SECTION 4
Pediatric Health and Nutrition Immunization Immunization, according to the World Health Organization (WHO), is a process by which a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine.1 Vaccines help in stimulating the body’s immune system, which can protect individuals against infection or disease.1 The WHO estimates suggest that immunization averts about 2–3 million deaths each year.1 Immunization is recommended in children to prevent several diseases from birth until 18 years of age. There are four different types of vaccines, namely (i) attenuated vaccines which are weakened live viruses used in certain vaccines for measles, mumps, and rubella (MMR); (ii) killed vaccines, which have inactivated bacteria or virus such as IPV; (iii) toxoid vaccines which contain the inactivated toxin of the bacteria; tetanus and diphtheria vaccines are toxoid vaccines, and (iv) conjugate vaccines which contain parts of the bacteria and protein, for example, the Hib vaccine.2 Committee on Vaccines and Immunization Practices recommends an immunization schedule to be followed among children aged from 0 to 18 years. Figure 1 shows the scheduled vaccines for the particular age group.3 Fig. 1: Immunization schedule.3
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Section 4: Pediatric Health and Nutrition
Nutritional Requirements4 Good nutrition is vital for the growth and development occurring during the first year of an infant’s life. Consumption of appropriate quantities and types of foods provides adequate amount of essential nutrients. Several factors influence the energy or caloric requirements of an infant. These include body size and composition, metabolic rate (the energy the body expends at rest), physical activity, size at birth, age, sex, genetic factors, energy intake, medical conditions, ambient temperature and growth rate. The birth weight of healthy infants doubles by 6 months of age, and triples by 12 months of age.
Carbohydrates Carbohydrates are classified into monosaccharides (e.g. glucose, galactose, fructose and mannose); disaccharides (e.g. sucrose, lactose and maltose); and polysaccharides (e.g. starch, dextrins and glycogen). Indigestible complex carbohydrates of plant origin are also referred to as dietary fibers. Functions of Carbohydrates in Infants’ Diet The functions of carbohydrates in infants’ diet are as follows:
They supply food energy for growth, activity and body functions
They enable the protein in the diet to be efficiently utilized for building new tissue
They allow normal use of fats in the body
Provide building blocks for some essential body compounds Sources of Carbohydrates in Infants’ Diet
Lactose is the major carbohydrate normally consumed by young infants. It is present in breast milk and cow’s milk-based infant formula. Additional sources of carbohydrates in later infancy include cereal and other grain products, fruits and vegetables. Legumes, whole-grain foods, fruits and vegetables are a good source of dietary fiber. Breast milk does not contain dietary fiber. Infants generally do not consume fiber in the first 6 months of life.
Proteins All proteins, whether in the body or in the food we eat, are made up of individual units known as amino acids. Twenty amino acids which make up proteins are classified into two basic groups—essential (or indispensable) and nonessential (or dispensable). Essential amino acids cannot be synthesized by the body and must be obtained from the diet. Functions of Proteins
Build, maintain and repair tissues (e.g. tissues of the eyes, skin, muscles, heart, lungs), manufacture important enzymes, hormones, antibodies, etc.
Serve as a potential source of energy, if sufficient energy is not obtained from carbohydrate or fat in the diet.
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Perform very specialized functions in regulating body processes. Sources of Proteins
Breast milk and infant formulas provide sufficient protein to meet a young infant’s needs if consumed in adequate amounts. During later infancy, in addition to breast milk and infant formula, sources of protein include meat, poultry, fish, egg yolks, cheese, yogurt, legumes, and cereals and other grain products.
Lipids
Essential Amino Acids Isoleucine Threonine Leucine Tryptophan Lysine Valine Methionine Histidine
Phenylalanine Lipids include fats, oils, and fat-like substances, such as cholesterol. Fatty acids form the major constituents of many lipids. Fatty acids that cannot be synthesized by the body are referred to as essential fatty acids, for example, linoleic acid and -linolenic acid. The fatty acids, arachidonic acid (ARA) and docosahexaenoic acid (DHA) are derived from linoleic acid and -linolenic acid, respectively. They are referred to as long-chain polyunsaturated fatty acids (LCPUFA). Functions of Fats
Serve as a major source of energy (approximately 50% of the energy consumed in breast milk and infant formula)
Promote the accumulation of stored fat in the body. The stored fat acts as an insulation to reduce body heat loss and as a cushion to protect body organs
Facilitate the absorption of the fat-soluble vitamins A, D, E, and K
Provide essential fatty acids required for normal development of brain, healthy skin, hair and eyes
Provide resistance to infection and diseases Sources of Fats
During infancy, breast milk and infant formula are vital sources of lipids, including essential fatty acids. Although the lipid content of breast milk varies, after about the first 2 weeks postpartum, breast milk provides approximately 50% of its calories from lipids.Infant formula also provides nearly 50% of its calories from lipids. Breast milk provides about 5.6 g/L of linoleic acid and approximately 0.63 g/L of n-3 polyunsaturated fatty acids (-linolenic acid and DHA). On the contrary, infant formula provides 3.3–8.6 g/L of linoleic acid and 0–0.67 g/L of -linolenic acid and DHA. In the older infant’s diet, food sources of lipids other than breast milk and infant formula are meats, cheese and other dairy products, egg yolks, and any fats or oils added to home-prepared foods.
Vitamins Infants’ diet should not be supplemented with vitamin or mineral during the first year of life, unless prescribed by a healthcare provider. Excessive amounts of certain vitamins and minerals can be toxic or even fatal to infants.
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Functions and Sources of Vitamins in Infants’ Diet
Water-Soluble Vitamins Vitamin
Functions
Sources
B1 (thiamin)
Helps the body to release energy from carbohydrates during metabolism and plays a crucial role in the normal functioning of the nervous system
Breast milk, infant formula, whole-grain breads, cereals, and other fortified or enriched grain products, legumes, and potatoes
B2 (riboflavin)
Helps the body to release energy from protein, fat, and carbohydrates during metabolism
Breast milk, infant formula, dairy products, egg yolks, green vegetables and wholegrain breads, cereals, and fortified grain products
B12
Proper functioning of the nervous system and healthy blood cells
Major sources: Breast milk and infant formulas Other sources: Complementary foods, such as meat, egg yolks, and dairy products provide this vitamin later in infancy as well
Folate
Cell division, growth and development of healthy blood, cells and formation of genetic material within every cell
Breast milk, infant formula, green leafy vegetables, oranges, whole-grain breads, cereals, and fortified or enriched grain products, legumes, egg yolks and liver
B6 (pyridoxine)
Helps the body to use protein to build tissues and aids in fat metabolism
Breast milk, infant formula, liver, meat, whole-grain breads, cereals, and other fortified or enriched grain products, legumes, and potatoes
Niacin
Helps the body to release energy from protein, fat, and carbohydrates during metabolism
Breast milk, infant formula, egg yolks, poultry, meat, fish, and whole-grain breads, cereals, and fortified or enriched grain products. Niacin can be formed in the body from tryptophan present in foods (meat, poultry, cheese, yogurt, fish, and eggs)
C
Forms collagen (a protein that gives structure to bones, cartilage, muscle, blood vessels, and other connective tissue), helps maintain capillaries, bones, and teeth, heals wounds, plays a role in the body’s ability to resist infections, and enhances the absorption of iron
Major sources: Breast milk and infant formulas. Additional sources: Vegetables (e.g., tomatoes, cabbage, potatoes), fruits (e.g., citrus fruits, papaya, and strawberries), and infant and regular fruit and vegetable juices naturally high in or fortified with vitamin C
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Section 4: Pediatric Health and Nutrition
Fat-Soluble Vitamins1 Vitamin
Functions
Sources
A
Formation and maintenance of healthy skin, hair, and mucus membranes, proper vision, growth and development, healthy immune and reproductive systems
Major sources: Breast milk and infant formula. Other sources: Egg yolks, yellow and dark green leafy vegetables and fruits (e.g., spinach, greens, sweet potatoes, apricots, cantaloupe, peaches), and liver
D
Proper formation of bones, proper utilization of calcium and phosphorus in the body
Sunlight, fish, liver, egg yolk, and breast milk (minor amounts)
E
Protects vitamin A and essential fatty acids in the body, prevents the breakdown of tissues
Infants: Breast milk and infant formula Older infants: Green leafy vegetables, vegetable oils and their products, wheat germ, whole-grain breads, cereals, and other fortified or enriched grain products, butter, liver, and egg yolks
K
Helps in blood clotting
Infant formula, green leafy vegetables, pork and liver
Manifestations of Vitamin Deficiencies in Infants Vitamin deficiency
Signs and symptoms in infants
A
Poor growth, damage of varying intensity to the eyes (night blindness), loss of appetite, increased susceptibility to infections, and skin change
D
Inadequate intestinal absorption of calcium and phosphorus resulting in improper bone formation and tooth mineralization. Rickets (characterized by swollen joints, poor growth, and bow legs or knock knees) can result from vitamin D deficiency
K
Breast milk has low vitamin K levels. Hence, exclusively breastfed infants are at an increased risk of bleeding including cerebral hemorrhage due to vitamin K deficiency
C
Scurvy, characterized by poor bone growth, bleeding, and anemia
B12
Failure to thrive, movement disorders, delayed development, and megaloblastic anemia (anemia characterized by large red blood cells)
B2
Growth inhibition, skin changes and dermatitis, anemia, and lesions in the mouth
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Section 4: Pediatric Health and Nutrition
Recommended Average Intake of Vitamins in Infants The recommended dietary intake (RDA) is the average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97–98%) healthy individuals in a group. It is calculated from an estimated average requirement (EAR). If sufficient scientific evidence is not available to establish an EAR, and thus calculate an RDA, an adequate intake (AI) is usually developed. For healthy breastfed infants, an AI is the mean intake. The average intake of vitamins in infants is shown in Table 1:5 Table 1: Recommended Dietary Intake of Vitamins Age: 0–6 months
Age: 7–12 months
Vitamin A
400 g retinol active equivalent/day
500 g retinol active equivalent/day
Vitamin D
10 g/day*
10 g/day*
Vitamin E
4 mg/day
5 mg/day
Vitamin K
2 g/day
2.5 g/day
Vitamin C
40 mg/day
50 mg/day
Vitamin B1
0.2 mg/day
0.3 mg/day
Vitamin B6
0.1 mg/day
0.3 mg/day
Vitamin B2
0.3 mg/day
0.4 mg/day
Folate
65 g/day
80 g/day
Vitamin B12
0.4 g/day
0.5 g/day
2 mg/day of preformed niacin
4 mg/day of niacin equivalents
Niacin *Recommended dietary intake.
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Minerals Mineral
Functions
Sources
Recommended RDA/AI
Calcium
Plays an important role in bone and tooth development, blood clotting, and maintenance of healthy nerves and muscles
Breast milk, infant formula, yogurt, cheese, fortified or enriched grain products, some green leafy vegetables (turnip greens)
AI for infants 0–6 months: 210 mg/day 7–12 months: 270 mg/day
Iron
Helps in the proper growth and formation of healthy blood cells. It is a vital component of hemoglobin, which carries oxygen throughout the body; myoglobin, which stores oxygen; and many enzymes in the body
Breast milk, infant formula, whole-grain breads, cereals, and fortified grain products, dark green vegetables, legumes
AI for infants 0–6 months: 0.27 mg/day
Helps in the formation of protein, and thus aids in wound healing. Required for formation of blood, general growth and maintenance of all tissues, taste perception, and a healthy immune system
Breast milk and infant formula, meat, egg yolks, and cereals, legumes, cheese, yogurt
AI for infants 0–6 months: 2 mg/day
Sodium
Maintains water balance in the body, regulates blood volume, and ensures proper functioning of cell membranes and other body tissues
Breast milk contains a relatively small, but adequate amount of sodium for growth
Estimated minimum requirement for infants is 100–200 mg/day
Fluoride
Reduces susceptibility of the teeth to decay
Fluoridated water, infant formulas prepared with fluoridated water, some marine fish
AI for infants 0–6 months: 0.01 mg/day 7–12 months: 0.5 mg/day
Zinc
RDA for Infants 7–12 months: 11 mg/day
RDA for infants 7–12 months: 3 mg/day
Feeding Infants and Young Children Breastfeeding Breastfeeding is the most ideal and safest form of nourishment for an infant. Breast milk is the best source of nutrients for the young infant.6 Colostrum, Transitional and Mature Breast Milk Lactation progresses through three stages: colostrum, transitional milk, and mature milk.6
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Colostrum: It is the first fluid secreted by the mother’s breasts postpartum.7 It is yellowish with a high protein and mineral content, low fat and lactose concentrations and provides 67 kcal/dL according to the needs of the newborn during the first week of life.3 Colostrum is rich in immunologic components (secretory IgA, lactoferrin, leukocytes) and developmental factors (epidermal growth factor). Concentrations of sodium, chloride, and magnesium are higher and the concentrations of calcium and potassium are lower in colostrum than in the milk produced later.7 Colostrum facilitates the growth of Lactobacillus bifidus in the gastrointestinal tract of the newborn and the elimination of meconium.6 Transitional milk: The transitional phase of lactation lasts from the seventh day or the tenth day, up to 2 weeks postpartum. The composition of colostrum changes during this stage. The concentration of immunoglobulins and proteins decreases and the levels of lactose, fat and energy content increase until reaching the characteristics of mature milk.6 Mature breast milk: Mature breast milk is a homogenous mixture containing three fractions: emulsion (fat droplets), suspension (casein micelles) and solution (water-soluble components). Maternal milk contains 88% of water with an osmolarity similar to that of plasma. Hence, exclusive breastfeeding on demand, without supplementation with water is crucial to keep the nursing infant well hydrated.6 Benefits of Breastfeeding for the Baby and Mother Breast milk has anti-infectious, anti-inflammatory, and immunomodulatory properties and offers protection against diverse pathologies.6 Benefits for the Baby
Breast milk protects the infant against gastrointestinal and respiratory infections.
Breast milk reduces the incidence of acute otitis media, urinary tract infection, and meningitis caused by Haemophilus influenzae.
Breast milk decreases the incidence of allergic diseases in breastfed infants.
Breast milk exerts a beneficial effect on the development of the infant’s oral cavity, leads to adequate tooth alignment and rare cases of malocclusion, and reduces the risk of sleep apnea during adulthood3
Breast milk enhances the development of the mother–child bond
Apart from nutrients, breast milk also contains flavors derived from foods, beverages, and spices ingested or inhaled by the mother.
Breast milk functions as a ‘bridge’ between the in utero experiences (e.g. flavors in amniotic fluid) and the solid foods introduced during complementary feeding and beyond.8
Benefits for the Mother Breastfeeding offers a series of physiological benefits for the mother.6 In the immediate postpartum period, breastfeeding is associated with uterine contractions, which reduce the risk of postpartum bleeding.
Adequate involution of the uterus accompanied by a decrease in postpartum bleeding protects the maternal iron reserves, and thus reduces the risk of anemia.
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Breastfeeding leads to a rapid weight loss in the mother, particularly during the first month postpartum.
Breastfeeding confers protection against breast cancer.
Breastfeeding exerts a contraceptive effect, with a consequent increase in the interval between gestations. Repeated and closely spaced pregnancies are a major cause of maternal morbidity and mortality in developing countries. Protective Factors in Breast Milk
Breast milk exerts several non-nutrient beneficial effects.9
Leukocytes are present in high numbers in breast milk and are found to exert activity in the gastrointestinal tract of the infant and induce a local and systemic immune response.
Secretory immunoglobulin A (sIgA) is present in large quantities in breast milk. These antigens bind to potential pathogens and prevent their attachment to the infant’s cells. They neutralize infectious agents and also limit the damaging effects of tissue inflammation that can occur with other antibody types.
Breast milk contains the enzyme lysozyme. This enzyme disrupts the proteoglycan layer of the bacterial cell wall and thus inhibits the growth of several bacterial species.
Lactoferrin, which is one of the most abundant proteins present in breast milk, removes essential iron and thus deprives the micro-organisms of iron and prevent their growth in the infant.
Nucleotides present in breast milk enhance immune function in infants. Breast Milk vs. Whole Cow’s Milk
Protein Content and Quality Protein in breast milk provides about 7% of calories while that in whole cow’s milk provides about 20% of calories. The average whey/casein ratio in breast milk is 35:65 and in whole cow’s milk, it is 19:81. The greater casein content in whole cow’s milk is undesirable since casein forms a tough curd, which is hard for infants to digest. The concentration of the essential amino acids, cystine and taurine is higher in breast milk than in whole cow’s milk.10 Fatty Acids Lipids in breast milk as well as whole cow’s milk provide 50% of calories. The concentration of linoleic acid and polyunsaturated fatty acids are greater in breast milk than in whole cow’s milk. Linoleic acid in breast milk provides 4% of calories, while in whole cow’s milk, it provides only 1.8% of calories.10 Mineral Content Compared to breast milk, whole cow’s milk contains low concentrations of zinc, niacin, vitamin C and vitamin E. The sodium and potassium content of whole cow’s milk is approximately three times higher than those in breast milk. Furthermore, the concentrations of calcium and phosphorus in whole cow’s milk are four and six times higher, respectively, when compared to those in breast milk. The high phosphate load has been implicated as a causative factor of late hypocalcemic tetany of the neonate.10
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Complementary Feeding Complementary feeding is defined as “the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk.”11 According to the WHO, exclusive breastfeeding should be practiced from birth to 6 months of age. Complementary foods should be introduced at 6 month of age, while continuing breastfeeding. Frequent, on-demand breastfeeding should be continued until 2 years of age or beyond.12 The Infant and Young Child Feeding Guidelines (2010) by Indian Academy of Pediatrics stipulate that “appropriately thick homogenous complementary foods made from locally available foods should be introduced at six completed months to all babies while continuing breastfeeding ad libidum. Complementary food should be a ‘balanced food’ consisting of various (as diverse as possible) food groups/components in different combinations (see Table 2). As the child shows interest in complementary feeds, the variety should be increased by adding new foods in the staple food one by one.”13 Table 2: Amount of food to offer at different ages11 Age
Food texture
Frequency
Average amount of each meal
6–8 months
Start with thick porridge, well mashed foods
2–3 meals/day plus frequent breastfeeding
Start with 2–3 tablespoonfuls
9–11 months
Finely chopped or mashed foods, and foods that baby can pick up
3–4 meals plus breastfeed. Depending on appetite, offer 1–2 snacks
Half of a 250 mL cup/bowl
12–23 months
Family foods, chopped or mashed if necessary
3–4 meals plus breastfeed. Depending on appetite, offer 1–2 snacks
Three-fourths to one 250 mL cup/ bowl
Follow-up Formulas Follow-up formulas are designed to be a liquid part of the complementary feeding diet from the 6th month on and for young children. The essential composition of follow-up formula according to the CODEX standard is as follows:14 Energy A 100 mL of the ready-for-consumption product should provide not less than 60 kcal (or 250 kJ) and not more than 85 kcal (or 355 kJ). Protein Total quantity of protein should be more than 5.5 g/100 available calories (or 1.3 g/100 available kJ)
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Fat Not less than 3 g and not more than 6 g per 100 calories (0.7 and 1.4 g per 100 available kJ).
Common Health and Nutritional Problems in Children Childhood diseases still continue to morbidly or mortally affect young children in India.15 Of all the problems faced, some of the common nutrition and health-related issues faced by children are as follows.
Nutritional Problems Malnutrition It has been observed that 1 in 3 of the world’s malnourished child resides in India. Malnutrition is so rampant among the community that approximately 46% of children below the 3 years can be termed small-for-age, 47% are underweight and 16% are wasted.15 Ensuring adequate weight gain, frequent feeding of nutrient-rich foods using fortified foods are some important step to avert malnutrition among the pediatric population.16 Obesity The prevalence of obesity among pre-school children is on a upward climb, ranging between 1 and 12% among Indian children.17 Management of obesity must include dietary management by proportionately reducing the dietary fat, carbohydrate and protein intake; physical activity enhancement by recommending at least 60 min of moderate physical activity; restriction on sedentary activities such as reducing TV viewing time and in serious cases initiating pharmacological and/or surgical treatment.18 Vitamin A Deficiencies According to the WHO report, vitamin A deficiency in India is classified as a severe public health problem in Indian preschool children. The proportion of preschool children with serum retinol levels
