1. WEANING THE MALNOURISHED INFANT
Noel W. Solomons MD
CeSSIAM, Guatemala City, Guatemala

2. CLARIFICATION AND DISCLAIMER
Malnutrition can denote any form of disturbed nutritional status due to deficiency/insufficiency, excess, or imbalance (Uauy & Solomons, 2006).
The present topic includes up to moderate degrees of each of these conditions, but excludes consideration of feeding of severe (third-degree), clinical forms of undernutrition (i.e. kwashiorkor, marasmas), which is the domain of therapeutic feeding and rehabilitation.

3. CLARIFICATION AND DISCLAIMER
WEANING is a process which extends from the first initiation of non-EBF (introduction complementary foods) to the cessation of lactation.
The sense and interpretation of the present topic is mostly on weaning the child, already malnourished at the initiation of the weaning process.
[Malnutrition developing during weaning would be attributable, in part, to poor execution of the routine principles of adequate complementary feeding.]

4. THE BASICS

5. FRAMEWORK/DEFINITIONS
Exclusive Breast Feeding: The provision of human milk without any other liquids or foods. The only permitted exceptions are medications by dropper or in crushed tablet form, including vitamin D and iron supplements.
WHO Recommendation (2001) “exclusive breastfeeding for 6 months and thereafter continued breastfeeding during the first 2 years and beyond together with complementary food of high quality.”

6. FRAMEWORK/DEFINITIONS
Weaning: The period of transition from exclusive breast feeding to cessation of human milk offering in the infant or toddler’s diet.
Complementary Foods (WHO): Anything other than human milk (i.e. water, beverages {including replacement formula}, semi-solids and solid foods).
Complementary Foods (ESPGHAN): Complementary foods = biekost, i.e. solid and semi-solid foods. Infant and follow-up formula not included in definition.

7. Weaning the Well-nourished Child

8. ORIGINS OF CONTEMPORARY INTEREST
Fervor over promotion of breast milk substitutes (1970s) and the International Code of Marketing of Breast Milk Substitutes (1981)
More refined estimates of recommendable intakes for infants
Persistence of risk of undernutrition in early years of life
Food technology options to improve the nutritional quality

9. GEOGRAPHIC EXTENSION/HOT SPOTS
All countries with a high prevalence of stunting
All countries with a high prevalence of infant wasting

10. RELEVANCE
To the extent that undernutrition is a risk factor in child death, it would be important to reverse the low-weight status
To the extent that rapid catch-up growth is a risk factor for later-life metabolic abnormalities and chronic disease, the rate of recovery poses as a caveat

11. THE
LOGICAL
CONTEXT

12. Exclusive Breast Feeding EBF supports adequate growth
In theory, there should be few, if any, malnourished infants at the time of weaning IF all infants begin life with
Exclusive Breast Feeding
EBF supports adequate growth

13. Scenario #1: Infant is malnourished because of intra-uterine growth retardation or prematurity, unrecovered during the first 6 months of life
Scenario #2: Infant is malnourished because weaning process has been delayed too long. Child’s requirements not being met by EBF.
Scenario #3: Infant is malnourished because weaning has been initiated to early. Infant unable to assimilate foods and defend against food-borne illness
Scenario #4: Infant is malnourished because of an underlying congenital or acquired disease, including HIV

14. Parsing Scenario #3:
Causality: Infant is malnourished because of premature weaning.
Reverse Causality: Infant was weaned because of emerging malnutrition, and a perception that EBF was insufficient.

15. THE ROLE OF INFLAMMATION

16. THE EMERGING (BIOLOGICAL-
UPDATES
THE EMERGING (BIOLOGICAL-
EPIDEMIOLOGICAL-
CLINICAL) ISSUES

17. UPDATE: DIAGNOSIS OF INFANT UNDERNUTRITION
What was malnourished in terms of height or weight deficit before 2006 may no longer be deficient with the new WHO Growth Standards. The threshold for declaring to be underweight for age has moved lower as of 2006.

18. Weaning the Well-nourished Child

19. Weaning the Mal-nourished Child

20. UPDATE:Complementary Feeding
Fewtrell states:
“The fat content of the diet is an important determinant of its energy density and should not be less than 25% of energy intake. A higher proportion might be required if the appetite is poor, the infant has recurrent infections or is fed infrequently.”
Chpt 2.4 Pediatric Nutrition in Practice (2008)

21. UPDATE:Complementary Feeding

22. UPDATE:Complementary Feeding

23. UPDATE: Caution on End-Point!
Height for age: If “stunting” is the malnourished state trigger, feeding per se will have limited leverage to stimulate linear growth.
Weight for age: Even using the WHO 2006 standard, if an infant has a short length, he or she will be overweight or obese when achieving target weight.
The trigger diagnosis should be weight-for-height and the monitoring criterion should be weight-for-height.

24. UPDATE: Complementary Feeding: PROBLEMATIC MICRONUTRIENTS
Ken Brown stated:
“We defined ‘problem nutrients’ as those for which there is the greatest discrepancy between their content in complementary foods and estimated requirements for these nutrients.”
Problem nutrients: Iron, Zinc, Calcium, certain B-Vitamins, and occasionally Vitamin A

25. UPDATE: COMPLEMENTARY FEEDING: PROBLEMATIC NUTRIENTS ADDRESSED
Design: Comparison of iron and micronutrients as powder, crushable tablets and high-nutrient-density spread vs no treatment:
Observation #1: All modalities produced equivalent increases in iron stores as indicated by circulating ferritin increments.
Observation #2: Only the HNDS (Nutributter) enhanced height and weight growth.
Adu-Afarwuah S et al. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: Effects on growth and motor development. Am J Clin Nutr 2007:86:

26. UPDATE: CONTROVERSY ON RAPID VERSUS SLOW “CATCH-UP” GROWTH
Proposition 1: The velocity of weight recovery is a determinant of later term risk of metabolic syndrome components, as early as childhood
Proposition 2: Growth velocity is not a risk factor for impaired health

27. TAKE-HOME MESSAGES: WEANING

28. TAKE-HOME MESSAGES: WEANING

29. SUGGESTED READING
 Classic Literature
Gordon JE, Chitkara ID, Wyon. Weanling diarrhea. Am J Med Sci 1963;245:  
Brown KH, Dewey KG, Allen LH. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, WHO – UNICEF, 1998.

30. SUGGESTED READING (con’t)
Contemporary Literature
Brown KH. Breastfeeding and complementary feeding of children up to 2 years of age. Nestle Nutr Workshop Ser Pediatr Program. 2007;60:1-10.  
Solomons NW. Weaning infants with malnutrition, including HIV. Nestle Nutr Workshop Ser Pediatr Program. 2007;60:
Fewtrell M. Complementary foods. In: Koletzko B (ed) Pediatric Nutrition in Practice. Basel, Karger 2008:

31. Thank You