Objectives of ANP are —

a) To promote local food production e.g. poultry, horticulture, kitchen garden etc.

b) To provide nutritional education

c) To provide supplementary nutrition to preschool children (3-6 years) and pregnant/lactating mothers.

Organization: Program is sponsored and implemented by state governments, with local Balsevika under supervision of block development officer as implementer in the field.

Activities: Applied Nutrition program in India is a community awareness program rather than supplementary nutrition program, with emphasis on promotion of agricultural/non-agricultural food production, increased consumption of low-cost, locally grown foods and create awareness about their nutritive values.

Although one of the best conceived nutritional program, it could not achieve desire results and currently continues to be a low-priority program. Baiwadi nutrition program in India (1970-71) are implemented by voluntary organizations, with grant-in aid from social welfare ministry.

It aims to provide supplementary nutrition to rural pre-school children (3-6 years) along with pre-primary education, through Baiwadis – most peripheral center at village/community level.

Special nutrition program (1970-7 1), a state-sponsored program at present, is being gradually merged with ICDS. Primary objective of this program is provide supplementary nutrition and Vitamin A prophylaxis to pre-school children and supplementary nutrition and iron/folic acid supplementation to pregnant/lactating mothers, though a net work of Baiwadis.

Wheat-based supplementary nutrition program in India (1986), a jointly funded scheme by center & state with same objectives and beneficiary group as for special nutrition program, was initially started to cover nonICDS areas with one difference — use of subsidized wheat from public distribution system for supplementary nutrition. However, it is also being gradually incorporated under ICDS.

a) Infections include Common like ARI, Diarrhea, TB, helminthiasis. Severe Gram —ye sepsis, septic shock, DIC and Opportunistic Candidiasis

b) Hypothermia

c) Metabolic

Hypoglycemia

Hypocalcaemia

Hypomagnesemia

d) Fluid & electrolyte imbalance

Dehydration

Hypokalemia

Hypernatremia

e) Lactose intolerance

f) Severe anemia & other nutrient deficiencies

g) Congestive cardiac failure

Late (Recovery) complications:

a) Diarrhea (lactose intolerance)

b) CCF (high protein & solute diet)

c) Unmasking of subclinical vit/mineral deficiencies

d) Recovery syndromes (see text)

Long-term effects:

a) Growth retardation

b) Cognitive & learning disabilities

Hypomagnesemia, if present, should be treated with TM 50% magnesium sulfate (0.2 mllkg 12 hourly for 2-3 days).

Nutrient deficiencies: Iron-deficiency anemia due to poor dietary intake and/or co-parasitic infestations is common, which should be treated with oral iron therapy (1 mg/kg/d of elemental iron) along with deworming agents (P0 albendazole 400 mg, single dose). Blood transfusions, though necessary in severe cases, should be avoided in PEM due to risk of CCF and should not exceed 10 mI/kg of packed cells at one time.

Other necessary nutrient supplements in PEM include – single doses of Vitamin A (P0 50,000- 2,00,000 IU), Vitamin K (2.5 mg TM) and Mg SO4 (2 ml 50% sol TM) on admission and daily oral supplementation with folic acid (1 mg) and zinc (2 mg/kg), from first day onwards.

g) Congestive cardiac failure is not uncommon in kwashiorkor, due to impaired cardiac function, fluid overload, and sudden shift of edema fluid in intravascular compartment after blood/plasma transfusions. Diagnosis of CCF in an edematous child may be difficult, but absence of Weight loss despite reducing edema or presence of basal crepitations suggests this possibility. Digitalis therapy carries high risk of toxicity in PEM and hence in these cases, CCF should preferably managed with diuretics and supportive therapy, unless refractory.

Step II – Dietary management: Intensive and supervised dietary therapy needs to be started, soon after the control of complications.

For the sake of simplicity, dietary management may be divided into three steps calculation of nutritional requirements; selection of appropriate type, frequency and method of supplementation, and monitoring of nutritional intake.

a) Calculation of nutritional requirements: Dietary requirements in PEM are relatively higher than in well-nourished children due to additional needs for catch-up growth and replenishment of stores. However, most of them are anorexic or cannot tolerate higher intake due to mal absorption e.g. lactose intolerance. Cases with kwashiorkor also carry risk of CCF if treated with high protein diet since beginning. Hence, it is advisable to begin the dietary therapy with minimum essential intake i.e. 100 cal/kg and 2 gm/kg of proteins according to actual weight and increase by 10-20% every alternate day, till the final aim is achieved (Table 6.11).

b) Selection of appropriate feeds, frequency & mode of administration: Diet plan in PEM cannot be generalized and needs to be tailored in each case. Depending on the age, severity, acceptance and economic feasibility, early dietary therapy may be provided with — i) regular home-made diet in higher quantity and better quality (in mild to moderate PEM), ii) regular home diet, supplemented by high- energy feeds, or iii) therapeutic diets in initial phase, followed by gradual shift to home diet.

Some noteworthy principles of early dietary therapy are as follows —

• Diet should be age-appropriate, acceptable and closely resemble the home diet

• It should be energy-dense i.e. high caloric value with low-bulk. Caloric content and palatability may be improved by adding edible oil or animal- fats e.g. ghee, butter etc. Coconut oil is excellent source of extra calories and being a medium-chain triglyceride, absorbed directly without emulsification. Upto 10-15% of total calories may be given as visible fat in PEM.

• It is preferable to use high biological value proteins e.g. eggs. Protein content in vegetarian diet may be increased by using Soya-bean or ground-nut preparations.

• High-carbohydrate diet should be avoided in early stages, due to frequent lactose-intolerance in severe PEM.

• In anorexic patients, nasogastric feeding with relatively liquid diets e.g. enriched milk may be used initially followed by gradually thickening.

• Feeds should be given more frequently and in smaller aliquots, to improve acceptability. Breast feeding should be continued, if possible, even in older children as a source of additional energy.

• Feeds must be prepared hygienically, involving parents in the selection/preparation of therapeutic diets to improve their nutritional awareness.

• Dietary practices and cultural beliefs e.g. regarding consumption of eggs or non-vegetarian diet should be respected to improve acceptability.

Amylase rich foods (ARF) are easily digestible and enriched sources of proteins and vitamins, prepared by soaking common cereals or pulses in water for 12 hours > sprouting by wrapping in a moist cloth for 48 hours, > drying > roasting> grueling to make porridge. On soaking, the amylase breaks down grain-starch into easily-digestible maltodextrins, reducing the viscosity and bulk of diet. Germination also enhances vitamin content.

c) Monitoring: During dietary therapy, all cases should be closely monitored for dietary intake, signs of recovery, and recovery phase complications.

Common complications in recovery phase are —

a) Diarrhea due to relative lactase deficiency and other mal absorptive states, precipitated by increased nutritional intake,

b) Congestive cardiac failure due to shift of edema fluid in intravascular compartment, following high solute & protein diet,

c) Un-masking of subclinical vitamin & mineral deficiencies e.g. scurvy, zinc deficiency, due to disturbed adaptation.

Two well-defined clinical syndromes seen during the recovery phase are Kahn ‘.c and Gomez recovery syndromes, probably caused by unmasking of subclinical nutrient deficiencies.

Kahn’s recovery syndrome is characterized by sudden onset of tremors and encephalopathy, probably due to unmasked deficiency of gamma aminobutyic acid (GABA) – a major neuro-inhibitor.

Gomez recovery syndrome is characterized by progressive abdominal distension, ascites, hepatomegaly and diarrhea, due to secondary malabsurption and dyselectrolytemia e.g. hypokalemia.

Step III – Consolidation phase begins after 1-2 weeks of intensive dietary therapy and aims to maintain nutritional gains and prepare for discharge. Important steps in this phase include —

a) Gradual shift from therapeutic to home-diet,

b) Continued vitamin/mineral supplementation,

c) Completion of age-appropriate immunization,

d) Nutritional counseling to parents,

e) Evaluation of home environment,

f) Continuous growth monitoring.

Ideally, all PEMs need close supervision till complete recovery, defined as achievement of ideal Weight for Height, which nzay take 6-8 weeks. However, as to wait fill complete recovery in overcrowded hospitals is neither possible nor desirable, fulfillment of a discharge criteria should be adhered, to prevent the recurrence.

Prevention: Malnutrition is more of a socio-economic problem, rather than medical disease. A comprehensive approach is required, especially in developing countries to overcome it. Important preventive steps against PEM include —

I. Promotion of general health and nutrition

A) Actions at family level to promote:

• Correct Breast feeding & weaning practices

• Consumption of cheap, local, nutritive foods

• Correct cooking practices

• Avoidance of wrong food taboos & habits

• Equitable food distribution in the family

• Setting of kitchen gardens/poultry keeping

• Correct feeding practices during illnesses

• Nutrition in pregnant/lactating mothers

• General child health/hygiene,

Family planning practices

B) Action at community level:

• Nutritional surveillance

• Nutritional education

• Development of local low-cost foods

• General measures to improve child health e.g.

- Improved water supply and sanitation

— Widespread immunization services

— Preventive/curative health-care facilities

• Creation of local-job opportunities

C) Action at national level to promote:

• Agricultural production

• Food-storage facilities & public distribution

• General rural/urban-slum development

• Poverty-alleviation measures,

• Food-subsidies to high-risk population

• Targeted health and nutritional programs

D) Action at International level:

• International aid to stimulate socioeconomic development in developing countries.

• World food program (1963), to meet food requirements in needy countries.

• International cooperation during emergencies e.g. natural disasters and wars

U) Specific protection to high-risk children:

• Nutritional surveillance in pre-school children

• Nutritional supplementation/food fortification

• Periodic deworming & iron supplements etc.

• Immunization to control infections

III) Early diagnosis and management:

• Growth monitoring of under-5 children

• Nutritional assessment at all contact points

• Early diagnosis & management of PEM

• Early diagnosis & treatment of infections

IV) Follow-up and rehabilitation:

• Nutritional rehabilitation centers/services

• Follow-up of recovered cases

WHO defines Protein energy malnutrition as “a range of pathological conditions arising from the coincidental lack in varying proportions of proteins and calories, occurring more frequently in infants and children and commonly associated with infection.” This term includes both – the wasting (predominant weight deficit) as well as the stunting (predominant height deficit).

Prevalence

Although rarely a presenting illness, Protein energy malnutrition is an underlying problem in 50% of childhood morbidity. Reported prevalence of Protein energy malnutrition differs in various nutritional surveys, due to differences in the diagnostic criteria. Recent information indicates that —

• Current prevalence of under nutrition children is 40%, while wasting and stunting is present in 23% and 45%, respectively (NFHS III 2006).

• Prolonged under nutrition i.e. stunting is more common than acute Protein energy malnutrition i.e. wasting.

• While the incidence of severe Protein energy malnutrition has declined in recent years, mild/moderate PEM continues to be widely prevalent.

Ecology: Malnutrition is a result of complex interplay between inadequate dietary intake, due to various dietary, socio-economic and cultural factors and b) increased nutritional requirements, due to infections or illnesses. Common etiological factors, associated with Protein energy malnutrition include —

a) Child-related factors:

• Low birth weight

• Absence or early cessation of breast feeding

• Delayed weaning

• Incorrect dietary habits e.g. food fads.

• Recurrent/persistent infections e.g. diarrhea, respiratory infections, measles, helminthiasis, etc.

b) Maternal Factors:

• Lactation failure

• Maternal malnutrition/illnesses

• Ignorance about child-feeding practices • Inappropriate agricultural practices, production and distribution of food grains.

• Generalized economic depression.

• Inadequate primary health care.

Pathogenesis

Protein energy malnutrition represents a gap between nutritional requirements and dietary intake of the child, though actual pathophysiology is much complex. It is not yet clear, why some malnourished children present differently from others (marasmus vs. kwashiorkor)? Various theories have been suggested to explain different clinical presentations in Protein energy malnutrition, as follows —

a) Dietary theory explains these differences on the basis of relative deficiency of calories and proteins in diet. Accordingly, predominant caloric deprivation leads to marasmus while kwashiorkor indicates primary protein deficiency. However, no significant differences between protein or caloric contents of diets in children with marasmus and kwashiorkor have been consistently found.

b) Duration theory: Duration of nutritional deprivation has significant impact on the clinical spectrum of Protein energy malnutrition, as shown in Viteri‘s triangle. Children with gradual nutritional deprivation e.g. delayed weaning, tend to develop marasmus while those with sudden insult e.g. early cessation of breast feeding or intercurrent infections, are prone for kwashiorkor.

Effect of duration on Protein energy malnutrition (Viterik Triangle)

c) Gopalan theory of adaptation is based on the success of compensatory mechanisms in nutritionally deprived child. During early stages of widening intake- requirement gap, the body tries to adapt by —

i) Curtailing energy expenditure by reduced physical activity and growth,

ii) Efficient utilization of available calories by enhanced glucose uptake by cells, and

iii) Utilizing endogenous stores e.g. muscle proteins and subcutaneous fat via neoglucogenesis.

However, these adaptive mechanisms involve many metabolic and hormonal changes and their success depends on the availability of enough time and endogenous resources for compensation. Children with gradual nutritional deprivation tend to adapt better and develop marasmus-like illness with growth failure, muscle wasting and loss of subcutaneous tissue. Lack of urgency for endogenous catabolism as well as limited muscle mass and hepatic stores in these cases prevent development of edema and hepatomegaly.

In children with sudden nutritional deprivation, less time is available to adjust for lower energy intake, necessitating rapid mobilization of endogenous stores (neoglucogenesis), leading to kwashiorkor-like features with edema (due to protein utilization) and fatty hepatomegaly (due to lipolysis).

d) Role of infections: Infections and nutrition are closely linked to each other and infections e.g. diarrhea, ART or measles, are common preceding events for manifest Protein energy malnutrition in sub clinically undernourished children, due to sudden widening of demand-supply gap. Kwashiorkor is relatively more common in infection-precipitated Protein energy malnutrition than marasmus, due to inadequate adaptation.

e) Golden theory of free radicals attempts to explain edema and other changes in kwashiorkor, due to cell injury and increased cellular permeability following excess accumulation of free-radicals.

• Separation e.g. dead, single or working mother

c) Socio-economic factors: Poverty and unemployment, Large family size, Unhygienic living conditions, Inequitable food distribution in family, with mothers and infants being last priority, Disadvantaged children e.g. girls, orphans, etc.

d) Cultural factors: Wrong beliefs/superstitions e.g. colostrums is harmful, certain hot/cold foods to be avoided in children, milk aggravates diarrhea etc.; Wrong customs e.g. delayed weaning for religious ceremonies (annaprashan).

• Wrong cooking practices e.g. peeling of vegetables before cooking, use of polished food, draining away the water after cooking etc.

e) Community factors:

• Natural/man-made disasters with food shortage e.g. famines, wars, civil unrests.

Presence of infections may be clinically masked in Protein energy malnutrition due to poor inflammatory responses e.g. fever and leukocytosis. Hypothermia is an important indicator of infection in these children.

Diarrhea in PEM may also result from mal absorption due to intestinal villous atrophy and consequent lactase deficiency, as well as due to hepatic/pancreatic dysfunction.

Diagnosis

Protein energy malnutrition involves assessment of dietary intake, assessment of nutritional status, classification of severity, and identification of complications.

I) Assessment of dietary intake is the first step in screening for Protein energy malnutrition by —

• Dietary recall, the most frequently used method that involves detailed dietary history, including average daily intake in last few days before illness.

• Diary method by asking parents to keep a written record of the exact quantity of food items consumed by the child, for about a week followed by calculation of average daily caloric & protein intake.

• Replicate diet method is the most precise but complex method, mainly used for research purpose. Parents are asked to keep aside exact replica of food items, consumed by the child over a period. Later, investigators weigh these items, calculate dietary value and assess the precise intake.

II) Assessment of nutritional status is based on many anthropometric, morphological and biochemical parameters, discussed as follow —

a) Anthropometric parameters may be broadly divided into — i) age-dependent parameters ii) age-independent parameters and iii) Mass-screening parameters.

Age-dependent parameters are simple and most practical indicators of Protein energy malnutrition, when compared with reference norms for corresponding age. In practice, two parameters are most informative Weight (Wt) – an indicator of the severity of malnutrition as well as of nutritional recovery, and Height (Ht) – an indicator of the duration of malnutrition.

Age-independent parameters are useful when the exact chronological age of child is in doubt. These parameters are derived by comparing the relationship between two age-related parameters — one early indicator e.g. Weight or Mid-arm circumference (MAC) and other late indicator e.g. Height or Head circumference.

Weight for Height and Kanawati index are two commonly used age-independent indicators of Protein energy malnutrition. However, Weight for Height may be misleading in chronic cases due to proportionate fall in Weight as well as Height.

• Screening parameters are simple, inexpensive tools for mass nutritional surveillance of preschool children by paramedical workers. These tools are mainly based on MAC, which is fairly consistent between 1-5 years of age (16-18 cm), due to replacement of body fat with muscle mass. MAC of< 13.5cm and 12.5cm in this age group indicate malnutrition and severe malnutrition respectively (misleading in kwashiorkor due to edema).

Commonly used screening tests in India include —

a) Shakir’s tape is a special plastic tape with three color zones – green, yellow and red, each representing MAC of >13.5 cm, 12.5-

b) Morphological parameters are of limited value for diagnosis of Protein energy malnutrition and include —

• Hair changes e.g. — a) smaller diameter of hair root-bulbs (<11 mm), b) reduced proportion of anagens i.e. growing hair root-bulbs (<50%) and c) reduced anagen: telogen (resting hair root- bulbs) ratio.

• Buccal mucosal changes e.g. – increased proportion of broken or mutilated cells (>50%) in buccal smear, than in well-nourished children (5-10%).

c) Biochemical parameters are mainly useful for early diagnosis of Protein energy malnutrition, before the Weight is affected. These changes are more obvious in kwashiorkor than marasmus, due to poor adaptation (Table 6.3).

Earliest biochemical change in Protein energy malnutrition is a decrease in essential amino acid (EAA) levels – which can’t be synthesized endogenously, leading to altered EAAI non-EAA ratio in plasma.

This ratio (Glycine+Serine÷Glutamine+Taurine/ Valine+Leucine+Isoleucine+Methionine) is <2 in normal children, 2-3.5 in subclinical Protein energy malnutrition and >3.5 in Kwashiorkor.

III) Classification of severity: Various classifications systems for Protein energy malnutrition are in vogue to denote severity and duration of PEM, though some important ones are as follows —

a) Weight-based classifications are simple but do not indicate the duration of malnutrition. Most popular

one in this category is Indian Academy of Pediatrics or lAP classification, Others include Gomez classification (Weight >90% normal; 75-90% grade I, 60-74% grade II, <60% grade III) or Jellife s classification (>90% normal, 81-90% grade I, 71-80% grade II, 61-70% grade III, <60% grade IV).

b) Height-based classifications are rarely used in practice and include Waterlow ‘s classfication (Height >95% normal, 90-95% marginal, 85-90% moderate and <85% severe Protein energy malnutrition) and Mclaren ‘i classfication (Height >93% normal, 80-93% short-stature and <80% nutritional dwarfs).

c) Multi-parameter classifications are most informative and include Welcome trust classification, Waterlow’s classification and WHO classification

d) Clinical classification of marasmus depends on the extent of muscle wasting and subcutaneous fat loss.

Investigations: Although Protein energy malnutrition is a clinical diagnosis, following investigations are required on admission, to exclude or identify complications.

1. Complete hemogram including peripheral smear for anemia and infections (malaria).

2. Urine examination, especially for pus cells (UTI);

3. Stool examination, especially for fat globules (mal absorption), reducing sugars (lactose intolerance) and microscopic ova/cysts;

4. Chest skiagram for tuberculosis, respiratory infections;

5. Tuberculin test, which may be false negative in severe Protein energy malnutrition due to impaired cell mediated immunity.

6. Biochemical tests, specially —

a) S. albumin (hypoproteinemia), b) Blood sugar (hypoglycemia), c) S. Na, K, Ca and Mg (dyseictrolytemia), d) Liver function tests

7) Microbial cultures (blood, urine, others)

Other relevant investigations

Hospitalization is indicated in cases with severe PEM, life-threatening complications, severe anorexia and refusal to accept oral feeds, emotionally deprived or neglected child, and failure of domiciliary treatment.

PEM Management aims towards diagnosis & treatment of complications, dietary management for recovery & catch-up growth, and prevention of recurrence.

Accordingly, it may be divided into 3 steps — I) Emergency phase, II) Intensive dietary management, III) Consolidation or rehabilitation phase

Step I – Emergency phase: During first 24-48 hours of presentation, main emphasis is on the diagnosis and PEM Management of early complications as follows —

a) Hypothermia (rectal temperature <35.5°c) is more common in marasmus, due to fat insulation, severe infections and hypoglycemia, which should be treated with gradual warming under radiant warmer or with a blanket, temperature monitoring and frequent feedings.

b) Infections are difficult to recognize in PEM Management, due to poor inflammatory response and absence of constitutional signs e.g. fever. Presence of refractory hypothermia, hypoglycemia, shock and bleeding tendencies e.g. DIC indicates potentially serious underlying infection. Empirical antimicrobial therapy is indicated in these cases. Gram negative sepsis and septic shock is common in PEM Management, which needs intensive fluid and isotropic therapy.

c) Hypoglycemia, though more common in marasmus, is frequently asymptomatic due to low-energy adaptation. Symptomatic hypoglycemia with altered sensorium and seizures may be life-threatening and should be treated immediately with IV dextrose 10% (5-10 mI/kg) as bolus, followed by maintenance infusion of dextrose-containing fluids and frequent feedings.

Hypothermia, hypoglycemia and infections are closely linked complications of PEM Management and presence of any one of them warrants towards search for others.

d) Dehydration following co-existent diarrhea, vomiting, poor oral intake and redistribution of body fluids is common and may be difficult to assess in malnourished children due to edema. Urine output is the most reliable indicator in these cases. Management of dehydration in malnourished cases depends on its severity.

Mild to moderate dehydration is preferably treated with 5-10 ml/kg/hr of WHO-recommended low- sodium ORS or ReSoMal (rehydration solution for severely malnourished children), either orally or via nasogastric tube. ReSoMal can be prepared at home by diluting 1 pack of WHO -ORS in 2 liters of water and adding 50 gm of sucrose and 40 ml of mineral-mix solution.

IV fluids are necessary in severe dehydration or shock, though need a cautious approach due to altered fluid/electrolyte homeostasis and risk of over hydration/CCF. A simple plan is to initiate with 30 mi/kg of Ringer lactate over 2 hours, followed by 10 ml/kg/hr till oral feeding is established. Potassium (30-40 meq/L) should be added in IV fluids, after baby has passed urine.

e) Dyseleetrolytemia is common due to poor intake, CIT losses in diarrhea/vomiting and redistribution of body fluids. Even in absence of clinically obvious signs, a malnourished child generally has relatively more total body water due to loss of adipose tissue, extracellular hypematremia due to renal retention, intracellular hypokalemia due to redistribution of body potassium, hypocalcemia due to decreased albumin-bound fraction, hypophosphatemia due to muscle wasting, and hypomagnesaemia.

Hypokalemia: Intracellular K depletion is common even in asymptomatic PEM, which manifests with muscle weakness, abdominal distension and ECG changes. It should be treated with addition of Potassium into IV fluids (2-3 meq/ kg), after the child has passed urine. It is advisable to continue oral potassium supplements (2-4 meqIkg/d) during recovery phase.

Hyponatremia may develop due to persistent vomiting/diarrhea, though total body sodium is increased in severe PEM. Hence, hypertonic fluids should be avoided even in cases with biochemical hyponatremia.

Hypoealeemia, if symptomatic (tetany, seizures), is treated with slow infusion of IV calcium gluconate 10% (1 mI/kg) with cardiac monitoring. PEM Management

Principles: General characteristics of a balanced diet for children, based on dietary goals from various sources (Prudent diet; WHO) are as follows —

a) Quantitatively, it should fulfill recommended daily allowances for all nutrients.

b) Qualitatively, it should provide 15-20% of calories from proteins, 20-30% by fats* and rest 50-60% from carbohydrates, along with all desired micro nutrients.

* However, not more than 10% calories should be from saturated tats.

c) It should contain adequate mix of various foodstuffs like cereals, pulses, vegetables, milk and other animal products, according to local dietary habits, customs and economic capacity. Various types of mixed Balanced diet include —

• Double mix (cereals + pulses),

• Triple mix (cereals + pulses ÷ vegetables) or

• Quadri -mix (cereals + pulses + vegetables ÷ animal food)

Cereal-pulse combination is a very rational dietary practice, as cereal proteins are deficient in lysine and pulse proteins in methionine. Combining them together complements each others amino acid deficiency to increase the nutritive value of food thus being Balanced diet for children.

d) Daily salt intake should not exceed >5 gm/day, though higher intake may be necessary in tropical countries like India.

e) It should be palatable, digestible and hygienic.

Note that weaning is a complementary process and not the discontinuation of Breast feeding, which should continue as long as possible.

Aims: BM is all that a baby needs till first 4-6 months of life. At this age, weaning is necessary as —

a) Breast milk output reaches a plateau (600-700 ml/ day) by this age,

b) Growing baby’s dietary requirements exceed the supply from mother’s milk,

c) Baby’s stomach is ready to receive and digest food, other than the breast milk.

Weaning process: Weaning should be a gradual and pleasant experience to the baby. Some important principles during weaning are —

• Start with one food item at a time and continue it for a week or so, till the baby gets used to it before adding next item. Multiple food items should not be started at same time.

• Increase the quantity, consistency and frequency of each feed gradually, till desired intake is achieved.

• Feed with a spoon and never use the bottle. Older children should be encouraged to feed from separate plate, to assess the exact intake.

• Weaning must be complete by 1 year of age, when baby should be qualitatively eating the regular family diet, albeit in quantities of —1/2 of the mother’s diet. Breast feeding should continue as long as possible, as a source of supplementary nutrition.

Early weaning before 4 months is harmful due to reduction in BM intake and higher risk of infections & allergies from weaning foods.

Ideal weaning foods should be —

a) Age-appropriate. As the mastication process in relatively immature in young infants, weaning should begin with thinner feeds like soups & juices, followed by mashed foods and lastly, the chewable foods. In early infancy, gut mucosa is relatively immature and permeable to undigested proteins, which may induce allergic mechanisms. Hence, eggs should not be introduced in diet before 6 months.

b) Home-made, less expensive and easily digestible. Commercial foods are better to be avoided as these are expensive and may contain harmful additives or high salt content.

c) Culturally and culinary acceptable: Non-Vegetarian foods are richer in proteins, though vegetarian foods are equally good, if used in combination of cereals and pulses. Caloric content may be further enhanced by adding oil, ghee, sugar, jiggery etc. Liking of baby is equally important as some babies prefer spicy food, while others like sweets.

d) Freshly and hygienically prepared.

Late weaning beyond 6 months affects optimal growth of the baby as well as may creates difficulties in subsequent weaning due to development of breast-affinity in baby.

Top feeding may be loosely classified as exclusive top-feeding, or supplementary top-feeding along with Breast feeding like in partial lactation failure. Important issues in top-feeding are as follows —

Which milk to use in top feeding? Although many age-appropriate commercial formula feeds are available, prohibitive cost and risk of incorrect dilution by illiterate and poor mothers render them unsuitable for regular use in India. Dried skimmed milk powders or evaporated/condensed milks are also unsuitable for top feeding due to same reasons as well as unbalanced composition.

Skimmed milk powders top feeding have high protein & solute content (risk of dehydration), while condensed milks have excess carbohydrates (risk of diarrhea).

Pasteurized or fresh-boiled cow milk is the most practical top feeding alternative to Breast feeding, if top feeding is unavoidable. Composition of the cow’s milk is nearest to the breast milk except high protein load, which may be reduced by dilution.

It should be diluted with water in 1:1 ratio during first two weeks (longer in pre terms) and in 2:1 ratio during next two weeks. Undiluted cow milk may be used beyond neonatal period in full terms. Sugar may be added (1 tsb/l00 ml) to compensate for carbohydrate loss due to dilution.

Commercial formulas top feeding are specially prepared to bring their composition nearest to BM after dilution and hence, if used at all, should be diluted strictly according to the manufacturer’s instructions.

How much to give in top feeding? Quantity of top milk depends on baby’s age, gestation and weight. As a general rule, top- milk should provide 1 10-120 cal/kg/day. Calculated amount should be divided into 8 rations (3 hourly) during first two month and 6-7 rations (4 hourly) subsequently, to be given during each feed. A term baby normally accepts 50 ml feeds during first 2 weeks, 100 ml between 2-8 weeks and 150-250 ml subsequently.

How to give? Top feeding may be given by bottle, spoon, or indigenously designed utensils like Bondla or Paladi. Although convenient, risk of infection and other complications is maximum with bottle-feeding, which should be avoided as far as possible.

Ten Steps to Successful Lactation

1) A written Breast-feeding policy

2) Training of health-staff in Breast feeding promotional skills

3) Antenatal Counseling towards Breast feeding

4) Initiation of Breast feeding, within 30 minutes of delivery

5) Exclusive Breast feeding & no pre-lacteal feeds

6) Practicing rooming-in

7) Encourage demand feeding

No artificial teats/pacifiers to Breast feeding infants

9) Correct Breast feeding practices & continuance of lactation by EBM if the baby is separated from mother for medical reasons

10) Breast-feeding support groups

d) Which precautions to take? Important precautions, necessary to prevent complications of top feeding are—

a) Proper preparation of feeds

• Proper quantity and dilution of feed

• Use of fresh boiled milk diluted formula

• Proper temperature of feed

b) Proper preparation of feeding equipment

• Proper sterilization of feeding bottle/utensils

• Proper teat-hole size to allow drop by drop flow of milk from inverted bottle.

c) Correct technique of feeding

• Semi-upright position to avoid aspiration

• Burping after feeding

d) Early vitamin/mineral supplements, as Vitamin C and iron are deficient in cow milk.

e) How to sterilize feeding bottle/utensils for top feeding? Although bottle feeding is strongly discouraged, proper sterilization is necessary, if unavoidable. Bottle & nipple may be sterilized by boiling or chemical sterilization by dipping for 10 minutes in Milton solution (2% sodium hypochlorite). Other feeding utensils need not be boiled but should be properly cleaned with running or warm water.

* For top feeding, Before boiling, bottle should be properly cleaned with brush and lukewarm salt-water to remove the stickiness. Subsequently, bottle and nipple should be boiled for 15-20 minutes and 5 minutes respectively and left in container itself, till required, to prevent re-contamination.

Complications of Top feeding

Related to the milklformula:

• Under nutrition (over-diluted milk)

• Dehydration (concentrated formula feeds)

• Oral mucosal scalding (hot feeds)

• Constipation (high solute load)

• Allergic problems (high protein content)

• Recurrent respiratory infections (no immune factors) Related to the bottle

• Diarrhea (contaminated bottle)

• Overfeeding or underfeeding

• Aerophagia due to wrong bottle position

• Nipple confusion — difficulty in simultaneous Breast feeding

• Weaning problems (refusal to part with bottle)

• Defective dentition/Caries (sp. with night feeds)

Common Weaning Foods* for Indian Children

Between 4-6 months (1-3 times a day)

• Thickened fruit juices & soups

• Mashed fruits like banana, papaya, cheekoo etc.

• Boiled-mashed vegetables like carrot, potatoes etc.

• Milk-cereal porridge (ragi/ nachni/ suji), kheer etc

Between 6-8 months (3-4 times a day)

• Cereal-pulse combinations like khichri, rice-dal

• Chewable foods, softened in dal like bread, chapati

• Eggs (Not < 6 months due to risk of allergy in later life)

• Non-veg: like mashed chicken, fish, by 7-8 months Between 9-12 months (4-6 times a day)

• All foods eaten by the family, though less spicy.

I) breast and nipple problems,

II) partial or complete lactation failure, and

III) Breast feeding problems in special situations like sick mother, sick baby or working mother.

I) Breast feeding problems & nipple problems are very common and often used as an excuse to start top-feeding, despite adequate milk output. These problems are more common in primipara mothers and include —

a) Flat or inverted Nipples, which do not project easily, prevent proper attachment of baby to the breast thus leading to Breast feeding problems. Antenatal breast examination is the ideal avenue to identify these problems, which may be managed by — a) nipple-stretching exercises, b) use of a breast pump to pull the nipple out before every feed, or c) syringe method.

Syringe method is a simple suction device, prepared by cutting the nozzle end of a syringe and inverting its piston. When the smooth end of syringe is pressed against the nipple and piston is pulled gently, the inverted nipple pulls out of the breast tissue. This should be done before each breast-feed to avoid Breast feeding problems.

b) Sore Nipples are painful, tender nipples with or without cracks or bleed, caused by — a) wrong attachment of baby on the breast, b) forcible separation of baby while sucking, iii) repeated washing of breasts with soap solutions before feeds, iv) local fungal infections (thrush).

Sore nipples are managed by proper attachment of baby, starting each feed on the less- affected breast, application of hind-milk on the nipple as emollient, and d) local anti-fungal treatment, if necessary.

c) Breast engorgement indicates inadequate expression of milk despite adequate production, leading to hard, painful, warm and swollen breasts. It is usually caused by infrequent Breast feeding due to — a) delayed initiation at birth, b) maternal/neonatal sickness or c) painful breast and nipple conditions.

Most of these cases are self-limiting and can be prevented or managed by — a) frequent demand feeding, b) frequent expression of milk, if baby! Mother is sick, and c) local hot-water compresses to relieve pain.

d) Breast Abscess (mastitis) may develop due to infection of engorged breast, with cracked nipple as a portal of entry for infection causing Breast feeding problems.

These cases are treated with — a) antibiotics and surgical drainage, b) symptomatic therapy with analgesics & hot compresses (breast massage should be avoided), and c) frequent expression of BM, which may than be fed to the baby.

Milk is secreted in alveoli by epithelial cells and pushed forward by contraction of myoepithelial cells. Each alveoli drains its output via lactiferous tubules & ducts into — 10-15 lactiferous sinuses, which lie below the areola and open out onto the nipple. The size of the breast depends on the amount of fat and supporting tissue and does not reflect upon the milk-producing capacity.

Physiology of lactation depends on two interdependent processes in mother production of milk (Prolactin reflex), and secretion or ejection of milk (Oxytocin reflex), as well as actual sucking by the baby, dependent on neonatal reflexes.

A) Production of milk  is a factor of Physiology of lactation (Prolactin reflex): When a baby sucks, afferent impulses from nipple stimulate prolactin secretion from anterior pituitary. Prolactin acts on the milk-producing alveolar epithelial cells to stimulate milk secretion. Thus, the prolactin reflex depends on how early, how often and how strongly the baby sucks.

Prolactin activity and milk production, which is another factor of Physiology of lactation, is facilitated by adequate emptying of breasts after each feed, early onset of lactation, frequent suckling, expression of breast milk, and night feeds.

Prolactin secretion is inhibited by pre-lacteal feeds, incorrect positioning and painful breast conditions physical or mental stress to mother.

B) Milk Ejection/Let down (Oxytoein reflex) is also a factor for Physiology of lactation and is also initiated during suckling when afferent impulses from nipple reach the posterior pituitary to stimulate oxytocin production. Oxytocin contracts the myo-epithelial cells surrounding the alveoli and lactiferous sinuses, to push the milk forward towards the nipple.

The squeezing sensation in the breast during Breast feeding is a sign of a good “let-down reflex”. Oxytocin secretion is affected by the physical and mental state of the mother.

In Physiology of lactation, Oxytocin activity and milk ejection is enhanced by Sight and sound of baby, pleasant thoughts of baby and maternal confidence in her ability to breastfeed.

Oxytocin secretion and milk ejection is reduced by — a) mother’s anxiety or low-confidence, b) mental stress or worry, and c) pain or discomfort during breast feeding.

C) Actual sucking by baby (Neonatal reflexes) is also a factor of Physiology of lactation: Three neonatal reflexes i.e. sucking, swallowing and rooting reflex participate in milk extraction during Breast feeding.

i) Rooting reflex helps the baby to latch onto the nipple. When the breast or nipple touches the baby’s chin, philtmm, upper lip or cheek, the baby opens his/her mouth to search for the nipple.

ii) Suckling reflex helps the baby to draw milk by converting the nipple and areola into a teat pressed between the lower jaw and hard palate. Wave-like movements of tongue facilitate sucking. For successful lactation, the baby should be well attached to the breast, with the nipple and most of the areola in his mouth.

iii) Swallowing reflex: In Physiology of lactation, After every 2-3 sucks, collected milk is swallowed by baby, followed by deep breath. Each suck-swallow-breathe cycle lasts for—i seconds.

Nutritional superiority in advantages of breast feeding

BM is easily digestible and contains all essential nutrients in the right quantity and quality, as per baby’s requirements. Major nutritional advantages of breast feeding are as follows —

a) Energy from BM is mainly derived from easily digestible carbohydrates like lactose.

b) Protein content in BM, though less than in cow milk, is qualitatively superior due to —

- Better whey-casein ratio: 75% of human milk proteins are easily digestible whey proteins or lactalbumin, unlike casein-rich cow milk, which is difficult to digest due to curd formation.

- Essential amino acids (EAA): BM contains All the EAAs in appropriate concentrations to facilitate proper cognitive development. Cow milk is deficient in cysteine and other EAAs.

- It also includes High protein content in animal milk increases risk of allergic disorders, due to absorption of macromolecules through immature gut mucosa.

- It includes Fat content in EM is quantitatively comparable to cow milk, but with better quality i.e. higher PUPA and EFA content Cow milk is richer in saturated fats, which are difficult to digest and increases risk of hypertension or heart disease in adult life. Human milk also contains lipase enzyme, essential for fat absorption.

- It includes Vitamin contents in EM is adequate (except Vitamin K), while cow milk is deficient in Vitamin C and D, Low Vitamin K content in BM is responsible for higher risk of hemorrhagic disease of newborn, which may be prevented by prophylactic Vitamin K supplement at birth.

- Mineral (ash) content of BM is much lower (1.5 %) than in cow milk (>7.0 %). High ash content in cow milk poses additional solute burden over developing kidney with limited concentration capability.

- Iron content in EM is comparable to cow milk, but BM iron is better absorbed (—50%) than cow milk iron (10%), due to lesser phosphate load.

- Calcium content is lesser in BM, though EM calcium is better absorbed & utilized due to appropriate Ca: P ratio. Consequently, tetany is less common in Breast fed children.

Water: EM contains adequate water (88%) and hence, no additional water is required in exclusively breast-fed babies, with less risk of infections.

B) Anti-infective properties of advantages of breast feeding: EM is essentially sterile, except in presence of systemic or local (breast) matemal infection. Further, presence of various anti-infective substances in BM is responsible for lower incidence of GIT and respiratory infections in Breast fed infants. These factors include —

i) Humoral factors of advantages of breast feeding like Non-specific and specific IgG antibodies & Secretory IgA, for local immunity

ii) Cellular factors like Phagocytic cells like macrophages & Cellular-release factors like lysozymes

iii) High complement activity

iv) Organism-specific protective factors like

v) Others

• Bifidus Factor, which facilitates the growth of Lactobacillus bifidus in gut and prevents pathogenic colonization,
• Lactoferrin, a protein that binds the iron and inhibits growth of pathogenic bacteria like E.coli, which need iron for their metabolism.
• Lower pH of EM prevents bacterial overgrowth.

C) Emotional bonding advantages of breast feeding: Breast feeding creates an emotional bond between baby and mother, necessary for future growth, development, and parent-child adjustment.

D) Advantages of breast feeding to mother include —

• Enhanced oxytocin secretion to facilitate placental expulsion and uterine involution with less risk of post-partum hemorrhage.
• Convenience and less workload, obviating the need for boiling/mixing the top-milk. She also doesn’t have to worry about the milk supply and spoilage.
• Natural contraception: Lactational Annecorinne due to high prolactin levels is common during first 6 months, with —98% protection.
• Lower incidence of breast and ovarian cancers.
• Cosmetic recovery: Breast feeding mothers regain their figure faster, due to more caloric consumption.

E) Advantages to family: Breast feeding is a good economic practice for family as well, due to —

• Negligible cost, except the hidden expenses for additional nutrition to mother.
• Less health-care expenses, due to lesser morbidity.

F) Advantages of breast feeding to the community include —

• Ecological benefits due to less consumption of natural resources for animal-milk production (fodder), boiling (fuel) and washing the utensils (water).
• Lesser morbidity and public health expenses.
• Population control.