Public Health Issues in Infant Nutrition
Beena A. Minai and Evan Howe
Infant nutrition represents a serious problem in many parts of the world. In many parts, and indeed in the examples that spring to mind, it is a lack of nutrition that causes the concern. However, it is also true that excess of inadequate nutrition can be responsible for the harm that is done to an infant’s development. In a recent World Health Organization (WHO) publication, malnutrition was cited as being “responsible, directly or indirectly, for 60% of the 10.9 million deaths annually among children under five.[i]” Over-nutrition results in considerable morbidity later in life in many regions of the world. The causes of this begin as early as the infant years.
For the purposes of this
discussion, infant nutrition will consider individuals who are under the age of
three. A large part of this period of a
child’s development is occupied by exclusive breastfeeding and complementary
feeding procedures. During these first
three years of life, the child is developing in a large number of ways. These changes and the nutrition that guides
them will have effects on the individual throughout her or his life. Also, since this is a rather fragile portion
of a child’s life, proper nutrition will impact overall survival. Reasons for which this problem persists
include lack of resources and lack of information in the parents. To approach this problem from a public health
perspective, one must undertake to understand the particular barriers that are
preventing proper nutrition in a particular population. Is it lack of information? Lack of access to proper nutrition? Lack of ability to prepare or present proper
nutrition to an infant? The specific
nature of the problem can vary widely, but important considerations for
approaching this problem will be highlighted in this paper. Recommendations of nutritional needs of
infants have been published by UNICEF, WHO, and the
NUTRITIONAL NEEDS OF THE INFANT
The recommendations for infant nutrition stress the role of exclusive breast feeding during the first six months of life. This exclusive breastfeeding indicates that no other supplements should be given to the infant during this period. The practice of exclusive breastfeeding ensures that the infant will be receiving the proper mix of nutrients during the first six months of development. Also, breast feeding provides a great deal of immunological support for the infant that is being challenged by a whole host of new foreign pathogens. SIDS, diabetes, obesity, and asthma are noted to occur at a lower frequency in breast fed individuals.[ii] An added benefit of exclusive breastfeeding is the benefit to the mother. Increased spacing between children and decreased risk of ovarian and breast cancer are a couple of the benefits.
Worldwide the rate of exclusive breastfeeding is around 35%[iii]. This rate is considered to be much lower than the rate that is either desired or possible. Therefore, efforts at increasing the rate of breastfeeding are in order. Particular challenges to increasing this practice include maternal employment, social acceptance of the practice of breastfeeding (both in terms of general acceptance of the concept and acceptance of breastfeeding in public spaces), lack of education about the benefits of breastfeeding, normative advertising favoring formula feeding, and lack of encouragement from the nutrition team in terms of breastfeeding.
Specific recommendations of the AAP regarding breastfeeding include
· Pediatricians and other health care professionals should recommend human milk for all infants in whom breastfeeding is not specifically contraindicated
· Practices that encourage breastfeeding initiation should be encouraged. . .
· Direct skin-to-skin contact with the mother should be maintained from birth until the time of the first feeding
· Water, formula, and other fluids should not be provided unless ordered by a physician
· 8-12 feedings daily should be encouraged
· Breastfeeding practices should be observed and evaluated while the mother and infant are in the hospital
· Parents and providers should be made aware that breastfeeding is adequate for meeting the infant’s nutritional needs for the first six months
· Breastfeeding should be maintained even in the case of hospitalization, with breast pumping if necessary
These recommendations will aid in the creation of policies and practices that will help to encourage breastfeeding among infants. Of particular note is the challenge of mothers who are employed outside the home. This challenge can be met in some circumstances by breast pumping and feeding the child the collected milk. However, there are times when this becomes difficult. Along these lines, policies which enable mothers to maintain their employment while being in close proximity to their infant will be needed. Examples of these policies have been published elsewhere[iv] and include lactation breaks, pumping facilities, support from co-workers, and flexible work schedules. Creative solutions to encourage mothers to breastfeed and cooperation from employers is a necessary part of the infant nutrition scheme.
After a period of six months, it is considered appropriate and necessary to begin supplementing the infant’s feeding with additional elements. General concerns in this period include appropriate timing, appropriate supplementation, and attention to the physical-psychological cues towards eating. Again, this period is critical in setting patterns that will continue throughout the rest of the infant’s life. Thus, it is important to pay close attention to the types and ways foods are prepared.
Again in this situation, the role of education is critical in providing for sufficient infant nutrition. Parents and other childcare providers should be given the training and information necessary to make good choices about the nutritional needs of their child. In this phase, however, a new challenge comes to the foreground. This challenge is access to proper nutrition sources. On the one hand, this can mean making sure that infants are provided with adequate amounts of fats and proteins as they are going through this period of transition to a variety of foods. On the other hand, this means making sure that energy-rich foods are not displaced by energy-poor foods such as large amounts of water, juices, or soda. The caloric needs should be building towards 900 kcal/day at 12 months.[v]
Three key areas for health care policy to develop are information, access, and responsive feeding.
The first of these areas, information, has similar needs to the information needs of exclusive breastfeeding. Misconceptions of the parents and community need to be displaced in a sensitive manner so that an understanding of the nutrition needs of the infant is developed. Classes can be offered and providers can work to educate patients. Thus, proper education of providers is also a goal in some circumstances. Another challenge in the area of information is the role of normative media messages that suggest certain elements of nutrition that might be included.
Access to proper nutrition is a problem across all age ranges, but can be a particularly acute problem in the infant population when the needs are much more specific. In developed regions of the world, access issues include developing stores and health care centers where nutritional supplements can be obtained at a reasonable cost—a cost competitive with other, less nutritious, options. In developing regions of the world, access can simply mean providing the right kind of foods in the right places.
Attention to the physical-psychological aspects of feeding involves helping the infant to recognize patterns of hunger and satiety. Training care providers to be attentive to regular feeding patterns and signs that the infant is done eating will be important for developing feeding patterns that will sustain the infant over the rest of the years of her or his life. Portion control is a major issue in a number of adolescent and adult patients. By addressing this issue through controlled, but responsive, feedings at a young age, some of these issues can be avoided later on. Also, attention to the feeding needs of an infant will help to detect nutritional needs that are not being met or allergies that are developing to particular foods.
This period of introduction to the foods that will be sustaining an infant throughout the rest of life is critical in order to develop healthy eating patterns and also to meet the increasingly broad nutritional needs that the infant presents.
MEMBERS OF THE NUTRITION TEAM[vi]
Physician-The well being of infants and children is dependent on their nutritional status from uterus to adult life. It is a known fact that people listen to the advice of their physicians more then any other health care provider. The department of pediatrics considers nutrition an essential component of its practice.
The Healthy People 2000 initiative of the US Department of Health and Human Services and the Guide to Clinical Preventive Services, from the U.S Preventive Medicine Task Force enforces the pediatrician’s responsibility in providing nutrition services and counseling.
Physicians feel that their medical
school and residency training in nutrition related issues is inadequate.
According to a national survey conducted by The National Academy of Sciences
Committee on Nutrition Education in 1989 only 23%
The role of the pediatrician is central, not only in that patients pay attention to their advice, but they are the only health care providers licensed to prescribe treatment whether in the form of diet or medication.
Nutrition assessment has the following components:
1. Screening of general health to identify periods of nutritional vulnerability
2. Measurement of height, weight and head circumference and comparing them with last measurements
3. Evaluating dietary intake according to basic food groups
4. A complete physical examination
If an assessment of nutritional imbalance is observed the physician should explain the treatment to the parents, provide brief counseling and referral if necessary, and follow-up. In a study conducted in 1992 it was found that parents are the primary influencers of their children’ eating behavior, so educating the parent is very important.
Nutritional assessment should be a routine practice on infants and children during well child visits. While the parents are in the waiting room they should be given a dietary form to fill out. Physicians’ waiting room should be stocked with appropriate literature, posters emphasizing the importance of a healthy diet, lifestyle should adorn the walls, a bulletin board displaying nutritional messages, this positive reinforcement sends out the message that the pediatrician feels that nutrition is important.
Public Health Worker-Public health workers have a responsibility to accurately assess the regional nutrition situation and to design interventions that will appropriately address any deficiencies that are found. The field of public health is, in fact, populated by members from the rest of the nutrition team. However, there is a specific duty and need in the role of nutrition to consider the situation from the point of view of the population and systemic barriers. Whether this role is filled by a nurse, physician, or dietitian, it is a distinct set of questions that must be addressed. The aim of public health nutrition is to improve the nutritional status of the community in which one is involved. It is responsible for identifying nutritional concerns and needs and creating solutions for the community.
Dietitian-The health care providers
who have the most extensive training in nutrition are the RD’s (registered
dietitians). Approximately 40% of the 65,000
Nurses-As major players in the
health care team, nurses are often the ones to conduct the communication to
patients about the nutritional needs of their infant. While the physician is traditionally seen in
Parents-The most central player in the nutrition team for an infant is the parents. The parents usually have the most contact with the child and are able to control the nutritional intake. The parents also have the most one-to-one contact with the infant. As very individualized care takers, they are able to interpret the information that is provided to them from the various sources and the various other members of the nutrition team. Parents have the responsibility of caring for the infant and usually have a stronger emotional drive to do so. By educating parents about the nutritional needs of their infant, the health care team can gain an important ally.
Not only are the parents important members of the nutrition team due to their role as care takers. They also play an important part in providing positive role-modeling for the infant. By starting early with regular, nutritious meals, the parents will be able to raise a child in the context of healthy eating choices. This role is even more important in the context of populations that are exposed to high levels of nutrient-poor foods. In these cases, the choice for healthy, well rounded meals becomes difficult. Thus, parents should be encouraged to set up these positive eating habits in the entire household.
Failure to Thrive (FTT)- Nearly 5-10% of US children are affected by FTT, which occurs mostly because of inadequate nutrition with outcomes ranging from poor growth to mental retardation. To identify FTT the health care provider must regularly take measurements of height, weight, arm, and head circumference and record them on the growth chart. Dealing with this problem requires that the nutrition team address any abnormal slowing in growth as early as possible. Dropping below the fifth percentile in growth is considered extremely troubling. Guidelines for addressing failure to thrive were addressed in a 2003 American Family Physician article[vii] and deal with creating a high-calorie, well rounded diet for the child.
Snacking-While the problem of snacking is not a large problem in young infants, as infants move towards including more and more solid foods in their diet, the temptation to feed with snack foods becomes greater. Also, the danger of disconnecting the physical sensation of hunger from the action of eating becomes of greater concern. It is important to keep distinct the need for the growing infant to eat frequent, small meals and the danger of “grazing” or eating simply out of boredom. Interviewing parents about eating patterns for the infant can be helpful to detect problems related to snacking. Parental attitudes towards snacking can also be an important source of information.
Obesity-While obesity is traditionally considered a problem of adults and, more recently, of adolescents, increasing information indicates that the problem of obesity has roots all the way in to infancy and the food choices that were made during complementary feeding or formula feeding. These choices have been show to have an impact on the eating habits later in life. In order to address these problems currently, exclusive breast feeding should be encouraged throughout the first six months and the transition to other food types should be made carefully and include adequate amounts of protein and fats.
Vitamin Deficiencies-The deficiencies can be especially critical in the infant population when development is occurring at such a quick pace. The vitamins are required elements of the diet that can not be obtained except through being consumed directly. Other minerals such as iron, zinc, and iodine are also important elements to be considered in nutrition programs. Vitamin A deficiency is currently one of the most pressing vitamin deficiencies. The most cost effective strategy to address this problem so far has been to fortify food sources with these critical vitamins and minerals.[viii] This problem has been shown to be best addressed at a population level and thus requires extensive monitoring in order to assess the sorts of deficiencies that are present in a particular population and determine the method by which fortified foods may best be provided.
Protein Deficiency-Protein is one of the most important components in the diet of an infant transitioning from breast milk. In order to meet the protein needs of children, it is important to feed with frequent servings of meat or vegetable protein. Protein in malnourished children will allow quicker growth and help the individuals to reach a healthy body mass on the growth curve.
FOOD AND NUTRITION SERVICES
FNS manages the nutrition assistance program of the U.S department of agriculture (USDA). It’s goal:
1. Provide access to food for children and needy families through it several ongoing food programs
2. Encourage healthy eating behavior and balanced diet via its nutrition education efforts.
FNS works in collaboration with the states in all its programs. The way responsibility is shared is that the state takes care of determining the eligibility of participants for the food distribution benefits, and also the administrative structuring regarding the distribution of food benefits. FNS in turn provides the funding for the program. Each day one out of every five Americans receives nutrition assistance through one or more of the 15 FNS programs
A component of FNS known as The Center for Policy Promotion (CNPP) was established in December 1994, its focus is to improve the diet of the American people, and has done so by issuing THE DIETARY GUIDELINES FOR AMERICANS and the FOOD GUIDE PYRAMID. Though, the dietary guidelines don’t apply to children under 2. In fact, health experts advise against restricting fat in young children’s diets, as fat is one of the six nutrients essential for proper growth and development. At no other age is there more importance and need of fat in the diet then in infancy and early childhood, which is considered the most rapid period for growth and development. For this reason FDA and USDA have implemented specific rules to govern the labeling of food for children under 4.
CNPP has also issued the HEALTHY EATING INDEX, which is the only Federal index of overall diet quality. CNPP works along with the USDA to coordinate and promote the nutrition education policy and provides the necessary information to consumers, policymakers, and professionals in health, education, industry and media.
The mission of the center is authorized by the Organic Act of May 15, 1863, and the National Nutrition Monitoring and Related Research Act of 1990.
Nearly one in five children live in poor households, single mothers and their children comprise a large part of poor households. FNS provides the following programs for nutrition assistance and benefit to children:
Food Stamps Program:
The Food Stamp Program is a cornerstone of the USDA nutrition assistance programs; it provides benefits monthly to eligible participants, which depends upon household size, income, assets and other factors. Over half the participants are children. USDA runs a toll free line 800-221-5689 for information about the food stamp program. By mandate of the congress all the states had to convert their food stamp coupons to EBT card system (electronic benefit transfer) by 2002.
Food Stamp Program currently serves nearly 19 million people a month. Federal government pays for the benefits and shares administrative expenses with the states. Congress appropriated $21.2 billion for this program in FY 1999, the most recent year for which FNS has posted statistics.
Special supplemental nutrition program for women, infants and children (WIC):
The objective of the WIC program is to improve health of
* Low-income pregnant women (through pregnancy and up to six weeks postpartum)
*Breastfeeding mothers (up to one year)
*Non-breastfeeding mothers (up to six months after birth of infant)
*Infants and children up to five years of age
The program encourages moms to breastfeed; a larger variety of food is offered to breastfeeding moms then those postpartum ones who are not breastfeeding.
The nutrients frequently lacking in the diet of the target population include proteins, iron, calcium, vitamins especially vitamin A and C, WIC provides vouchers for food which is rich in these nutrients, WIC also supplies iron fortified infant formula and cereal. In addition to receiving food services the participants are also provided with counseling facilities, nutrition education at WIC clinics, screening and referral to other health, welfare and social services. WIC also runs a Farmer’s Market Nutrition Program, which provides coupons to WIC participants for authorized farmer’s markets where they can have access to fresh fruits and vegetables.
A study of WIC program and Medicaid costs in the five states showed that women who participated in this program had lower Medicaid costs for themselves and their babies in the initial weeks after birth.
WIC currently serves more then 7.3 million people in a month. Congress appropriated 3.924 billion in FY 1999 for this program.
CACFP is operated through the USDA to ensure that children enrolled in daycare eat nutritious, well-balanced meals. The primary goal of the childcare segment of this program is to improve the diets of young children. Childcare providers that participate in the program receive reimbursement for the food costs provided that the meals served meet nutritional requirements of the program. About 2.6 million children benefit from the program. Congress approved $1.61 billion in FY 1999 for this program.
Head start is a child development program that has served low-income children and their families since 1965.The program consists of comprehensive two-generation services that begin before the child is born and focus on enhancing the child’s development and supporting the family as primary educators of their children during the first three years of the child’s life. The program focuses on four areas:
1. Child development
2. Family development
3. Staff development
4. Community development.
Nutrition services are part of the program. Community Nutritionists serve an important role in the implementation of nutrition guidelines in the Head Start programs.
The Head Start Bureau, the Administration on Children, Youth and Families (ACFY), Administration manages Head Start program for Children and Families (ACF), Department of Health and Human Services (DHHS).
Head Start has 15,872 centers throughout the country. According to the 2000 Head Start Fact Sheet, in fiscal year 1999 total number of enrollments was 826,016 in about 47,360 Head Start classrooms.
One of the
most outstanding infant nutrition programs is CONIN. This program was developed in
UNICEF and WHO have provided various sets of guidelines to meet the nutritional needs of infants. These are listed here in the bibliography. Of particular note in their programs is the implementation of specific community based initiatives that aim to empower local leaders to make changes in the way that infant nutrition is understood in the community. These initiatives also aim to increase the rates of breastfeeding among mothers.
Another UNICEF priority is the provision of micronutrients to the population through fortification of foods. This is done through collaboration with governments in order to determine the proper vehicle by which this might be carried out.
A third direction that UNICEF aims is the monitoring of infant nutrition statistics. Using the various anthropometric techniques, UNICEF is able to assess the nutritional status of a particular population and to identify a crisis when it occurs. The resources to address this specific problem are also then made available.
WHO devotes much of its efforts to similar programs of collaboration on both the international and local levels. However, additional priorities in WHO involve eliminating the economic inequalities that are at the root of so much of malnutrition. Additionally, WHO works to link the areas of research and program implementation in order to provide, accurate, up-to-date, responsive solutions to the types of problems that are identified in the area of infant nutrition.
The Pan-American Health Organization (PAHO) is also very active in developing nutrition programs that will meet the needs of infants and be responsive to local needs. They work with local community members to provide encouragement for nutrition initiatives. They also work to coordinate efforts between communities so that a unified approach can pool shared learning experiences.
SPECIAL TOPIC: BREASTFEEDING AND HIV+ MOTHERS
Breastfeeding in HIV positive
mothers is a complex topic and more information on this can be found elsewhere
in this textbook. However, as a brief
guideline, infants who have been exclusively breastfed by HIV positive mothers
show a lower rate of infection than infants who have been breastfed and
supplemented by other nutritional sources.
CHALLENGES TO IMPLEMENTING NUTRITION PROGRAMS AND FINAL THOUGHTS
The role of nutritional services in today’s public health system is a two-tier phenomenon, at the level of the community and that of the individual at risk. As such the health care providers should tailor their efforts to address both. The first step at either level is data collection to ascertain the needs of the community, set priorities, and to determine the available resources. This will also help in defining the population at risk and those in need for targeted programs.
Efforts should be made to promote increased government and private sector response to child nutrition. Sources for such an effort include national public health initiatives like the Healthy People 2000 and 2010, Pediatric Nutritional Surveillance System (PedNSS), managed care organizations and local initiatives to improve nutrition such as hospital based or community outreach programs. The community nutritionist should be able to synthesize these resources into cohesive initiatives directed at the priorities distilled from baseline data. These initiatives should include checks and balances to allow constant monitoring to ascertain if the goals of these programs are being met. Feedback mechanisms should also be in place so that effective activities are promoted and ineffective ones are curtailed or withdrawn while the program is running.
Budgeting and monitory constraints should be kept in mind when programs are developed. Cost effectiveness and opportunity cost should be incorporated into the planning phase so that valuable resources are utilized in an optimal manner. A number of resources exist on programs that have been put into place in other regions. When the learned experiences of these programs are pooled together, a greater amount of public health power can be put in practice.
The role of local employers and community leaders in encouraging healthy choices in childhood nutrition cannot be overemphasized. In many cases, there are ways that infant nutrition needs can be met through more informed decisions. Public acceptance of breastfeeding and the incorporation of this as a practice that can fit more easily within the context of society is one example of a way that community attitudes can influence nutrition. Also, in the context of food choices in older infants, the role-modeling by the parents has already been stressed, but these changes also need to be accepted by the community as a whole in order to support the nutrition of the individual. Good nutrition must be a priority as a whole in society.
With the number of changes and the amount of effort required in many cases, the road to solid infant nutrition will not be an easy or short one. As additional research brings forth its results, there will be new insights into ways that nutrition should be structured for the maximum beneficial effect. It is also important to consider these developments. Nutrition is one of the major keys to preventative health care and must not be abandoned if healthy lives are to be obtained in adulthood.
Parents and Childhood Nutrition http://www.health.state.ny.us/nysdoh/chronic/obesity/parents.htm
Childhood Obesity and the Link to Infant Feeding http://www.childhood-obesity.org
M. B. Aldous. Nutritional issues for infants and toddlers. Pediatric Annals 1999;28:101-105.
S. A. Schlicker, S. T. Borra, C. Regan. The weight and fitness
L. G. Pardini. Community nutrition. Handbook of pediatric nutrition. p 225-240.
A. B. Lasswell. Incorporating nutrition into pediatric practice:physicians and dieticians working together to improve children’s health. Pediatric Annals 1992;21:676-687.
Smith Z. Failure to thrive: early intervention to address dietary issues is vital. [Review] [7 refs] Community Nurse. 5(9):S3-4,S6,1999.
Food and nutrition service program data. http://fns.usda.gov/fns/menu/about/PROGRAMS/PROGDATA.HTM
Labeling rules for young children’s food. Department of
Health and Human Services.
Healthy school meals resource system. http://schoolmeals.nal.usda.gov:8001/framework/index.html
Head Start. Administration for children and families. U.S Department of Health and Human Services.
Zero To Three. National center for infants, toddlers and familieshttp://www.zerotothree.org/
Association for children’s nutrition growth.
FRAC food research and action center
National center for chronic disease prevention and health and health promotion
E. Kennedy. What are American children eating? Implications for public policy. Nutrition Reviews 1995;53:111-126
G. C. Frank, A.Vaden, J. Martin. School health promotion child nutrition programs. Journal of school health. 1987;57:451-460
[i] WHO/UNICEF Global Strategy for Infant and Young Child Feeding. 2003
[iii] WHO/UNICEF Global Strategy for Infant and Young Child Feeding. 2003
[iv] e.g. http://www.breastfeeding.asn.au/bfinfo/mfwp.html
[v] WHO Department of Child and Adolescent Health “Feeding the Non-Breastfed Child 6-24 Months of Age” Meeting Report 8-10 March 2004.
[vi] Portions of this section were taken substantially from the previous chapter by Beena A. Minai
[viii] World Health Report 2002
[ix] Portions of this section were taken substantially from the previous chapter by Beena A. Minai