Infants and preschool-age children

Provided that the mother has adequate breastmilk, breastfeeding alone with no added
food or medicinal supplementation is all that is needed for the normal infant during
the first six months of life. The advantages of exclusive breastfeeding during that
period are discussed in the next chapter. Exclusive breastfeeding means that not even
water, juice or other fluids are provided; none of these are needed. The infant should
be examined regularly at the clinic, where weight gain is seen to indicate adequate
nutrition. At the clinic a schedule for immunization will be set up, and this needs to be
followed. Infants born with low weight (because of prematurity, for example) or twins
may need special attention, and possibly iron or other supplements should be given.
Up to six months of age many breastfed infants have considerable natural immunity to
many infections.
As the children get older they gain weight and length. The increased energy
requirements are based more on the weight of the child than on the age. Because
healthy, well-nourished children follow a growth pattern, however, there is a close
correlation between recommendations based on age and those based on weight. Table
5 shows the energy requirements of infants. A baby 2.5 months of age weighing 5 kg
requires 5 x 120 kcal = 600 kcal, whereas a baby eight months of age weighing 8 kg
requires 8 x 110 kcal = 880 kcal.
At six months of age complementary feeding should be introduced gradually while the
infant continues to be breastfed intensively and to receive most of his or her energy
and other nutrients from breastmilk and not from complementary foods. From six to
12 months, it is highly desirable that breastfeeding should continue and that the child
should get as much milk as possible from the mother while other foods, first semi-
solid and then solid, should be introduced to the diet of the infant for normal growth
and health.
Breastmilk is relatively deficient in iron, and the infant's store of iron is sufficient only
until about six months of age. From six to 12 months, the normal infant may be
expected to gain between 2 and 3 kg. The infant, while continuing to receive
breastmilk, will now need foods to provide extra energy, protein, iron, vitamin C and
other nutrients for growth.
The needed energy can usually be obtained from a gruel of whatever is the local staple
food. The quantity and bulk can profitably be reduced if some edible oil or fat-
containing food is also eaten. If the staple is a cereal such as maize, wheat, millet or
rice, it will also provide a useful quantity of protein, but if it is plantain or a root such
as cassava or yam, it will supply very little protein. In this case, once relatively little
breastmilk is being consumed it is important to provide extra protein-rich foods from
those available to the family.
In the 1950s and 1960s it was thought to be very important that complementary foods
and then foods given after termination of breastfeeding should include animal protein
in large amounts. This has been shown to be unnecessary. In developing countries
these foods are often too expensive for poor families or are unavailable. More
important is the need to feed the young child frequently, with foods that are not too
bulky and are both nutrititious and of high energy density.
TABLE 5
Energy requirements of infants during the first year
Age Energy requirement
(months) (kcal/kg)
0-3 120
36 115
6-9 110
9-12 105
Average 112
Legumes such as beans, peas, lentils, cowpeas and groundnuts are good sources of
protein and should be added to the diet of the child. They can be ground or crushed
before or after cooking.
The above foods, as well as providing energy and protein, will also provide some iron.
Additional iron can be obtained from edible green leaves, which also contain carotene
and vitamin C. Carotene and vitamin C can also be obtained from fruit. Ripe papayas
and mangoes are excellent sources and are usually most acceptable to young children.
Vitamin C can alternatively be provided by citrus fruits (e.g. Oranges) or other fruits
(e.g. guavas). Gradually, as more teeth erupt, the child can be put on a more solid diet.
By the age of two years, the child may have stopped breastfeeding and may be
completely weaned.
The term "weaning" has been used to describe the introduction of foods and fluids
other than breastmilk and the transition to a solid diet without breastmilk. However,
people in Northern countries also talk of "weaning from the bottle". The word is
therefore often misunderstood, and it may be better not to use it because of the
confusion it causes. Rather, the transition can be described as four stages:
the first four to six months when all the infant's nutrients come from
breastmilk;
the next few months when just as much (or more) breastmilk is provided but
other appropriate, often soft, nutritious foods are introduced in increasing
amounts, with efforts to prevent these from causing a decline in breastmilk
consumption;
the next stage, perhaps starting at about 12 to 15 months, when the baby is
still breastfeeding but is getting considerably more of his or her nutrients from
nutritious foods - most of them ordinary village or family foods than from
breastmilk;
the end of breastfeeding, the stage termed "sevrage" (a good French term
literally meaning "severance from the breast"), which can occur as late as the
mother wants, sometimes when the infant is over two years of age.
After sevrage appropriate family foods are provided. These need to be nutritious,
suitable for the child, energy dense and given frequently, perhaps four to six times per
day, not just in two or three meals per day as may be the family practice. The young
child should be fed between family mealtimes if these are limited to two or three per
day.
The mother responsible for feeding a toddler who is no longer breastfeeding must
keep in mind that the child, whether boy or girl, has special needs.
Special needs of a young girl in the months following sevrage
She needs a variety of foods, as great as or greater than that given to any other member of the
family.
She is growing rapidly and needs energy-dense foods and extra protein-rich foods.
She has few teeth, and requires soft food.
She has a relatively small appetite and intake capacity and needs more frequent meals than
older persons.
She requires clean food and clean utensils to avoid infection.
She must as far as possible be protected from communicable diseases.
She should have the love, affection and personal attention of her mother for her mental and,
indirectly, her physical well-being.
Attention from the father and other members of the family will also contribute to her
development and well-being.
The proper feeding of a toddler requires time and patience. Special utensils or
equipment are not necessary, but a sieve or strainer is useful. Adult foods can be
chopped up and forced through a strainer into a cup or on to a plateful of gruel for the
child. A strainer can readily be made if none is available. Otherwise, various foods
can be crushed before cooking using a pestle and mortar, which are found in most
households.
In some societies gruel or porridge made from the local staple is made sour or
partially fermented. This is a good practice. Small amounts of germinated cereal
seeds, often millet or sorghum, are crushed and added to maize or other porridge. The
amylase present breaks down some of the starch, causing the porridge to become
thinner (more liquid), so it is easier for the young child to consume, and making it
more energy dense. The food is also safer, because the growth of disease-causing
organisms is inhibited in sour or fermented gruel. Some societies sour children's foods
by addition of lime or lemon juice. This also is advantageous, and enhances the
absorption of iron.
The period from six to 36 months of age is of paramount importance nutritionally.
The mother should take the child regularly to a clinic if one is available. The
happiness, general appearance and weight of the child are the best general indicators
of adequate nutrition. The use of a weight chart to help the mother follow the growth
of the child is described in Chapter 34. Many children of this age in developing
countries do not grow at the rate they should, and some develop protein-energy
malnutrition (see Chapter 12).
The first three years of life are also those when the important micronutrient
deficiencies of vitamin A and iron are most likely to occur in children. From three
years of age the risks are reduced, but in many parts of the world growth continues to
lag, incidence of intestinal worms and other parasitic diseases may increase and other
nutrition and health risks arise.
From three years of age onwards the child has usually stopped breastfeeding and is
consuming family foods. The child can now obtain adequate nutrients in three meals
per day, but until the child reaches the age of five years, parents should make certain
that the child is eating adequately and getting his or her fair share of the most
desirable foods, which may well be those that are most tasty and in shortest supply.
Special attention may need to be given when children have a poor appetite or when
they are ill and their appetite is reduced. For the whole family, but especially for
children, care must be taken that food, water and other fluids are safe and not
contaminated. Good personal and household hygiene are of the greatest importance.
Washing hands with soap and water before meals or food handling is a good family
rule.
Kimea or power flour: an approach to providing more energy-dense foods
Traditional ways of thinning porridge, using products which are termed "malted" (from the
process used in beer production), are now being recommended for societies that do not
customarily use them. Malted flour, termed "kimea" in the United Republic of Tanzania, is
usually made by germinating cereal seeds or grains by moistening them, drying them for a few
days and then pulverizing the dried grains into a powder. When added even in tiny amounts to
stiff maize porridge (called"ugali" in Tanzania, Kenya and elsewhere in Africa), kimea thins the
porridge into a more liquid gruel (termed "uji"). This remarkable property has led to its being
called "power flour". The power lies in the enzyme amylase which is in the germinated flour.
Amylase digests starch, the complex carbohydrate in cereal grains, into simple carbohydrates,
thereby thinning the porridge. This makes the food easier for the young child to eat, safer
because it harbours fewer disease-causing bacteria, and perhaps easier to digest. Above all it is
more energy dense.
Parents should understand the needs of the child and see that the right foods are
available in adequate quantities and prepared in palatable ways
The nutrient requirements of children of different ages and weights are provided in
Annex 1. It is clear that as children increase in weight and age they need more food to
provide them with more energy and more of the other nutrients essential for growth
and health. Thus a child aged six to 12 months and weighing 8.5 kg requires 950 kcal
per day, whereas a child aged five to seven years weighing 19 kg requires 1 820 kcal
[almost twice as much) and a boy aged 17 years weighing about 60 kg requires 2 770
kcal (almost three times as much).
Mothers need to understand that as children grow beyond infancy, they increase in
weight and require more food to eat. Table 6 indicates that as young boys and girls get
older, heavier, taller and more active, they need to eat more food, especially a greater
quantity of staple foods including cereals (e.g. rice, maize, wheat) and legumes (e.g.
beans, cowpeas).
School-age children
The vast majority of schoolchildren in developing countries attend primary schools.
Most are at day schools, few of which provide a midday meal. In rural areas the
school is often some kilometres from the parents' home. The child frequently has to
leave home early and walk a considerable distance to school. Often the child has little
or no breakfast at home before he or she sets out; there is no meal at school; and the
first, and sometimes only, meal of the day is late in the afternoon.
The nutritional needs of a schoolchild are high. The adolescent child has
proportionately higher requirements for most nutrients than the average adult. It is
practically impossible for an adolescent to obtain adequate quantities of the right
foods from one or even two meals a day. It is highly desirable that school-age children
cat some food before going to school and some food at school, or during the middle of
the day outside the school grounds, as well as the food eaten at home.
Food before going to school
It is not practical for many mothers to rise before dawn to spend the considerable time
necessary to light a fire and prepare a hot meal for children before school-time.
Therefore, if no hot breakfast is available, some fruit, cold cooked potatoes, rice,
cassava or even cold porridge should be left over from the previous day for the
schoolchild to eat before leaving home in the morning. In some areas cold chapattis,
tortillas or wheat products such as bread may be available.
Food eaten at school
This may consist of a midday school meal or a snack taken to school.
A midday school meal is the ideal. It should provide reasonable amounts of the
nutrients most likely to be missing or short in the home diet. A whole-grain cereal as
the basis and a side dish of legumes with vegetables or green leaves make an excellent
school meal. There are many possibilities, depending on what foods are locally
available. The meal might include some protein-rich food and some food containing
vitamins A and C.
School meals are beneficial because they often supply much-needed nutrients; they
can form the basis for nutrition education; they are a good way of introducing new
foods; and they prevent hunger and malnutrition. School meals, in addition to
improving nutritional status, may increase enrolment, especially for girls, and may
reduce absenteeism. However, in many developing countries, for many reasons,
school meals are unavailable. Parents' organizations can sometimes work with
teachers to organize community school feeding or food supplementation or nutritious
snacks. School meals can provide a good environment for nutrition education. Further
nutrition education can be carried out as an extracurricular project. A school vegetable
garden or orchard can provide foods with valuable extra nutrients for the midday
meal. Poultry keeping, small animal production (rabbits, guinea-pigs, pigeons, etc.)
and fish pond construction, in areas where they are suitable, are educative projects and
can provide food for a school meal
TABLE 6
Amount of uncooked foods to satisfy the nutrient needs of children (g)
Age Cereal grains Legumes Vegetables Fruit Oils or fat
(years)
2-3 150-250 100- 125 75- 100 50 100 20
4-5 200-350 125 175 100-150 100-150 30
6-9 300-400 150-200 100-150 100-150 30
10-13 400-500 200-250 100-150 100-150 30
A midday school meal might be provided by the government or local authority as part
of the education system and could be paid for from the normal school fees
Alternatively, a midday meal system might be started and paid for from special fees
collected from the pupils daily, weekly or per term. Local organizations might provide
certain food items free or at low prices for school feeding, thus reducing the overall
cost.
The cost of school feeding can be reduced by local self-help efforts on the part of
villagers, parents' committees and pupils These efforts may fit in well with self-help
community projects For example, a small kitchen shelter can be built on a self-help
basis Instead of a paid cook, a rota of parents can take turns doing the cooking. Pupils
can collect fuelwood at weekends However, it must be stressed that the provision of a
midday school meal must not detract from the parents' responsibilities to provide a
good diet for schoolchildren at home.
In the absence of a school lunch, parents should send their children to school with
some food to be eaten at midday. However, they may have real difficulty in finding
suitable foods The various foods suggested for a cold breakfast can equally provide
the solution for a midday snack The sort of food taken will vary according to what is
available locally Possibilities include a few bananas, cooked whole cassava, sweet or
ordinary potatoes roasted in their skins, fruit, tomatoes, roasted maize on the cob,
roasted groundnuts, coconuts, cold grilled fish, smoked cooked meat, hard-boiled
eggs, a calabash of sour milk or some bread, a chapatti or tortillas.
Some schools above primary level are boarding schools These usually provide three
meals a day, and the menu should be based on recommendations made to the school
by someone with dietetics training Occasionally schools plead lack of money as an
excuse for an inadequate diet School meals need not be luxurious, but they should be
balanced and should provide all the nutrients necessary for growth and health The
child with an inadequate diet will not only fail to grow properly, but may also develop
anaemia and other signs of malnutrition and will not be able to concentrate on or
benefit fully from the education provided.
Increasingly in urban areas, and even to some extent in more heavily populated rural
districts, entrepreneurs set up stalls and the like near schools so they can prepare and
sell foods to schoolchildren (see Chapter 40) These "street foods" often have the
advantage of providing access to cooked foods at relatively low cost, but the
disadvantages include poor hygiene, poor-quality food and high prices. Where the
main source of a midday snack or meal for primary or secondary schoolchildren is a
vendor, the food is available only to children who have money to purchase it. Often
the wealthier children participate and the children from the poorest families, or those
whose parents will not provide money, do not.
Other concerns
The health of schoolchildren also needs consideration. In many countries school
health services are non-existent or very poor. Examination for sight and hearing
defects is important. Routine deworming might be initiated. Attention to micronutrient
deficiencies may be needed in areas where children are at risk of iron, vitamin A or
iodine deficiency. Iodine is especially important when girls reach puberty and before
they have their first pregnancy.
Unfortunately, in some countries a large percentage of school-age children do not
attend school. In some countries far more boys than girls attend school. Out-of-school
children have the same nutritional and health needs as children attending school, but
they do not benefit from school meals and other services. They are an often forgotten
and relatively neglected group of the population, including children from the poorest
families as well as children with disabilities, either physical or psychological.
Older persons
Older people, like all others, need a good diet that provides for all their nutrient needs.
In more affluent societies, older adults are often plagued with chronic diseases that
have nutritional origins or associations. These conditions include, among others,
arteriosclerotic heart disease, sometimes leading to coronary thrombosis;
hypertension, which may lead to stroke or other manifestations; diabetes, with its
serious complications; osteoporosis, which frequently leads to hip fracture or collapse
of vertebrae; and loss of teeth because of dental caries and periodontal disease. As
discussed in Chapter 23, these diseases are rapidly becoming more prevalent in
developing countries.
Many older people, especially if unfit, take less exercise and so may need less energy
(see Annex 1). They may, therefore, eat less food and as a result get fewer
micronutrients, but their needs for micronutrients are unchanged (see Figure 2).
Consequently, conditions such as anaemia are common. Older people who have lost
many or all of their teeth or who have gingivitis or other gum problems may find it
difficult to chew many ordinary foods and may need softer foods. Fed on a normal
family diet, they may eat too little and become malnourished. They may also suffer
from illnesses which reduce their appetite or desire for food, which may also lead to
malnutrition.
In many rural traditional societies old people are cared for at home by relatives and
others in the community. By contrast, many older people in the richer, industrialized
countries of the North live lonely lives and are relegated to old people's nursing
homes and other unpleasant institutions. In some developing countries the traditional
support systems and extended families are breaking down, especially with
urbanization and migration, and old people there may end up lonely, living in poverty,
with chronic illnesses, poor hearing and vision and perhaps psychological problems.
Compounding these problems, they will face difficulties in producing food,
purchasing it and preparing it.
Many of the older people are poor women, who are especially vulnerable. They are
members of society in special need of both good care and a good diet, just as children
are in their early years.
In some countries special services are established to help older or poor people obtain
food in soup kitchens or in their homes. These services can be helpful. Preferable,
however, would be community and family efforts to care for older people who cannot
care for themselves and who are at risk of malnutrition and disease.