CHILD NUTRITION: WHAT DO WE KNOW? (Part 1)
Submitted by W Kumwenda and GJ Gericke
Good nutrition is very important for everyone, especially for infants and young children, because it is directly linked to all aspects of their growth and development. Adequate nutrition during infancy and early childhood is essential to ensure the growth, health, and development of children to their full potential (WHO, 2009). Studies have linked good nutrition to better school performance, being physically active, and eventually a healthy adulthood (WHO, 2005). Optimal nutrition during the 1,000-day period between the start of a woman’s pregnancy and the child’s second birthday is important for the future health and wellbeing of the child (WHO, 2016). The first 1000 days of a child is a unique period of opportunity when the foundations of optimum health, growth, and neurodevelopment across the lifespan are established (Prado & Dewey, 2014). It is therefore important for pregnant mothers and children below two years of age to have optimal nutrition to lay the foundation for the child’s future cognitive, motor and social skills, school success and productivity (State of the world report, 2012). The period from birth to two years is also very critical and it is characterised by a high growth rate and increased vulnerability to infectious diseases that requires appropriate feeding (Black, Victora, Walker, Bhutta, Christian, De Onis, Ezzati, Grantham-McGregor, Katz & Martorell, 2013). Providing optimal IYCF is therefore important to improve child’s health (WHO, 2005).
The aim of this discussion is to reflect on current understanding of the importance of optimal child nutrition from birth to six months of age; also referring to the importance of support for breastfeeding.
Infant and young child feeding practices
Optimal infant and young child feeding practices (IYCF) is one of the most effective ways to improve child health (WHO, 2009). Nutrition has a great impact in a child’s life, and feeding practices have a direct impact on the nutritional status and wellbeing of a child. The first two years of a child’s life are critical for their growth and development, and optimum nutrition during this time is essential (Kumar, Goel, Mittal & Misra, 2006; Victora, Adair, Fall, Hallal, Martorell, Richter, Sachdev, Maternal & Group, 2008). Appropriate feeding lowers morbidity and mortality in children and reduces the risk of chronic diseases later in life (WHO, 2015). Proper feeding during this period means ensuring early initiation of breastfeeding and exclusive breastfeeding during the first six months, the introduction of safe and nutritionally adequate complementary foods with continued breastfeeding for up to two years or beyond (Black et al., 2013; UNICEF, 2011). Optimal breastfeeding is at the top of the list of effective preventive interventions for child survival (Bartle, 2013). It is estimated that about 800 000 children's lives could be saved every year among children under the age of five years, if all children in the ages of zero to 23 months were optimally breastfed (Black et al., 2013). Optimal breastfeeding and appropriate complementary feeding have a more positive impact on the child’s health than that achieved with immunisation, safe water and sanitation (Carlo Bartle, 2013). To ensure optimal IYCF the WHO and UNICEF recommend the following practices: early initiation of breastfeeding within one hour of birth, exclusive breastfeeding for the first six months of life and the introduction of nutritionally-adequate and safe complementary (solid) foods at six months together with continued breastfeeding up to two years of age or beyond (WHO, 2015).
Breastfeeding
Breastfeeding is important for the infants to achieve optimal growth as it gives both short-term and long-term benefits to the child. Breastfeeding reduces infections and mortality among infants, improves mental and motor development, and protects against obesity and metabolic diseases that occur later in life (Murage et al., 2011). Breast milk carries antibodies from the mother that help combat diseases, protecting babies from diarrhoea and acute respiratory infections (Dòrea, 2009). There is an increased risk of diarrhoea and other infections in infants who are either partially breastfed or not breastfeed at all (WHO, 2010). Breast milk provides the baby with anti-bacterial, anti-viral and anti-parasitic agents and strengthens the infant's developing immune system. Breastfeeding also stimulates an infant’s immune system and response to vaccination (Dòrea, 2009). In addition, colostrum, which is the first milk produced, is rich in antibodies and high in anti-infective properties that it is considered to be ‘the first immunisation’ an infant receives (Bartle, 2013 ; WHO, 2010). Breastfeeding also improves the child’s intelligence quotient (IQ) (Kramer & Kakuma, 2004) and is associated with higher income in adult life (Victora, Bahl, Barros, França, Horton, Krasevec, Murch, Sankar, Walker & Rollins, 2016). Breastfeeding enhances neurological, visual and motor development, and protects the infants against allergies, skin disease and asthma. Moreover, breastfeeding supports infants’ immune systems and may protect them later in life from chronic conditions such as obesity and diabetes (UNICEF, 2011). Exclusive breastfeeding also contributes to the health and wellbeing of mothers; it reduces the risk of ovarian and breast cancer and leads to more rapid maternal weight loss after birth. It is also a method of birth control known as the lactation amenorrhoea method and therefore helps in spacing pregnancies (Labbok, Clark & Goldman, 2004; NSO & ICF-International, 2016) .
Initiation of breastfeeding
There is growing evidence that suggests early initiation of breastfeeding, that is within one hour of birth, protects the new born from acquiring infections and reduces new born mortality (WHO, 2015). A study in rural Ghana (Edmond et al. 2006) showed that early initiation within the first hours of birth could prevent up to 22% of neonatal deaths, and initiation within the first day could prevent 16% of deaths. Another study done in Nepal (Mullant et al., 2008) found that approximately 19.1% of all neo-natal deaths could be avoided with initiation of breastfeeding within the first hour of life. Furthermore, early initiation of breastfeeding also serves as the starting point for a bond between mothers and the new born that can have long lasting effects on the child’s health and development (WHO, 2010). Therefore, it is important to initiate breastfeeding within the first hour of life. In Malawi, about 95% of the children were reported to have been initiated on breastfeeding within the first hour of birth (NSO & Macro, 2011).
Exclusive breastfeeding
It is important that infants be fed on breast milk alone during the first six months of life. During this time, breast milk alone with no water is enough to provide adequate nourishment for the infant as it provides all the nutrients, antibodies and immune factors an infant needs (WHO/UNICEF, 2003). Exclusive breastfeeding also help in reducing mortality in children (Kramar & Kakuna, 2004). It has been estimated that exclusive breastfeeding could prevent up to 1.4 million deaths every year out of the 10 million annual deaths among under-five children (Black et al., 2008; UNICEF, 2011). Breastfeeding has to be done on demand, whenever the infant wants and it is usually done eight to 12 times in a 24 hour period (WHO, 2009). By the age of six months, a baby has at least doubled his or her birth weight, and becomes more active. At this age, the infants have high nutritional needs for rapid growth, and exclusive breastfeeding is no longer sufficient to meet the infants’ energy and nutrient requirements hence complementary feeding should be introduced (Jones et al., 2003). However, breastfeeding should continue with complementary feeding up to two years of age or beyond, and it should be done on demand; as often as the child wants. This is because breast milk provides high quality nutrients (WHO & UNICEF, 2008). Moreover, breast milk can provide one half or more of a child’s energy needs between six and 12 months of age, and one third of energy needs between 12 and 24 months (Dewey & Brown, 2003). This is an important contribution to the nutritional requirements especially in resource constrained settings. It is therefore important that infants continue to breastfeed up to two years or more even after the introduction of complementary feeds (WHO, 2009).
Support for breastfeeding
Counselling and education delivered by health staff has been found to increase the odds of breastfeeding initiation (Sinha et al., 2015). It has also been observed that combined individual and group counselling has a greater effect than either alone (Haroon, Das, Salam, Imdad & Bhutta, 2013). In societies, where food insecurity is common, nutrition education combined with provision of appropriate complementary foods has been proven to reduce risk of stunting in children under 2 years of age (Imdad, Yakoob & Bhutta, 2011; Lassi, Das, Zahid, Imdad & Bhutta, 2013).
Peer support, counselling and education or support by the father or significant others are part of home and family environment interventions. Interventions based on peer support have been found to increase breastfeeding continuation (Ingram, MacArthur, Khan, Deeks & Jolly, 2010; Jolly, Ingram, Khan, Deeks, Freemantle & MacArthur, 2012; Sinha et al., 2015; Sudfeld, Fawzi & Lahariya, 2012). However, context seems to influence the effectiveness of the intervention. Effect of peer support was smaller in communities having high prevalence of formula-feeding (Sudfeld et al., 2012) and in developed countries compared with low- or middle income countries (Jolly et al., 2012).
Community environment includes group support and counselling, social mobilisation and mass media. Interventions in communities have been found to influence early initiation of breastfeeding, promotion of exclusive breastfeeding and continued breastfeeding (Sinha et al., 2015; Zamawe, Banda & Dube, 2015). Hall et al. (2011) found that community based interventions improved exclusive breastfeeding duration in low and middle income countries. Fairbank et al. (2000) also suggested that group health education would be effective in improving breastfeeding practices. In addition to interventions implemented only in community setting, interventions combining different settings within the community has been found to be effective and it was suggested that instead of educating only mothers, increasing awareness of whole communities would benefit most (Sinha et al., 2015).
Maternity leave, workplace support and the employment status of the mother which often influence infant feeding practices, are categorised here as work setting. Interventions in work setting may include facilitating longer maternity leaves, expressing breastmilk at work or having breastfeeding breaks during work day. Interventions in the work environment have been found to have no influence on initiation of breastfeeding, had small insignificant influence on probability of exclusive breastfeeding, but had significant positive effect on breastfeeding duration and prevalence of any breastfeeding (Sinha et al., 2015). In addition, policies and legislation, related to breast feeding, child nutrition and health policies also have an influence on IYCF practices (Moran, Morgan, Rothnie, MacLennan, Stewart, Thomson, Crossland, Tappin, Campbell & Hoddinott, 2015; Sinha et al., 2015).
