Nutrition and feeding in

infant and young children

Ruey Terng Ng
Department of Paediatrics
University of Malaya
• Every infant & child has the right to good nutrition
• “Convention on the Right of the Child”
• Undernutrition is associated with 2.7 million child deaths annually or
45% of all child deaths
• Globally in 2015, 156 million children under 5 were estimated to be
stunted, 50 million were estimated to be wasted, 42 million were
overweight or obese
• Infant and young child feeding is a key area to improve child survival
and promote healthy growth and development
Nutrition in the first 1,000 days
• The period from the start of a mother’s pregnancy through her child’s
second birthday.
• Critical window when a child’s brain and body are developing rapidly
• The quality of nutrition during this period is of paramount importance
and essential to lay the foundation for a healthy and productive
future
• The damage that caused might be irreversible if the children do not
get the right nutrient during this period
Breastfeeding
• Optimal breastfeeding is critical
• It could save the lives of over 800,000 children under the age of 5
years each year
• WHO and UNICEF recommend:
• Early initiation of breastfeeding within 1st hour of life
• Exclusive breastfeeding for the first 6 months of life
• Introduction of nutritionally-adequate and safe complementary foods at 6
months together with continued breastfeeding up to 2 years of age or beyond
• However, only 36% of infants age 0—6 months worldwide were
exclusively breastfed over the period of 2007—2014
WHO statement 2003

• ‘…infants should be exclusively breastfed during the first 6 months of

life. Thereafter they should received nutritionally adequate & safe
complementary foods while breastfeeding continues up to 2 years of
age & beyond.’
Breastfeeding
• Exclusive breastfeeding for 6 months has remarkable benefits for both
infant and mother
• Protection against GI infections observed in both developing and
industrialized countries
• Early initiation of breastfeeding at 1 hour of life protects newborn from
acquired infections and reduces neonatal mortality
• Risk of mortality secondary to diarrhoea and other infections can potentially
increase in infants who are partially or not breastfed
Breastfeeding
• Breast milk is important source of energy and nutrients in children
aged 6—23 months
• >1/2 of energy needs between 6—12 months
• 1/3 of energy needs between 12—24 months
• Also serve as critical source of energy and nutrients during illness
• Reduces mortality among children who are malnourished
• Reduces the risk of overweight or obese during late childhood and
adolescent
Breastfeeding
• Children and adolescents who were breastfed during infancy perform
better in academics and have higher school attendance
• Better in developmental milestones
• Also found associated with higher income during adult life
• Overall reduction in health costs results in economic gains for
individual families as well as the national level
Breastfeeding
• Recommendations have been refined to address the needs for infants
born to HIV-infected mothers
• Anti-retroviral therapy (ART) allows these children to exclusively breastfeed
from birth till 6 months of age and even continue till at least 12 months old
with a significant reduced risk of disease transmission
• WHO recommends all HIV-infected individuals, including pregnant women
and lactating mothers to take ART for life from when they first learn their
infection status
Feeding in exceptionally difficult
circumstances
• Require special attention and practical support
• Breastfeeding remains the preferred mode of infant feeding in almost
all difficult situations:
• Low-birth-weight or premature infants
• Mother living with HIV in settings where mortality due to diarrhoea,
pneumonia and malnutrition remain prevalent
• Adolescent mothers
• Infant and young children who are malnourished
• Families suffering the consequences of complex emegencies
Benefits for mothers

• Reduces risk of ovarian and breast cancer

• Helps in spacing pregnancies

• Excessive breastfeeding of babies under 6 months has hormonal effect 
prolactin  transient amenorrhoeic  Lactation Amenorrhoea Method
Complementary feeding
• Around the age of 4—6 months, infant’s need for energy and
nutrients starts to exceed breast milk’s supply
• Complementary feeds become necessary to fill the gaps
• Delay in introduction of complementary feeds potentially results in
growth faltering
• Gradually until the child ceases to nurse at the breast and is able to
consume the same food as the rest of the family
Guiding principles for complementary feeding
• Continue frequent, on-demand breastfeeding till 2 years of age or
beyond
• Practice responsive feeding (e.g. feeds infants directly, assist older
child, encourage but not forcing, etc.)
• Good hygiene and proper food handling
• Start at 4—6 months with small amount, increase gradually as the
child get older
• Gradually increase food consistency and variety
• Increase number of meals per day gradually
Right from the start…

• Proper nutrition begins at the market with the choice of food

purchase & continues at home in preparing & serving meals

• Offering a variety of foods of the 5 different groups, with special

nutrient contributions of each group  best way to maintain
nutrition that a growing child needs
Eating right: the Pyramid way…

• Food Guide Pyramid is a practical eating guide that emphasizes food

from 5 major food groups

• Flexible and realistic

• Meant for all healthy individual, ages 2 and over

• Guided by suggested servings for each group

How do we know if the child has eaten
enough?
• Children eat when they are hungry and usually stop when they are
full

• Ensure no prolong complete left out of a food group, as may lead to

specific nutrient deficiency

• Encourage child to explore different choices of food within the group

Child-size serving: Be realistic

• Never compare child’s serving portion to the adult’s

• Adult-size servings can be overwhelming

• Child-size servings encourages food acceptance

• Child-size serving = ~1/4—1/3 of adult’s

• Serve smaller serving and let the child to ask for more
Snacks count, too…

• … in between the time of main meals, but not disruptive…

• About 2 to 3 planned/scheduled snacks around normal daily events

• Make up an important part of childhood nutrition

• Choices should be of the Pyramid

Current challenges…

• Obesity

• Metabolic syndrome

• Type 2 diabetes

• NAFLD

• Feeding difficulties/ food refusal

• Failure to thrive/ faltering growth

Junk Food or ‘Junk Eating’?
• With lowered exercise patterns  steep rise in overweight & obesity
• ‘a public health crisis’
Categories…
1. ‘Fast food’
2. ‘Soft’ (sweetened) drinks
3. Confectionaries & sweets, incl. chocolate-containing products
4. Biscuits (cookies) & cakes
5. Chips
6. Frozen dairy products, incl. ice-creams & yogurts
7. Breakfast items
Arguments…
• ‘Fast foods’ not necessary ‘junk’ unless consumed
habitually & excessively
• Sweets & confectionaries – not inevitably hazardous if
consumed in moderation
• Fried potatoes, not in very thin strips/ wedges in deep
oil  acceptable component of balance diet
• Nutrient & energy density contents on breakfast
cereals very variable – may have added sugar, can be
a good source of nutrition
Children who ate ‘fast food’, compared with
those who did not…
• More dietary energy
• More energy-dense food
• More total dietary fat
• More total dietary carbohydrates
• More added sugars
• More sugar-sweetened beverages
• Less milk
• Fewer fruits & non-starchy vegetables
• Adolescent over-consumed ‘junk food’ regardless of their body mass,
were less likely to adjust their intakes so as not to exceed their usual
intakes than what were lean subjects
‘Junk’ drinking patterns

• Dramatic increase by almost 500% per capita soft drink consumption

in US the past 50 years

• Each 360ml of soft drink contains 10 teaspoonfuls of sugar and 628kJ

(=157kcal) of dietary energy (AAP 2004)
AAP policy statement 2004

• ‘Soft Drinks in Schools’ assoc. with

Overweight/ obesity

Displacement of milk consumption causing calcium deficiency and risk of

osteoporosis & fractures

Dental caries & risk of erosion of dental enamel

Dental damage exacerbated by acidic nature of many soft drinks (pH range
2—3)
• The mean adjusted energy intake was 7659kJ (1915kcal) / day for
children who drank an average of about 270ml of sweetened drinks
daily
• Harnack et al.: Soft drink consumption among US children and adolescents: Nutritional consequences. J Am Diet Assoc 1999;99:436—441

• Daily consumption of a single can of soft drink may increase a child’s

risk of developing obesity by 60%
• Ludwig et al.: Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet
2001;357:505—508
Other issues…

• Television viewing and other sedentary pursuits e.g. computer games

affects pattern of ‘junk food eating’ among today’s youngsters

• TV viewing tends to replace their fruit and vegetable consumption by

foods and drinks advertised
• Boynton-Jarrett et al.: Impact of television viewing patterns on fruit and vegetable consumption among adolescents. Pediatrics
2003;112:1321—1326
Obesity… Malaysian statistics

• 6th highest adult obesity rate in Asia… WHO 2010

• 60% of >18 years old overweight

• 2nd & 3rd Malaysian National Health & Morbidity Survey 2006:
• Adult obese/overweight 43%
• Childhood overweight 38%
• 3-fold increase in obesity prevalence among adults: 4.4—14% over period of
10 years
UPM study 2007

• Nationwide study of obesity

• Female 13.8%, male 9.6%
• Malays 13.6%, Indians 13.5%
• Chinese 8.5%
• Sarawak natives 10.8%
• Sabah natives 7.3%
• p < 0.0001
The Food Balance Sheets for Malaysia 1967—
2007
• 2 major upward shifts in the dietary patterns in Malaysia the past 4
decades:
• 82% rise in consumption animal product calories (267—485 kcal per capita
per day)
• 70% rise in sugar & sweeteners (28.8—48.7kg per capita per year)

• Increasing sedentariness  central public health challenges faced in

addressing obesity
Summary…
• Good eating has been the major global challenge due to rising of
obesity & issue of feeding difficulty
• WHO: exclusive breastfeeding for 6 months and continue for 2 years
• ESPGHAN: complementary feeds between 17 to 26 months of age
• Practice of good nutrition= right choice of food, right serving for age,
right parenting perception & right parenting skills