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1000 days

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  • 1. “Nutrition: Journey from Infancy to Childhood” Dr Kuntal Biswas Registrar Medical College & Hospitals, Kolkata
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  • 4. Epigenetics Physiology of Stress Neuroscience The Science of Early Brain and Child Development Education Health Economics One Science – Many ImplicationsThe critical challenge now is to translate game-changing advances indevelopmental science into effective policies and practices for familieswith children to improve education, health and lifelong productivity 5
  • 5. Altered Immunity Human rights in IDA & PEM The International Convention on Children Human Rights, to which nearly all countries of the world adhere, includes the right to access to food. 1600 Hunger and malnutrition are a violation of human rights. 1400 1200pg/ 10 6cells 1000 800 Nutrition is now so much a part of the 400 consciousness of today’s political leaders, 200 that the current political and economic 0 IL2 IL4 crisis 5 not1in the long run jeopardize the IL will IL 0 remarkable progress that has been achieved in overcoming or reducing the burden of IDA children malnutrition on the population of the PEM children Normal children country. 6
  • 6. Intervention TypesIncrease Intake of Vitamins Promote Good Nutritional and Minerals Practices• Vitamin A supplements • Breastfeeding• Zinc supplements • Complementary feeding• Micronutrient powders • Improved hygiene practices• De-worming drugs • Diet diversification• Iron/folic acid supplements • Wheat for pregnant women Prevent and Treat Moderate• Iodized oil capsules and Severe Malnutrition• Salt iodization • Treatment of severe• Iron fortification undernutrition with RUTF• Fortification of staple • Prevention/treatment of foods/bio-fortification moderate undernutrition• Vitamins 7
  • 7. 3 Objectives For Today• Provide a generalist’s overview of advances in developmental science• Present an organizing, integrated, eco bio developmental framework• Discuss ways pediatricians might assist in translating science into healthier life-courses Critical Concept Childhood Adversity has Lifelong Consequences. Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later. Barker Law states ‘Adulthood Diseases of Infancy –NCD- like- HTN, CAD, DM, Osteo Arthritis, Cancer etc 8
  • 8. Developing a Model of Human Health and DiseaseHow do you begin What are the to define or mechanisms measure the underlying these ecology? well-established associations? Life Course Science Early childhood ecology strongly associates with lifelong developmental outcomes 9
  • 9. Nutrition during & after pregnancy Conception to 2nd week – Umbilical cord not formed – Mother’s food intake does not have an effect on the embryo up to 2 wks – From 2 wks mother need extra Energy, extra Protein, extra EFA, extra Iron, Calcium & other Micronutrients. – Lactating mother need more than in Antenatal Period. 10
  • 10. Peak Age of Malnutrition Feeding Practices The incidence of malnutrition Inappropriate feedingrises sharply during the period practices are major cause offrom 6 to 18 mo of age in most the onset of malnutrition incountries. young children.The deficits acquired at this ageare difficult to compensate forlater in childhood. 11
  • 11. Intelligence quotient by type of feeding BF 12.9 points BF 2 points higher than FF higher than FF Study in 9.5 year-olds Study in 3-7 1996 year-olds 1982 BF 8.3 points higher than FF Study in 7.5-8 BF 2.1 points year-olds higher than FF 1992 Study in 6 months to 2 year- olds References: 1988 BM 7.5 points •Fergusson DM et al. Soc higher than no BM SciMed 1982 Study in 7.5-8 •Morrow-Tlucak M et al.BF = breastfed year-olds SocSciMed 1988FF = formula fed •Lucas A et al. Lancet 1992BM = breast milk 1992 •Riva Eet al. Acta Paediatr 1996
  • 12. Early Introduction of FoodsOther Than Breast milk Has Risks • All major medical organizations recommend exclusive breastfeeding the first six months • Infant’s digestive and immune systems are still developing • Starting complementary foods too early replaces a superior food (breast milk) with an inferior food 13
  • 13. Breastfeeding + Complementary Foods• First six months: Exclusive breastfeeding• After six months: – Breastfeed as often as the child wants• Begin complementary foods in small amounts• Until two years: – Breastfeed as often as the child wants – Continue complementary foods, gradually increasing quantities and frequency as the child gets olderWorld Health Organization, Complementary Feeding: Family foods for breastfed children. 2000. 14
  • 14. How to Know Baby Is Ready for Complementary Foods• Can sit up with support• Has good head and neck control• Has lost the “tongue thrust” reflex and is able to swallow solids• Is able to pick up objects with thumb and index finger• Shows keen interest in family meals and reaches for foods 15
  • 15. Beginning Complementary Foods• Complementary foods are an addition to breast milk, not a replacement• Breast milk continues to provide 35-40% of infant’s total daily energy needs for 12-23 months• Begin with very small amounts of complementary foods (a few teaspoons) – 6 to 8 months – 2-3 times/day – 9 to 11 months – 3-4 times/day – 12 to 24 months – 3-4 times/day plus 1-2 nutritious snacksThe requirement for breast-milk The estimated energy requirementssubstitutes after six months: from complementary foods, assuming an average breast-milk intake, are:• At 6–8 months, 600 ml/ day 200 kcal/day for infants aged 6–8 mos,• At 9–11 months, 550 ml/ day 300 kcal/day for infants aged 9–11 mos,• At 12–23 months, 500 ml/ day 550 kcal/day for child aged 12–23 mos. 16
  • 16. Only Cereals Complementary Food Cereals & PulsesCereals, Pulses & Citreous Fruits Stomach capacity of newborn to 1 yr increases by 10 times. Stomach Volume of adult is: 20.4ml/KG of BW & 30gm/KG of BW 17
  • 17. Three meals Three meals and two snacks Complementary foodsComplementary foods should be varied and include adequate quantitiesof meat, poultry, fish or eggs, vitamin A-rich fruits and vegetables daily.Where this is not possible, the use of fortified complementary foodsand vitamin mineral supplements may be necessary to ensure adequacyof particular nutrient intakes. 18
  • 18. Complementary foods Improvisation of House Hold Foods• As infants grow, the consistency • Household technologies such of complementary foods should as fermentation, soaking, change from semisolid to solid roasting and malting can foods and the variety of foods improve taste, texture, safety offered should increase. and quality of• By eight months, infants can eat complementary foods. ‘finger foods.’ • An adequate nutrient level remains a concern,• By 12 months, most children can particularly in diets that are eat the same types of food as the mainly plant-based. rest of the family. • Indian diets are often more viscous. 19 19
  • 19. Responsive Feeding• Offer complementary foods after • Feed infants directly; assist older children when they feed breastfeeding to avoid overfeeding with themselves solids and negatively impacting • Be sensitive to hunger and satiety mother’s milk supply cues• Offer only one new food at a time • Feed slowly and patiently –• Offer very small portions encourage children to eat but do (a few teaspoons at a time) not force them • Experiment with food• Vary tastes and textures combinations, tastes, and textures• Avoid potential allergy-producing foods • Minimize distractions (nuts, cow’s milk, casein) • Make feeding a time of learning and love • Learn healthy eating habits Let the Child  Feel important & loved  Feel understood and respected  Trust that others will care for him / her  Feel good about his / her body 20
  • 20. Appropriate complementary feeding Improving feeding behaviorsTimely – meaning that foods are introduced when the need for energy Improving complementary feeding and nutrients exceeds what can be requires attention to foods as well provided through exclusive and frequent breastfeeding; as to feeding behavior ofAdequate – meaning that foods provide sufficient energy, protein, and caregivers. micronutrients to meet a growing child’s nutritional needs; Infants and young children needSafe – meaning that foods are assistance that is appropriate for hygienically stored and prepared, and fed with clean hands using clean their age and developmental needs utensils and not bottles and teats; to ensure that they consumeProperly fed – meaning that foods are given consistent with a child’s signals adequate amounts of of appetite and satiety, and that meal frequency and feeding method – complementary food. actively encouraging the child to consume sufficient food using This is called responsive feeding. fingers, spoon or self-feeding – are suitable for age. 21
  • 21. Responsive Feeding• Feeding with a balance between • Feeding with positive verbal giving assistance and encouragement, without verbal encouraging self-feeding, as or physical coercion appropriate to the child’s level • Feeding with age-appropriate of development and culturally appropriate eating• Being sensitive to their early utensils hunger and satiety cues • Feeding in a protected and• Feeding by an individual with comfortable environment whom the child has a positive • Feeding times are periods of emotional relationship and who learning and love − talk to is aware of and sensitive to the children during feeding, with individual child’s characteristics, eye to eye contact including changes in physical and emotional state. 22
  • 22. Responsive Feeding• Feed slowly and patiently, • Establish regular meal and and encourage children to snack times beginning when eat, but do not force them. child is 9-12 mos old.• If children refuse many foods, experiment with • Routines help children look different food forward to each meal but combinations, tastes, don’t make the routine very textures and methods of strict. encouragement. • Research shows that children• Minimize distractions will choose a healthy diet during meals if the child when they are offered a loses interest easily. selection of different healthy• Offer 3 to 4 healthy food choices child likes at each meal. foods. 23
  • 23. Responsive FeedingDon’t force baby or toddler to eat Turn off the TV /computers, etcThis often results in children at mealtime.refusing the food and eating less. • The television can distractDon’t give up on new foods children from eating.• Patience is the key. • It also takes time away from• One may have to offer child a talking as a family.new food 10 or 15 times before Healthy eating and exercisehe/ she will eat it. go hand in handViscosity of Complementary Food Make active play a part ofFoods that are thick enough to stay everyday family life.in the spoon. 24
  • 24. Nutritional Deficiencies• Encourage children to Deficiencies in the diet are : drink and eat during illness • Energy “Cocktail“ and provide extra food • Protein Metabolic interactions after illness to help them re • Iron should be kept in mind cover quickly. • Vitamin A • Iodine while giving a "cocktail" • Zinc of various micronutrients • Copper in clinical practice. • Others are still widespread and are common causes of excess morbidity & mortality. 25
  • 25. Proper Food Handling• Wash caregivers’ and • Encourage families to children’s hands before food continue breastfeeding if preparation and eating baby becomes ill• Use clean utensils, cups, and • Avoid medications or birth bowls to prepare, serve, and control methods that can store food disrupt or endanger• Avoid the use of feeding breastfeeding bottles • Encourage the use of spoons• Serve foods immediately after and cups for feeding preparation complementary foods,• Store foods safely expressed breast milk, or breast milk substitutes 26
  • 26. Metabolic Interactions Between Various Micronutrients There is evidence for metabolic inter-relationships between different micronutrients.• Ascorbic acid is known to enhance the • Selenium deficiency may impair absorption of non- haem iron. utilization of iodine because it is a key• High intake of zinc may interfere with component of the enzyme which is absorption of iron and copper. required to convert thyroxin to• Riboflavin has an important role in the triiodothyronine. absorption, metabolism and utilization of • Molybdenum intake may aggravate iron copper deficiency because it promotes• Vitamin A helps in iron transport, urinary excretion of copper. hemoglobin production and thus • Vitamin E has a sparing effect on Vitamin A improve the status of iron stores. and Ascorbic acid by protecting them from oxidation.• Dietary phytates and tannins are • Magnesium facilitates absorption of Calcium known to interfere with the absorption from gut. of iron. • Calcium helps in the absorption of Vitamin• Zinc deficiency may aggravate B12 from the ileum but hypovitaminosis A because zinc is it interferes with absorption of Zinc. required for transport of hepatic vitamin • All Anti- Oxidants in excess act as Pro- A to the target tissues. Oxidants. 27 27
  • 27. Microbiota Impact: Current Thinking 28
  • 28. MILK MICROBIOTA COMPOSITION & MODE OF DELIVERYMODE OF DELIVERY (colostrum) MODE OF DELIVERY (6 months of breastfeeding) Cabrera-Rubio et al 2012 Am J Clin Nutr
  • 29. ORIGINAL INOCULUM REVISITED
  • 30. Approximate yield from milk (assuming no losses) Casein 32 kg Skim milk 889 kg Lactose 851 kg Casein whey 857 kg Cream 111 kg Wheywhole milk 6 kg 1000 kg(=1 tonne)
  • 31. Food Pyramid 32 32
  • 32. B r a i n d e ve l o p m e n t 5 to 6 Weeks Forebrain 7 WeeksNeurons formingrapidly,1000’s/ mts Midbrain Hindbrain• 50,000 brain cells produced/second in developing fetal brain• 100 billion brain cells in adult• 1million billion connections between these brain cells: Determine IQ.
  • 33. Human Brain Development Synapse Formation Dependent on Early Experiences Required3 Components1. Nutrition2. Prevention of infection3. Psycho Social Stimulation Synaptic Connections 34
  • 34. Maturation ProgressionMaturation generally proceeds from the back of the brain to the front.Explains in part… – Preference for physical activity (back of brain) – More risky, impulsive behaviors (limbic system) – More moody at times (limbic system) – Less than optimal planning and judgment (PFC) – Poor recognition of negative consequences (PFC) Impact of Early Stress CHILDHOOD STRESSHyper-responsive stress Chronic “fight or flight;” adrenaline /cortisolresponse; calm/coping Changes in Brain Architecture 35
  • 35. Eight Phases in Embryonic and Fetal Development at a Cellular Level1. Mitosis 2. Migration 3. Aggregation 4. Differentiation5. Synaptogenesis 6. Death 7.Rearrangement 8. Myelination Between 40 and 75 % of all neurons born in embryonic and fetal development do not survive.
  • 36. Brain Cell Connections in the Early Monthsnewborn 1 month 3 months 6 months6 Years Old 14 Years Old 37
  • 37. Out of BalancePrefrontal Cortex Amygdala Cold Cognition Hot Cognition Judgmental Emotional Reflective Reactive Calculating Impulsive Think about it Just do it Biological maturity by 24 Biological maturity by 18 Adapted from Ken Winters, Ph.D. 38
  • 38. Parenting as Primary Prevention of Ill HealthPromoting Parenting Skills in the first 1000 days– Parenting is personal – makes pediatricians NERVOUS!– “Positive/Nurturing/Supportive” Parenting– Are parenting skills “teachable?” YES!!• Early maternal supportexerts a positive influenceon hippocampaldevelopment• The positive effect ofmaternal support onhippocampal volumes wasgreater in nondepressedchildren Lusby et al., 2012. Available at: www.pnas.org/cgi/doi/10.1073/pnas.1118003109 39
  • 39. ThanksNation’s prospect depends on the Nutritional Status of People of that Country. 40

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