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

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.

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.]

THE BASICS

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.”

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.

Weaning the Well-nourished Child

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

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

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

THE LOGICAL CONTEXT

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

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

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.

THE ROLE OF INFLAMMATION

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

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.

Weaning the Well-nourished Child

Weaning the Mal-nourished Child

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)

UPDATE:Complementary Feeding

UPDATE:Complementary Feeding

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.

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

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 2007:86:412-420.

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

TAKE-HOME MESSAGES: WEANING

TAKE-HOME MESSAGES: WEANING

SUGGESTED READING  Classic Literature   Gordon JE, Chitkara ID, Wyon. Weanling diarrhea. Am J Med Sci 1963;245:345-377.   Brown KH, Dewey KG, Allen LH. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, WHO – UNICEF, 1998.

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;60:171-180. Fewtrell M. Complementary foods. In: Koletzko B (ed) Pediatric Nutrition in Practice. Basel, Karger 2008:103-105.

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