infants and preschool

8/12/2019 Infants and Preschool

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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 countriesthese 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 crushedbefore 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:


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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 orequipment 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 becomethinner (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


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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 theprocess 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 tostiff 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 growthand 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


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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 ispractically 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 asthe 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.)


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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 grainsLegumes 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


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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 notattend 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 thathave 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


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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 nursinghomes 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.

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