Artificial and complementary feeding

1. Supplementary Feeding and assessment of nutritional status
Yrzabek Dana GM 95

2. 2
Early initiation of
breastfeeding (within
1 hour of birth)
Exclusive
breastfeeding
(0-<6m)
Continued breastfeeding
(2 years or beyond)
Complementary
foods
Safe
and
appropriate
infant
and
young
child
feeding
in
emergencies
Complementary feeding (6-<24m)
Optimal infant and young child feeding recommendations

3. 3
Only breastmilk, no other
liquids or solids, not even
water, with the exception of
necessary vitamins, mineral
supplements or medicines.
0-<6 months
Exclusive breastfeeding
6-<24 month olds
Support for continued
breastfeeding for 2 years or
beyond
Introduce safe and appropriate
complementary foods
Frequent feeding, adequate
food, appropriate texture and
variety, active feeding,
hygienically prepared (FATVAH)
Complementary feeding

4. Assesment of nutritional status
WHAT FOR?
4
Normal growth is a sign of good health in
children.
Monitoring growth allows early detection of
the causes of poor growth.
Early recognition of poor growth allows early
intervention optimizing the possibility of
achieving good health and a normal adult
height.

5. Factors afecting growth & development
• Genes
• Racial/ethnic differences
• Hormones
• Nutrition
PediatricNutritionin Practice, KoletzkoB, KargerPublishers, 2008
5

6. Nutritional assessment
• Growth assessment (anthropometric measurements)
• Dietary, medical, and medication history
• Physical examination
• Laboratory tests
6

7. Growth evaluation
• obtaining, plotting and interpreting
• weight,
• length,
• head circumference
Standardized equipement
Growth charts
7

8. Heigh/ lenght
8

9. Heigh
9

10. Growth charts
• WHO (Growth standards< 5 yo, growth reference: 5-19 yo)
• OLA/OLAF (3-18 yo) –Polish population
• Specific groups of patients(cerebralpalsy, prematureinfants, Down
syndrome)
10

11. Percentiles vs SD
11

12. BMI in children
12

13. Malnutrition – failure to thrive in childhood is a state of undernutrition due to:
•inadequate caloric intake,
•inadequate caloric absorption,
•excessive caloric expenditure
In children without obvious organic symptoms 92
percent were diagnosed with a behavioral cause of
FTT.
The absence of obvious nonorganic symptoms does not
completely exclude a nonorganic cause of FTT.
13

14. 14

15. 15

16. 16

17. NUTRITION
17

18. Human milk
• nutrients, such as proteins, lipids, carbohydrates, minerals, vitamins, and
trace
• immune-related components such as sIgA, leukocytes, oligosaccharides,
lysozyme, lactoferrin, interferon-g, nucleotides, cytokines, and others.
18

19. Breastfeeding
Breast-feeding is the natural and advisable way of supporting the healthy
growth and development of young children.
The definition of exclusive breast-feeding by the World Health
Organisation (WHO) implies that the infant receives only breast milk
and no other liquids or solids except for drops or syrups consisting of
vitamins, mineralsupplements, or medicines.
Exclusive breast-feeding for around 6 months is a desirable goal, but partial
breast-feeding as well as breast-feeding for shorter periods of time are also
valuable.
Continuation of breast-feeding after the introduction of
complementary feeding is to be encouraged as long as mutually desired
by mother and child.
19

20. Exclusive breastfeeding
0-6 months!
• Infants should be exclusively breastfed for the first six months of life to
achieve optimal growth, development and health.
• Thereafter, to meet their evolving nutritional requirements, infants should
receive nutritionally adequate and safe complementary foods, while
continuing to breastfeed for up to two years or beyond.
20

21. Exclusive breastfeeding – reality in Europe
AT START (0 m/o)
•initiation of breast-feeding ≥90% in 14 countries; 60% to 80% in 6 other
countries; <60% in France, Ireland, and Malta.
AT THE END (6 m/o)
•rate of ANY breast-feeding at 6 months was more than 50% in only 6 countries.
HOW TO DEAL WITH IT?
21

22. Breastfeeding in Europe
22

23. Breastfeeding - benefits
23

24. Breastfeeding contraindications
1. HIV infection in mother:
•Transmission of HIV during breast-feeding.
•To minimise the risk of HIV-transmission, WHO recommends ‘‘when
replacement feeding is acceptable, feasible, affordable, sustainable and safe,
avoidance ofall breast-feeding by HIV-infected mothers is recommended,
otherwise, exclusive breast-feeding is recommended during the first months of
life’’. In Europe.
2. HTLV – 1/2 infection in mother
3. Herpes simplex lesions on a breast
4. Mothers who are receiving diagnostic or therapeutic radioactive isotopes or
have had exposure to radioactive materials, and in those who are receiving
specific medications @LactMed®
5. Classic variant of galactosaemia,
24

25. Supplementation in breast-fed infants
• Breast-fed infants should receive daily vitamin D supplementation regardless
of maternal vitamin D status.
• During the complementary feeding period, >90% of the iron requirements of
a breast-fed infant must be met by complementary foods.
• All infants should receive an oral supplementation of 400 IU/day of vitamin
D. The implementation should be ensured and supervised by paediatricians
and other health care professionals.
• In accordance with the European Food Safety Authority, the upper limit of
safety is set at 1000 IU/day for infants.
25

26. Complementary Feeding
26

27. Complementary Feeding
• The term ‘‘complementary feeding’’ should embrace all solid foods and liquids
other than breast milk or infant formula and follow-on formula.
• Avoidance or delayed introduction of potentially allergenic foods, such as fish
and eggs, has not been convincingly shown to reduce allergies, either in infants
considered at risk for the development of allergy or in those not considered to
be at risk.
• During the complementary feeding period, >90% of the iron requirements of a
breast-fed infant must be met by complementary foods. These should provide
sufficient bioavailable iron.
• Cow’s milk is a poor iron source. It should not be used as the main drink before
12 months, although small volumes may be added to complementary foods.
• Infants and young children receiving a vegetarian diet should receive a
sufficient amount (500 mL) of milk (breast milk or formula) and dairy products.
• Infants and young children should not receive a vegan diet.
27

28. Recommendations on obesity- ESPGHAN
1. The origin of obesity is multifactorial. Dietary interventions should be incorporated
into a multidisciplinary strategy for obesity prevention.
2. No single nutrient has been unequivocally associated with the development of
overweight and obesity.
3. Methodological limitations in study design and the complex nature of obesity must be
taken into account when interpreting the association with some of the reported dietary
factors.
4. Energy intake should be individually determined, taking into account energy
expenditure and growth.
5. Preferential intake of slowly absorbed carbohydrates, along with limiting the supply
of rapidly absorbed carbohydrates and simple sugars, should be promoted.
6. With respect to obesity prevention, no recommendations on fat quantity and quality,
protein or amino acid intake, or calcium and dairy product intake can be made.
7. No dietary modulators of gut microbiota can be recommended for obesity prevention.
28

29. 8. Plant foods can be used as the main food contributors to a wellbalanced diet. When
a vegetarian diet is practiced, appropriate planning (taking into account recommended
macro- and micronutrient intakes) and monitoring (growth and potentially zinc, iron,
vitamin B12, and vitamin D status) should be executed by a health care professional.
9. Sugar-sweetened beverages are a significant contributor to energy intake. Plain
water should be promoted as the main source of fluids for children.
10. Children should eat at least 4 meals, including breakfast, every day. Regular family
meals should be encouraged.
11. Fast food with large portion sizes and high energy density should be avoided.
12. Healthy food options should be promoted for snacking.
13. Food portion sizes should be appropriate for age and body size.
14. Nutrition and lifestyle education aimed at the prevention of obesity should be
included in the routine care of children by general paediatricians and other health
professionals.
29

30. Example of agreed criteria
Example of agreed criteria
for use of alternatives to mother’s milk
• Mother has died or is unavoidably absent
• Mother is very ill (temporary use may be all that is necessary)
• Mother is relactating (temporary use)
• Mother tests HIV positive and chooses to use a breastmilk substitute
• Mother rejects infant (temporary use may be all that is necessary)
• Infant dependent on artificial feeding* (use to at least six months or temporarily until
achievement of relactation)
* Babies born after start of emergency should be exclusively breastfed from birth.
30

31. Conditions to reduce dangers of artificial feeding:
Conditions to reduce dangers of artificial feeding:
the breastmilk substitutes
• Infant formula with directions in users’ language
• Supply of breastmilk substitutes until at least six months or until relactation
achieved. For six months, 20 kg of powdered formula is required, or equivalent
in other breastmilk substitutes
• Milk and other ingredients used within expiry date
• Home-modified animal milk must be adapted/modified according to specific
recipes and micronutrients added, HOWEVER, nutritional adequacy is unlikely
to be reached. Therefore, this should only be used as a last resort.
However, caregivers need more than milk.
31

32. 32

33. Energy
Sources of energy:
–fat is the principal source for infants under 6
months of age, approximately 50%
–carbohydrate – its role as an energy source
increases with the introduction of
complementary food
–protein

34. 0 – 6 monthsEnergy 110 to 140 kcal / kg
► Protein requirement is about 2 gm/kg
► Calcium 500mg/day
► Best food for the neonate is mother’s milk
RDA 6 to 12 monthsEnergy 98 kcal/kg
► Protein 1.65 gm/kg
► Calcium 500mg/kg
► Vitamin A 1550mcg/d
► Vitamin B1 50mcg/kg, B2 65mcg/kg
► Vitamin C 25mg/d
34

35. Energy requirement from BM and
complementary foods in kcal
Age (months) Industrialised countries
Breast-milk
(kcal)
Complementary
foods (kcal)
0-2 490 0
3-5 548 2
6-8 486 196
9-11 375 455
12-23 313 779

36. 36
Minimum daily number of meals for
children with low level of BM
Energy density
(kcal/g)
6 – 8
months
9 – 11
months
12 – 23
months
0.6 3.7 4.1 5.0
0.8 2.8 3.1 3.7
1.0 2.2 2.5 3.0

37. Energy requirements of infants and young children
Energy requirements of infants and young children per kilogram body weight are 2-3
times those of adults: the energy density of complementary foods is the key factor
determining energy intake.
• Factors affecting the energy density of complementary foods:
– fat (+)
– sugar (+)
– breast-milk (+)
– meal frequency (+)
– water (-)
– viscosity of complementary foods (-)
37

38. Gastric capacity in ml
(30 ml/ kg body weight)
Age
6 – 8 months
Age
9 – 11 months
Age
12 – 23 months
250 ml 285 ml 345 ml

39. 39

40. Proteins
• Recommended values of proteins were
extremely high in former SU, almost twice
a high per kg body weight than e.g. in
USA.
• Note! Infants and young children in former
Soviet Union were quite never deficient in
proteins.

41. Fat
Sources
• "visible" fats – cooking oils, butter, vegetable
oils (olive, sunflower, maize, and others), fat on
meats
• "invisible" fats – added to foods during
preparation and cooking and in the process of
food production (mayonnaise, sausages, etc.)
• Most infant formulas do not contain one of the
fatty acids essential for the developing brain
(docosahexaenoic acid).

42. Balance of fat intake
• During the introduction of complementary
foods and up to at least 2 years of age, it is
recommended that fats be included in the
diet providing for 30-40% of the total
energy intake.
• Too little fat: possible decrease in energy
intake.
• Too much fat: possible decrease in
micronutrient density.

43. Carbohydrates
• Consumption of added sugar should be
limited to a level providing up to 10% of the
total energy content of the diet.
• A high intake may worsen the vitamin and
mineral status.
• Sugars are present also in soft drinks in
large amounts, in “kompots” and “varenie”
as well.

44. Vitamin A
• Vitamin A is obtained from animal products as
provitamin retinol,
• or is converted from carotenes, in particular, a-,
b- and g- carotenes found in vegetable food.
• There are high levels of retinol in liver, milk
products, eggs and fish.
• Dark-green leafy vegetables and yellow and/or
orange fruit and vegetables (carrots, pumpkin,
apricots) are rich sources of carotenes.

45. Deficit and toxic effect of vitamin A
• A moderate decrease in the level of vitamin A
in the body without clinical signs is associated
with reduced resistance to infection.
• Moreover, vitamin A deficiency contributes to
the development of anaemia.
• The toxic effect including bone and liver
damage, may result from high doses of retinol,
especially when vitamin A supplements are
administered for a long period of time.

46. Sources of vitamin D
• The body obtains vitamin D primarily
through synthesis in the skin exposed to
the ultraviolet B radiation from sunlight.
• Foods rich in vitamin D include fatty fish
(sardines, salmon, herring, tuna), some of
the milk products (including infant
formulas), eggs, beef and liver.

47. Deficit of vitamin D
• The vitamin D status of newborns largely depends on
the mother's status. If the stores and intake of vitamin
D of the pregnant woman were low, then the newly
born baby will also have a low concentration in the
plasma and a low store of this vitamin.
• The content of vitamin D in complementary foods is
usually low, therefore, exposure to sunlight is
important for infants and children under 3 years of
age.
• Children with most of the skin protected from the
sunlight with clothes, dark-skinned children, those
living in northern latitudes and vegetarians are
vulnerable to the risk of developing vitamin D
deficiency.
• Vitamin D deficiency results in rickets in children and
osteomalacia in adults.

48. Vitamin C
• Vitamin C is required for the optimal functioning of
the immune system, for the processes of
haemopoiesis, collagen synthesis, it has an
antioxidant effect, stimulates absorption of non-
haem iron and facilitates transport of iron to tissues
by release from transferrin.
• Vegetables and fruit, berries, especially spinach,
tomatoes, potatoes, cabbage, currants, dog rose
fruit, citrus fruits are good sources of vitamin C.
Small amounts of vitamin C are present in animal
products (liver, brain, muscles).
• The vitamin is labile, a considerable proportion of it
is destroyed by cooking and prolonged storage.

49. Iodine
• Inadequate iodine intake results in impaired
synthesis of thyroid hormones that are required
for normal growth and mental development of
the infant, oxygenation of cells and
maintenance of basic metabolism.
• The content of iodine in animal and vegetable
products depends on the environment in which
these are grown. Sea fish and sea foods are
rich natural sources of iodine (160-1400 mg/kg).
About 200 g of sea fish per week can meet the
requirements of young children for this trace
element (50 mg/day).

50. Iodine fortification
• Iodized salt may be a source of iodine,
where natural sources are not available.
But:
• Note! Young children, especially in the first
4 months of life, have a limited ability of
their renal-excretory system to control
excessive sodium. Therefore, salt intake
should be low, and there is no need to add
salt during cooking for young children.

51. Specific needs of children living with
HIV
• deficit of B6, B12 is associated with faster
progression to the stage of AIDS
• normal level of B12 (>120 pmol/l) would
delay the progression to AIDS with 4 years
• increase of vitamin E ( >23 umol/l) delays
with 1.5 year
• deficit of vitamin A, D and zinc is
associated with faster progression to AIDS

52. Basic rules of successful
complementary feeding
• Choose the most appropriate time for
giving complementary food during the day,
• when the infant is most disposed or
hungry,
• and the mother can give more time to her
baby.
• The time before noon is to be preferred.

53. Basic rules II.
• Any complementary food should be introduced slowly,
starting with a teaspoon and gradually increasing to
full volume.
• Initially, it should be a homogeneous, medium-
consistency single-ingredient puree made of some of
the more typical products in the area, such as rice
porridge or mashed potatoes.
• To facilitate and expedite the infant's getting
accustomed to new foods, it is recommended that
expressed breast-milk be added to the complementary
food being introduced. In order to prevent reduction in
breast-milk production, a complementary food may be
introduced after breastfeeding.

54. Basic rules III.
• 5-6 days after the first complementary food has
been introduced, a 2nd one is added,
• then, in another 5-6 days, a 3rd one.
• The variety of foods used in infant's diet should
be increased during this time, adding various
multi-ingredient dishes, such as:
meat + vegetables, meat + vegetables* +
cereals, vegetables* + cereals, vegetables* +
fruit + cereals, etc.
* Including legumes: beans, peas, lentils

55. Quality of complementary food
Each time the infant takes complementary food,
the meal should be adequate in terms of its
• energy
(ensured by giving food which has the volume
and consistency that is appropriate for the
infant's age)
• nutrient value.
(variety of foods used)

56. Energy density of complementary foods
• The energy density should be, on the average,
at least 1 kcal per gram, depends on the
frequency of feeding.
• A lower calorific value is allowed only with an
increased frequency of feeding.

57. Correct Norms for Infant and Young Child
Feeding
Initiation of breastfeeding immediately after birth, preferably within one hour.
► Exclusive breastfeeding for the first six months
► Receives only breast milk and nothing else, no other milk. Food, drink or water.
► Appropriate and adequate complementary feeding from six months of age while
continuing breastfeeding.
► Continued breastfeeding up to the age of two years.
57

58. Feeding and assessment of nutritional status