alimentarius standards, to satisfy the normalnutritional requirements of infants up to between four and six months of age, and adaptedto their physiological characteristics. Literature review 44
  56. 56. Department of Koumarabhritya 4.2 Ideal time to start complementary feeding (the optimal duration of exclusive breastfeeding) (14) The debate over the optimal duration of exclusive breastfeeding has had a longhistory. Growth faltering is a commonly observed phenomenon in developing countriesafter about 3 months of age. This growth faltering has traditionally been attributed tothree factors: 1. The inadequacy of energy intake from breast milk alone after 3 or 4 months. 2. The poor nutritional quality (i.e., low energy and micronutrient content) of the complementary foods commonly introduced in many developing countries. 3. The adverse effects of infection on energy intake and expenditure. The inadequacy of breast milk for energy requirements beyond 3 or 4 months wasinitially based on calculations made by the Food and Agricultural Organization (FAO)and World Health Organization (WHO) in 1973. The belief that breast milk alone isnutritionally insufficient after 3 or 4 months, combined with the fact that complementaryfoods given in many developing countries are both nutritionally inadequate andcontaminated, led to concern about the so-called “weanling’s dilemma.” Breastfeeding isa life-and death issue in developing countries. A recent metaanalysis reported markedlyreduced mortality (especially due to infectious disease) with breastfeeding even into thesecond year of life. A recent study from India reported an increased risk of post neonatalmortality associated with exclusive breastfeeding >3 months, but reverse causality (illness Literature review 45