GUIDING%20PRINCIPLES%20FOR%20COMPLEMENTARY%20FEEDING%20OF%20THE%20BREASTFED%20CHILD

1
.

• .

GUIDING PRINCIPLES FOR COMPLEMENTARY FEEDING
OF THE BREASTFED CHILD Dr. Chessa
Lutter Child and Adolescent Health PAHO
2
Goal

• To develop a set of unified, scientifically based
  guidelines that can be adapted to local feeding
  practices and conditions

3
Development and Review Process

• Written by Kathryn Dewey, coordinated by PAHO
• Reviewed at Global Consultation for CF (Dec 2001)
• Revised and presented at the WHO Informal Meeting
  on Indicators for CF (Dec 2002)
• Extensive list serve discussion

4
Target Group

• Normal term infants
• Breastfed
• First two years of life
• 6-8 months
• 9-11 months
• 12-23 months

5
Format

• Guideline Ten specific guidelines, some with
  subsections
• Scientific rationale length differs depending
  on evidence base
• Tables include one on potential assessment needs
  and actions

6
Estimates of deaths averted in children lt 5 years
from preventive interventions (Jones et al.,
Lancet 2003)
Preventive interventions Number of deaths (x103) Proportion of total deaths
Breastfeeding 1301 13
Insecticide treated bed nets 691 7
Complementary feeding 587 6
Zinc 459 (351) 5 (4)
Safe birth 411 4
HIB vaccine 403 4
Water, hygiene, and safe disposal of sewage 326 3
Antenatal steroids 264 3
Management of temperature in newborns 227 2
Vitamin A supplementation 225 2
7
Estimates of deaths averted in children lt 5 years
through treatment interventions (Jones et al.,
Lancet 2003)
Treatment interventions Number of deaths (x103) Proportion of total deaths
Oral rehydration therapy 1477 15
Antibiotics for sepsis 583 6
Antibiotics for pneumonia 577 6
Treatment for malaria 467 5
Zinc 394 4
Newborn resucitation 359 (0) 4 (0)
Antibiotics for diarrhea 310 3
Vitamin A 8 lt1
8
Distribution of the 11.6 million under 5 child
deaths in the developing world
Malaria
Malnutrition54
Measles
Perinatal causes
Other causes
Diarrhea
ARI

• Source The Global Burden of Disease 1996,
  edición de Murray C.j.l. y López A.D., y
  Epidemiologic evidence for a potentiating effect
  of malnutrition on child mortality, Pelletier
  D.L, Frongillo E.A. y Habicht J.P., AMJ Public
  Health 199383 1130-1133.

9
Global weight-for-age Z-scores
0.5
0
-0.5
WAZ-scores
-1
-1.5
-2
0
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
53
55
57
59
Age
Africa
Latin America and Caribbean
Asia
Source Shrimpton, R. et al, 2001.
http//www.pediatrics.org/cgi/content/full/107/5/e
75
10
Global height-for-age Z-scores
HAZ-scores
-2.5
0
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
53
55
57
59
Age
Africa
Latin America and Caribbean
Asia
Source Shrimpton, R. et al, 2001.
http//www.pediatrics.org/cgi/content/full/107/5/e
75
11
Prevalence of stunting, low weight, and low
weight-for-height (lt-2 SD) in children in
Latin America and the Caribbean
12
Stunting (height-for-age lt -2 SD in the Region
Guatemala 1995
Haiti 1994/95
Bolivia 1993/94
Nicaragua 1998
Paraguay 1990
Peru 1996
Colombia 1995
Dom. Rep. 1996
Brazil 1996
36
7
0
5
9
11
13
15
17
19
21
23
25
27
29
31
33
35
3
Age (months)
13
Low height and weight for age and weight for
height, Bolivia
Percent
50
VULNERABLE AGE
40
Stunting
30
Low weight
20
10
Low weight-for-age
0
0
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
Age (Months)
Note Stunting reflects chronic
malnutrition wasting reflects acute
malnutrition underweight
reflects chronic or acute malnutrition, or a
combination of both. Plotted values are
smoothed by a five month moving average.
Source Demographic Health Surveys
14
1. DURATION OF EXCLUSIVE BREASTFEEDING AND AGE OF
INTRODUCTION OF COMPLEMENTARY FOODS

• Guideline Practice exclusive breastfeeding from
  birth to 6 months of age, and introduce
  complementary foods at 6 months of age (180 days)
  while continuing to breastfeed.

15
WHO Expert Consultation on the Optimal Duration
of Exclusive Breastfeeding, 2001

• Rationale for 6 months exclusive breastfeeding
• protective against gastrointestinal infections
• prolongs duration of lactational amenorrhea
• accelerates maternal weight loss
• may enhance infant motor development
• no adverse effects on infant growth

16
Breastfeeding and risk of mortality, Brazil
Victora et al., Lancet 1987
17
Breastfeeding and risk of mortality by age
Victora et al., Lancet 1987
18
Nutritional adequacy of exclusive breastfeeding
for six months

• Nutrients that may become limiting
• Iron
• Zinc
• Vitamin D
• Other vitamins, if maternal diet inadequate
• Medicinal supplements more beneficial than
  complementary foods when nutrients limiting

19
2. MAINTENANCE OF BREASTFEEDING

• Guideline Continue frequent, on-demand
  breastfeeding until 2 years of age or beyond

20
Potential advantages of breastfeeding beyond 12
months

• Breast milk provides 35-40 of energy
• Key source of fat, vitamin A, calcium, riboflavin
• May delay maternal return to fertility
• Decreased risk of morbidity mortality in
  populations with high risk of contamination
• Protects maternal health

21
Breastfeeding and risk of mortality by age
Victora et al., Lancet 1987
22
Breastfeeding and mortality by cause
WHO Collaborative Team, Lancet 2000
23
Breastfeeding and risk of gastroenteritis in the
U.S.
Duffy et al., Am J Public Health 1987
24
Breastfeeding and morbidity in Belarus
Kramer et al., JAMA 2001
25
Breastfeeding and risk of obesity in German
school children
months
Von Kries et al., Br Med J 1999
26
Front page Washington Post 2002 Mortenson et
al., JAMA 2002
27
Duration of breastfeedng and IQ in adults
(Mortenson et al., JAMA 2002)
28
Riesgo de cáncer de mama (premenopausia) en
mujeres que amamantó
29
3. RESPONSIVE FEEDING

• Guideline Practice responsive feeding, applying
  the principles of psycho-social care.
  Specifically
• a) feed infants directly and assist older
  children when they feed themselves, being
  sensitive to their hunger and satiety cues
• b) feed slowly and patiently, and encourage
  children to eat, but do not force them
• c) if children refuse many foods, experiment
  with different food combinations, tastes,
  textures and methods of encouragement
• d) minimize distractions during meals if the
  child loses interest easily
• e) remember that feeding times are periods of
  learning and love - talk to children during
  feeding, with eye to eye contact

30
Impact of responsive feeding practices

• Effects not yet well documented
• Interventions that included feeding behaviors as
  part of the overall package have reported a
  positive effect on child growth

31
4. SAFE PREPARATION AND STORAGE OF COMPLEMENTARY
FOODS

• Guideline Practice good hygiene and proper food
  handling by
• washing caregivers and childrens hands before
  food preparation and eating
• storing foods safely and serving foods
  immediately after preparation
• using clean utensils to prepare and serve food
• d) using clean cups and bowls when feeding
  children
• e) avoiding the use of feeding bottles, which
  are difficult to keep clean
• (see WHO Complementary Feeding Family Foods for
  Breastfed Children, 2000 for additional details).

32
Risk of diarrheal disease

• Peak incidence is 6-24 months, and is linked to
  contaminated complementary foods
• Feeding bottles in particular are likely to be
  contaminated (gt 30 in peri-urban Peru)

33
5. AMOUNT OF COMPLEMENTARY FOOD NEEDED

• Guideline Start at six months of age with small
  amounts of food and increase the quantity as the
  child gets older, while maintaining frequent
  breastfeeding. The energy needs from
  complementary foods for infants with average
  breast milk intake in developing countries are
  approximately
• 200 kcal per day at 6-8 months of age,
• 300 kcal per day at 9-11 months of age, and
• 550 kcal per day at 12-23 months of age.

34
Changes in energy recommendations
35
Energy needs from complementary foods (kcal/d),
based on revised total energy requirements (for
breastfed infants)

• Infant age
  (months)
• 6-8
  9-11 12-23
• Total energy needs 615 686 894
• Breast milk energy -413 -379 -346
• Energy needs from
• comp. foods 200 300 550

36
6. FOOD CONSISTENCY

• Guideline Gradually increase food consistency
  and variety as the infant gets older, adapting to
  the infants requirements and abilities. Infants
  can eat pureed, mashed and semi-solid foods
  beginning at six months. By 8 months most
  infants can also eat finger foods (snacks that
  can be eaten by children alone). By 12 months,
  most children can eat the same types of foods as
  consumed by the rest of the family (keeping in
  mind the need for nutrient-dense foods, as
  explained in 8 below). Avoid foods that may
  cause choking (i.e., items that have a shape
  and/or consistency that may cause them to become
  lodged in the trachea, such as nuts, grapes, raw
  carrots).

37
Oral neuromuscular development

• 0-6 mo Suckle/suck and swallow
• 4-7 mo Appearance of early munching
• 7-12 mo Biting, chewing
• Lateral movements of tongue movement of
  food to teeth
• 12-24 mo Rotary chewing movements

38
7. MEAL FREQUENCY ENERGY DENSITY

• Guideline Increase the number of times that the
  child is fed complementary foods as he/she gets
  older. The appropriate number of feedings depends
  on the energy density of the local foods and the
  usual amounts consumed at each feeding. For the
  average healthy breastfed infant, meals of
  complementary foods should be provided
• 2-3 times per day at 6-8 months of age and
• 3-4 times per day at 9-11 and 12-24 months of
  age.
• Additional nutritious snacks (such as a piece of
  fruit or bread or chapatti with nut paste) may be
  offered 1-2 times per day, as desired. Snacks are
  defined as foods eaten between meals - usually
  self-fed, convenient and easy to prepare. If
  energy density or amount of food per meal is low,
  or the child is no longer breastfed, more
  frequent meals may be required.

39
Rationale guided by three concepts

• The minimum number of meals required to attain
  the level of energy needed from complementary
  foods given mean energy densities of typical
  complementary food diets
• The minimum energy density (kcal/g) required to
  attain the level of energy needed from
  complementary foods in 2-5 meals per day by
  children in developing countries with low or
  average level of breast milk intake
• The relationship between meal frequency, BF
  frequency, and BF time before and after
  intervention to increase number of meals per day
  in Guatemala.

40
Meal frequency, BF frequency, and BF time before
and after an intervention to promote 5 meals/d in
Guatemala (Rivera et al., 1998)

• Meal Freq BF Freg BF time
• 6-12 mo (per 24 h) (per 12 h) (min/12 h)
• Before 3.1 8.1 54
• After 3.5 6.2 35
• ? 0.4 - 1.9 - 19 (p0.07)
• 13-18 mo
• Before 5.1 6.3 44
• After 3.7 7.9 39
• ? - 1.4 1.6 - 5
• 19-24 mo
• Before 5.0 6.9 41
• After 5.4 3.7 19
• ? 0.4 - 3.2 - 22

41
8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS

• Guideline Feed a variety of foods to ensure that
  nutrient needs are met. Meat, poultry, fish or
  eggs should be eaten daily, or as often as
  possible. Vegetarian diets cannot meet nutrient
  needs at this age unless nutrient supplements or
  fortified products are used (see 9 below).
  Vitamin A-rich fruits and vegetables should be
  eaten daily. Provide diets with adequate fat
  content. Avoid giving drinks with low nutrient
  value, such as tea, coffee and sugary drinks such
  as soda. Limit the amount of juice offered so as
  to avoid displacing more nutrient-rich foods.

42
Problem Nutrients

• Nutrients for which there is the greatest
  discrepancy between their content in
  complementary foods and the estimated amount
  required
• Identified by comparing observed nutrient density
  (amount per 100 kcal) with desirable nutrient
  density

43
Proportion () of nutrients that complementary
foods must provide for a 68 mo breastfed child

44
Estimated average iron requirement by reference
weight
45
Desired density of micronutrients per 100 kcal
(Dewey y Brown, 2003)
Perú
México
Guatemala
WHO (1998)
0.4
0.6
0.5
4.0
Iron (mg)
0.5
0.4
0.4
0.8
Zinc (mg)
19
60
27
125
Calcium mg)
--
0.06
0.07
0.09
Vitamin B-6 (mg)
46
Mean intake of nutrients provided by fortified
complementary food

47
Contribution of the fortified complementary food
to intake from the regular diet
Iron
Energy
12
1000
240
10
750
8
8.7
gr
Kcals
500
6
4
250
801
791
4.0
2
3.5
0.0
Programa
No-programa
Programa
No-programa
P lt0.0001
P 0.005
Nota el grupo de programa en este analisis
incluya solamente los niños que consumieron Mi
Papilla
48
(No Transcript)
49
Distribution of hemoglobin (g/dl), final survey
25
20
15
Frequencia
10
5
0
8
9
10
11
12
13
14
15
Hemoglobina (g/dl)
Programa
Non programa
50
Summary of problem nutrients

• Iron, zinc and vitamin B6 in most developing
  country populations
• Riboflavin and niacin in certain populations
• Calcium, vitamin A, thiamin, folate, vitamin C -
  judgment depends on which set of desired nutrient
  densities is used

51
Effects of added fat on energy, protein and iron
densities of maize pap

• Traditional Fat-added
• maize pap maize pap
• Amount of maize (g/100 g) 7 7
• Amount of fat (g/100 g) 0 5
• Energy density (kcal/g) 0.28 0.73
• Protein density ( energy) 8.9 3.3
• Iron density (mg/100 kcal) 0.5 0.2

52
9. USE OF VITAMIN-MINERAL SUPPLEMENTS OR
FORTIFIED PRODUCTS FOR INFANT AND MOTHER

• Guideline Use fortified complementary foods or
  vitamin-mineral supplements for the infant, as
  needed. In some populations, breastfeeding
  mothers may also need vitamin-mineral supplements
  or fortified products, both for their own health
  and to ensure normal concentrations of certain
  nutrients (particularly vitamins) in their breast
  milk. Such products may also be beneficial for
  pre-pregnant and pregnant women.

53
Rationale for supplements or fortified products -
infants

• Predominantly plant-based diets provide
  insufficient amounts of key nutrients
• Animal-source foods are costly and amounts
  consumed by infants may be insufficient
• Of 23 complementary food mixtures evaluated by
  Gibson et al. (1998), none met desired iron
  density few met desired zinc or calcium density

54
Rationale for supplements or fortified products -
mothers

• Certain nutrients in breast milk can be affected
  by maternal diet (vit A, thiamin, riboflavin, vit
  B6, vit B12, iodine, selenium)
• First choice is improvement of mothers diet, but
  cost-constraints limit options
• Adequate micronutrient intake during lactation
  can benefit both mother infant

55
10. FEEDING DURING AND AFTER ILLNESS

• Guideline Increase fluid intake during illness,
  including more frequent breastfeeding, and
  encourage the child to eat soft, varied,
  appetizing, favorite foods. After illness, give
  food more often than usual and encourage the
  child to eat more.

56
Merci!