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“Nutrition: Journey from Infancy to Childhood”




               Dr Kuntal Biswas
                    Registrar
      Medical College & Hospitals, Kolkata
1000 days
3
4
Epigenetics         Physiology of Stress       Neuroscience



                      The Science of Early
                        Brain and Child
                         Development


        Education                Health                Economics


  One Science – Many Implications
The critical challenge now is to translate game-changing advances in
developmental science into effective policies and practices for families
with children to improve education, health and lifelong productivity
                                                                      5
Altered Immunity                                  Human rights
         in IDA & PEM                          The International Convention on
         Children                              Human Rights, to which nearly all
                                               countries of the world adhere,
                                               includes the right to access to food.
                1600                           Hunger and malnutrition are a
                                               violation of human rights.
                1400

                1200
pg/ 10 6cells




                1000

                800                            Nutrition is now so much a part of the
                400
                                               consciousness of today’s political leaders,
                200
                                               that the current political and economic
                  0

                               IL2       IL4   crisis 5 not1in the long run jeopardize the
                                                   IL will IL 0
                                               remarkable progress that has been achieved
                                               in overcoming or reducing the burden of
                       IDA children            malnutrition on the population of the
                       PEM children
                       Normal children         country.                                   6
Intervention Types
Increase Intake of Vitamins     Promote Good Nutritional
  and Minerals                    Practices
• Vitamin A supplements         • Breastfeeding
• Zinc supplements              • Complementary feeding
• Micronutrient powders         • Improved hygiene practices
• De-worming drugs              • Diet diversification
• Iron/folic acid supplements   • Wheat
  for pregnant women            Prevent and Treat Moderate
• Iodized oil capsules            and Severe Malnutrition
• Salt iodization               • Treatment of severe
• Iron fortification              undernutrition with RUTF
• Fortification of staple       • Prevention/treatment of
  foods/bio-fortification         moderate undernutrition
• Vitamins

                                                               7
3 Objectives For Today
• Provide a generalist’s overview of advances in developmental
  science
• Present an organizing, integrated, eco bio developmental
  framework
• Discuss ways pediatricians might assist in translating science into
  healthier life-courses

                          Critical Concept
  Childhood Adversity has Lifelong Consequences.
  Significant adversity in childhood is strongly associated with
  unhealthy lifestyles and poor health decades later.
  Barker Law states ‘Adulthood Diseases of Infancy –NCD- like-
  HTN, CAD, DM, Osteo Arthritis, Cancer etc

                                                                        8
Developing a Model of
          Human Health and Disease


How do you begin                                      What are the
  to define or                                        mechanisms
  measure the                                        underlying these
    ecology?                                         well-established
                                                      associations?
                               Life Course
                                 Science




                         Early childhood ecology
                         strongly associates with
                   lifelong developmental outcomes                      9
Nutrition during & after pregnancy
                  Conception to 2nd week
                  – Umbilical cord not formed
                  – Mother’s food intake does not
                    have an effect on the embryo up
                    to 2 wks
                  – From 2 wks mother need extra
                    Energy, extra Protein, extra
                    EFA, extra Iron, Calcium &
                    other Micronutrients.
                  – Lactating mother need more
                    than in Antenatal Period.
                                                 10
Peak Age of Malnutrition
                                         Feeding Practices
 The incidence of malnutrition
                                    Inappropriate feeding
rises sharply during the period
                                    practices are major cause of
from 6 to 18 mo of age in most
                                    the onset of malnutrition in
countries.                          young children.
The deficits acquired at this age
are difficult to compensate for
later in childhood.                                            11
Intelligence quotient by type of feeding
                                            BF 12.9 points
    BF 2 points                             higher than FF
   higher than FF                            Study in 9.5
                                             year-olds
    Study in 3-7
                                                1996
     year-olds
       1982
                                             BF 8.3 points
                                             higher than FF
                                             Study in 7.5-8
     BF 2.1 points                           year-olds
    higher than FF                              1992
  Study in 6 months
    to 2 year- olds                         References:
         1988            BM 7.5 points
                                            •Fergusson DM et al. Soc
                        higher than no BM      SciMed 1982
                         Study in 7.5-8     •Morrow-Tlucak M et al.
BF = breastfed             year-olds           SocSciMed 1988
FF = formula fed                            •Lucas A et al. Lancet 1992
BM = breast milk            1992            •Riva Eet al. Acta Paediatr 1996
Early Introduction of Foods
Other Than Breast milk Has Risks
            • All major medical
              organizations recommend
              exclusive breastfeeding the first
              six months
            • Infant’s digestive and immune
              systems are still developing
            • Starting complementary foods
              too early replaces a superior
              food (breast milk) with an
              inferior food

                                              13
Breastfeeding + Complementary Foods
• First six months: Exclusive breastfeeding
• After six months:
    – Breastfeed as often as the child wants
• Begin complementary foods in small amounts
• Until two years:
    – Breastfeed as often as the child wants
    – Continue complementary foods, gradually increasing
      quantities and frequency as the child gets older
World Health Organization, Complementary Feeding: Family foods for breastfed children.
  2000.

                                                                                         14
How to Know Baby Is Ready for
    Complementary Foods

• Can sit up with support
• Has good head and neck control
• Has lost the “tongue thrust” reflex and is able to
  swallow solids
• Is able to pick up objects with thumb and index
  finger
• Shows keen interest in family meals and reaches
  for foods
                                                       15
Beginning Complementary Foods
• Complementary foods are an addition to breast milk, not a
  replacement
• Breast milk continues to provide 35-40% of infant’s total
  daily energy needs for 12-23 months
• Begin with very small amounts of complementary foods
  (a few teaspoons)
   – 6 to 8 months – 2-3 times/day
   – 9 to 11 months – 3-4 times/day
   – 12 to 24 months – 3-4 times/day plus 1-2 nutritious snacks

The requirement for breast-milk        The estimated energy requirements
substitutes after six months:          from complementary foods, assuming
                                       an average breast-milk intake, are:
• At 6–8 months, 600 ml/ day           200 kcal/day for infants aged 6–8 mos,
• At 9–11 months, 550 ml/ day          300 kcal/day for infants aged 9–11 mos,
• At 12–23 months, 500 ml/ day         550 kcal/day for child aged 12–23 mos.
                                                                          16
Only Cereals
                           Complementary Food
                                              Cereals & Pulses




Cereals, Pulses & Citreous Fruits
                                    Stomach capacity of newborn to
                                    1 yr increases by 10 times.

                                    Stomach Volume of adult is:
                                    20.4ml/KG of BW
                                    & 30gm/KG of BW


                                                                     17
Three meals           Three meals and two snacks




                       Complementary foods
Complementary foods should be varied and include adequate quantities
of meat, poultry, fish or eggs, vitamin A-rich fruits and vegetables daily.
Where this is not possible, the use of fortified complementary foods
and vitamin mineral supplements may be necessary to ensure adequacy
of particular nutrient intakes.                                         18
Complementary foods                     Improvisation of House Hold Foods

• As infants grow, the consistency            • Household technologies such
  of complementary foods should                 as fermentation, soaking,
  change from semisolid to solid                roasting and malting can
  foods and the variety of foods                improve taste, texture, safety
  offered should increase.                      and quality of
•    By eight months, infants can eat           complementary foods.
    ‘finger foods.’                           • An adequate nutrient level
                                                remains a concern,
• By 12 months, most children can
                                                particularly in diets that are
  eat the same types of food as the
                                                mainly plant-based.
  rest of the family.
                                              • Indian diets are often more
                                                viscous.
                                                                          19
                                                                           19
Responsive Feeding
• Offer complementary foods after           • Feed infants directly; assist older
                                              children when they feed
  breastfeeding to avoid overfeeding with     themselves
  solids and negatively impacting
                                            • Be sensitive to hunger and satiety
  mother’s milk supply                        cues
• Offer only one new food at a time         • Feed slowly and patiently –
• Offer very small portions                   encourage children to eat but do
  (a few teaspoons at a time)                 not force them
                                            • Experiment with food
• Vary tastes and textures                    combinations, tastes, and textures
• Avoid potential allergy-producing foods   • Minimize distractions
  (nuts, cow’s milk, casein)                • Make feeding a time of learning
                                              and love
                                            • Learn healthy eating habits
                                                   Let the Child
                                             Feel important & loved
                                             Feel understood and respected
                                             Trust that others will care for him
                                              / her
                                             Feel good about his / her body
                                                                                    20
Appropriate complementary feeding            Improving feeding behaviors
Timely – meaning that foods are
   introduced when the need for energy        Improving complementary feeding
   and nutrients exceeds what can be             requires attention to foods as well
   provided through exclusive and
   frequent breastfeeding;                       as to feeding behavior of
Adequate – meaning that foods provide
   sufficient energy, protein, and               caregivers.
   micronutrients to meet a growing
   child’s nutritional needs;                 Infants and young children need
Safe – meaning that foods are                    assistance that is appropriate for
   hygienically stored and prepared, and
   fed with clean hands using clean              their age and developmental needs
   utensils and not bottles and teats;
                                                 to ensure that they consume
Properly fed – meaning that foods are
   given consistent with a child’s signals       adequate amounts of
   of appetite and satiety, and that meal
   frequency and feeding method –                complementary food.
   actively encouraging the child to
   consume sufficient food using              This is called responsive feeding.
   fingers, spoon or self-feeding – are
   suitable for age.                                                            21
Responsive Feeding
• Feeding with a balance between        • Feeding with positive verbal
  giving assistance and                   encouragement, without verbal
  encouraging self-feeding, as            or physical coercion
  appropriate to the child’s level      • Feeding with age-appropriate
  of development                          and culturally appropriate eating
• Being sensitive to their early          utensils
  hunger and satiety cues               • Feeding in a protected and
• Feeding by an individual with           comfortable environment
  whom the child has a positive         • Feeding times are periods of
  emotional relationship and who          learning and love − talk to
  is aware of and sensitive to the        children during feeding, with
  individual child’s characteristics,     eye to eye contact
  including changes in physical
  and emotional state.
                                                                      22
Responsive Feeding
• Feed slowly and patiently,       • Establish regular meal and
  and encourage children to          snack times beginning when
  eat, but do not force them.
                                     child is 9-12 mos old.
• If children refuse many
  foods, experiment with           • Routines help children look
  different food                     forward to each meal but
  combinations, tastes,              don’t make the routine very
  textures and methods of            strict.
  encouragement.                   • Research shows that children
• Minimize distractions              will choose a healthy diet
  during meals if the child          when they are offered a
  loses interest easily.             selection of different healthy
• Offer 3 to 4 healthy food
  choices child likes at each meal. foods.
                                                                  23
Responsive Feeding
Don’t force baby or toddler to eat    Turn off the TV /computers, etc
This often results in children         at mealtime.
refusing the food and eating less.    • The television can distract
Don’t give up on new foods             children from eating.
• Patience is the key.                • It also takes time away from
• One may have to offer child a        talking as a family.
new food 10 or 15 times before        Healthy eating and exercise
he/ she will eat it.                  go hand in hand
Viscosity of Complementary Food       Make active play a part of
Foods that are thick enough to stay   everyday family life.
in the spoon.




                                                                   24
Nutritional Deficiencies
• Encourage children to             Deficiencies in the diet are :
  drink and eat during illness •    Energy
                                                      “Cocktail“
  and provide extra food        •   Protein
                                                Metabolic interactions
  after illness to help them re •   Iron
                                                should be kept in mind
  cover quickly.                •   Vitamin A
                                •   Iodine      while giving a "cocktail"

                                •   Zinc        of various micronutrients
                                •   Copper      in clinical practice.
                                •   Others
                                    are still widespread and are
                                    common causes of excess
                                    morbidity & mortality.
                                                                        25
Proper Food Handling
• Wash caregivers’ and            • Encourage families to
  children’s hands before food      continue breastfeeding if
  preparation and eating            baby becomes ill
• Use clean utensils, cups, and   • Avoid medications or birth
  bowls to prepare, serve, and      control methods that can
  store food                        disrupt or endanger
• Avoid the use of feeding          breastfeeding
  bottles                         • Encourage the use of spoons
• Serve foods immediately after     and cups for feeding
  preparation                       complementary foods,
• Store foods safely                expressed breast milk, or
                                    breast milk substitutes


                                                              26
Metabolic Interactions Between Various Micronutrients
     There is evidence for metabolic inter-relationships between different micronutrients.
•    Ascorbic acid is known to enhance the          •   Selenium deficiency may impair
     absorption of non- haem iron.                      utilization of iodine because it is a key
•    High intake of zinc may interfere with             component of the enzyme which is
     absorption of iron and copper.                     required to convert thyroxin to
•    Riboflavin has an important role in the            triiodothyronine.
     absorption, metabolism and utilization of      •   Molybdenum intake may aggravate
     iron                                               copper deficiency because it promotes
•    Vitamin A helps in iron transport,                 urinary excretion of copper.
     hemoglobin production and thus                 •   Vitamin E has a sparing effect on Vitamin A
     improve the status of iron stores.                 and Ascorbic acid by protecting them from
                                                        oxidation.
•    Dietary phytates and tannins are
                                                    •   Magnesium facilitates absorption of Calcium
     known to interfere with the absorption
                                                        from gut.
     of iron.
                                                    •   Calcium helps in the absorption of Vitamin
•    Zinc deficiency may aggravate                      B12 from the ileum but
     hypovitaminosis A because zinc is                  it interferes with absorption of Zinc.
     required for transport of hepatic vitamin      •   All Anti- Oxidants in excess act as Pro-
     A to the target tissues.                           Oxidants.                              27
                                                                                                27
Microbiota Impact: Current Thinking




                                      28
MILK MICROBIOTA COMPOSITION &
              MODE OF DELIVERY
MODE OF DELIVERY (colostrum)   MODE OF DELIVERY (6 months of breastfeeding)




                                          Cabrera-Rubio et al 2012 Am J Clin Nutr
ORIGINAL INOCULUM REVISITED
Approximate yield from milk (assuming no losses)

                               Casein
                                32 kg

                Skim milk
                 889 kg                         Lactose
                                                 851 kg

                              Casein
                               whey
                              857 kg


              Cream
              111 kg
                                                  Whey
whole milk                                        6 kg
 1000 kg
(=1 tonne)
Food Pyramid




               32
               32
B r a i n d e ve l o p m e n t
                                       5 to 6 Weeks
                                Forebrain
         7 Weeks
Neurons forming
rapidly,1000’s/ mts             Midbrain


                                Hindbrain




• 50,000 brain cells produced/second in
  developing fetal brain
• 100 billion brain cells in adult
• 1million billion connections between
  these brain cells: Determine IQ.
Human Brain Development
        Synapse Formation Dependent on Early Experiences
   Required
3 Components
1. Nutrition
2. Prevention of infection
3. Psycho Social Stimulation




                                        Synaptic Connections
                                                               34
Maturation Progression
Maturation generally proceeds from the back of the brain to the front.
Explains in part…
    –   Preference for physical activity (back of brain)
    –   More risky, impulsive behaviors (limbic system)
    –   More moody at times (limbic system)
    –   Less than optimal planning and judgment (PFC)
    –   Poor recognition of negative consequences (PFC)

                            Impact of Early Stress
                                CHILDHOOD STRESS


Hyper-responsive stress                       Chronic “fight or flight;” adrenaline /cortisol
response; calm/coping


                          Changes in Brain Architecture
                                                                                          35
Eight Phases in Embryonic and Fetal
          Development at a Cellular Level
1. Mitosis 2. Migration 3. Aggregation 4. Differentiation




5. Synaptogenesis 6. Death 7.Rearrangement      8. Myelination

                                              Between
                                              40 and 75 %
                                              of all neurons born
                                              in embryonic and
                                              fetal development
                                              do not survive.
Brain Cell Connections in the Early Months




newborn       1 month       3 months        6 months



6 Years Old                            14 Years Old

                                                       37
Out of Balance




Prefrontal Cortex                                          Amygdala
  Cold Cognition                                        Hot Cognition
   Judgmental                                             Emotional
    Reflective                                             Reactive
  Calculating                                              Impulsive
 Think about it                                            Just do it
  Biological maturity by 24                             Biological maturity by 18
                      Adapted from Ken Winters, Ph.D.                               38
Parenting as Primary Prevention of Ill Health
Promoting Parenting Skills in the first 1000 days
– Parenting is personal – makes pediatricians NERVOUS!
– “Positive/Nurturing/Supportive” Parenting
– Are parenting skills “teachable?” YES!!

• Early maternal support
exerts a positive influence
on hippocampal
development
• The positive effect of
maternal support on
hippocampal volumes was
greater in nondepressed
children




                              Lusby et al., 2012. Available at: www.pnas.org/cgi/doi/10.1073/pnas.1118003109
                                                                                                               39
Thanks




Nation’s prospect depends on the Nutritional Status
            of People of that Country.



                                                  40

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1000 days

  • 1. “Nutrition: Journey from Infancy to Childhood” Dr Kuntal Biswas Registrar Medical College & Hospitals, Kolkata
  • 3. 3
  • 4. 4
  • 5. Epigenetics Physiology of Stress Neuroscience The Science of Early Brain and Child Development Education Health Economics One Science – Many Implications The critical challenge now is to translate game-changing advances in developmental science into effective policies and practices for families with children to improve education, health and lifelong productivity 5
  • 6. Altered Immunity Human rights in IDA & PEM The International Convention on Children Human Rights, to which nearly all countries of the world adhere, includes the right to access to food. 1600 Hunger and malnutrition are a violation of human rights. 1400 1200 pg/ 10 6cells 1000 800 Nutrition is now so much a part of the 400 consciousness of today’s political leaders, 200 that the current political and economic 0 IL2 IL4 crisis 5 not1in the long run jeopardize the IL will IL 0 remarkable progress that has been achieved in overcoming or reducing the burden of IDA children malnutrition on the population of the PEM children Normal children country. 6
  • 7. Intervention Types Increase Intake of Vitamins Promote Good Nutritional and Minerals Practices • Vitamin A supplements • Breastfeeding • Zinc supplements • Complementary feeding • Micronutrient powders • Improved hygiene practices • De-worming drugs • Diet diversification • Iron/folic acid supplements • Wheat for pregnant women Prevent and Treat Moderate • Iodized oil capsules and Severe Malnutrition • Salt iodization • Treatment of severe • Iron fortification undernutrition with RUTF • Fortification of staple • Prevention/treatment of foods/bio-fortification moderate undernutrition • Vitamins 7
  • 8. 3 Objectives For Today • Provide a generalist’s overview of advances in developmental science • Present an organizing, integrated, eco bio developmental framework • Discuss ways pediatricians might assist in translating science into healthier life-courses Critical Concept Childhood Adversity has Lifelong Consequences. Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later. Barker Law states ‘Adulthood Diseases of Infancy –NCD- like- HTN, CAD, DM, Osteo Arthritis, Cancer etc 8
  • 9. Developing a Model of Human Health and Disease How do you begin What are the to define or mechanisms measure the underlying these ecology? well-established associations? Life Course Science Early childhood ecology strongly associates with lifelong developmental outcomes 9
  • 10. Nutrition during & after pregnancy Conception to 2nd week – Umbilical cord not formed – Mother’s food intake does not have an effect on the embryo up to 2 wks – From 2 wks mother need extra Energy, extra Protein, extra EFA, extra Iron, Calcium & other Micronutrients. – Lactating mother need more than in Antenatal Period. 10
  • 11. Peak Age of Malnutrition Feeding Practices The incidence of malnutrition Inappropriate feeding rises sharply during the period practices are major cause of from 6 to 18 mo of age in most the onset of malnutrition in countries. young children. The deficits acquired at this age are difficult to compensate for later in childhood. 11
  • 12. Intelligence quotient by type of feeding BF 12.9 points BF 2 points higher than FF higher than FF Study in 9.5 year-olds Study in 3-7 1996 year-olds 1982 BF 8.3 points higher than FF Study in 7.5-8 BF 2.1 points year-olds higher than FF 1992 Study in 6 months to 2 year- olds References: 1988 BM 7.5 points •Fergusson DM et al. Soc higher than no BM SciMed 1982 Study in 7.5-8 •Morrow-Tlucak M et al. BF = breastfed year-olds SocSciMed 1988 FF = formula fed •Lucas A et al. Lancet 1992 BM = breast milk 1992 •Riva Eet al. Acta Paediatr 1996
  • 13. Early Introduction of Foods Other Than Breast milk Has Risks • All major medical organizations recommend exclusive breastfeeding the first six months • Infant’s digestive and immune systems are still developing • Starting complementary foods too early replaces a superior food (breast milk) with an inferior food 13
  • 14. Breastfeeding + Complementary Foods • First six months: Exclusive breastfeeding • After six months: – Breastfeed as often as the child wants • Begin complementary foods in small amounts • Until two years: – Breastfeed as often as the child wants – Continue complementary foods, gradually increasing quantities and frequency as the child gets older World Health Organization, Complementary Feeding: Family foods for breastfed children. 2000. 14
  • 15. How to Know Baby Is Ready for Complementary Foods • Can sit up with support • Has good head and neck control • Has lost the “tongue thrust” reflex and is able to swallow solids • Is able to pick up objects with thumb and index finger • Shows keen interest in family meals and reaches for foods 15
  • 16. Beginning Complementary Foods • Complementary foods are an addition to breast milk, not a replacement • Breast milk continues to provide 35-40% of infant’s total daily energy needs for 12-23 months • Begin with very small amounts of complementary foods (a few teaspoons) – 6 to 8 months – 2-3 times/day – 9 to 11 months – 3-4 times/day – 12 to 24 months – 3-4 times/day plus 1-2 nutritious snacks The requirement for breast-milk The estimated energy requirements substitutes after six months: from complementary foods, assuming an average breast-milk intake, are: • At 6–8 months, 600 ml/ day 200 kcal/day for infants aged 6–8 mos, • At 9–11 months, 550 ml/ day 300 kcal/day for infants aged 9–11 mos, • At 12–23 months, 500 ml/ day 550 kcal/day for child aged 12–23 mos. 16
  • 17. Only Cereals Complementary Food Cereals & Pulses Cereals, Pulses & Citreous Fruits Stomach capacity of newborn to 1 yr increases by 10 times. Stomach Volume of adult is: 20.4ml/KG of BW & 30gm/KG of BW 17
  • 18. Three meals Three meals and two snacks Complementary foods Complementary foods should be varied and include adequate quantities of meat, poultry, fish or eggs, vitamin A-rich fruits and vegetables daily. Where this is not possible, the use of fortified complementary foods and vitamin mineral supplements may be necessary to ensure adequacy of particular nutrient intakes. 18
  • 19. Complementary foods Improvisation of House Hold Foods • As infants grow, the consistency • Household technologies such of complementary foods should as fermentation, soaking, change from semisolid to solid roasting and malting can foods and the variety of foods improve taste, texture, safety offered should increase. and quality of • By eight months, infants can eat complementary foods. ‘finger foods.’ • An adequate nutrient level remains a concern, • By 12 months, most children can particularly in diets that are eat the same types of food as the mainly plant-based. rest of the family. • Indian diets are often more viscous. 19 19
  • 20. Responsive Feeding • Offer complementary foods after • Feed infants directly; assist older children when they feed breastfeeding to avoid overfeeding with themselves solids and negatively impacting • Be sensitive to hunger and satiety mother’s milk supply cues • Offer only one new food at a time • Feed slowly and patiently – • Offer very small portions encourage children to eat but do (a few teaspoons at a time) not force them • Experiment with food • Vary tastes and textures combinations, tastes, and textures • Avoid potential allergy-producing foods • Minimize distractions (nuts, cow’s milk, casein) • Make feeding a time of learning and love • Learn healthy eating habits Let the Child  Feel important & loved  Feel understood and respected  Trust that others will care for him / her  Feel good about his / her body 20
  • 21. Appropriate complementary feeding Improving feeding behaviors Timely – meaning that foods are introduced when the need for energy Improving complementary feeding and nutrients exceeds what can be requires attention to foods as well provided through exclusive and frequent breastfeeding; as to feeding behavior of Adequate – meaning that foods provide sufficient energy, protein, and caregivers. micronutrients to meet a growing child’s nutritional needs; Infants and young children need Safe – meaning that foods are assistance that is appropriate for hygienically stored and prepared, and fed with clean hands using clean their age and developmental needs utensils and not bottles and teats; to ensure that they consume Properly fed – meaning that foods are given consistent with a child’s signals adequate amounts of of appetite and satiety, and that meal frequency and feeding method – complementary food. actively encouraging the child to consume sufficient food using This is called responsive feeding. fingers, spoon or self-feeding – are suitable for age. 21
  • 22. Responsive Feeding • Feeding with a balance between • Feeding with positive verbal giving assistance and encouragement, without verbal encouraging self-feeding, as or physical coercion appropriate to the child’s level • Feeding with age-appropriate of development and culturally appropriate eating • Being sensitive to their early utensils hunger and satiety cues • Feeding in a protected and • Feeding by an individual with comfortable environment whom the child has a positive • Feeding times are periods of emotional relationship and who learning and love − talk to is aware of and sensitive to the children during feeding, with individual child’s characteristics, eye to eye contact including changes in physical and emotional state. 22
  • 23. Responsive Feeding • Feed slowly and patiently, • Establish regular meal and and encourage children to snack times beginning when eat, but do not force them. child is 9-12 mos old. • If children refuse many foods, experiment with • Routines help children look different food forward to each meal but combinations, tastes, don’t make the routine very textures and methods of strict. encouragement. • Research shows that children • Minimize distractions will choose a healthy diet during meals if the child when they are offered a loses interest easily. selection of different healthy • Offer 3 to 4 healthy food choices child likes at each meal. foods. 23
  • 24. Responsive Feeding Don’t force baby or toddler to eat Turn off the TV /computers, etc This often results in children at mealtime. refusing the food and eating less. • The television can distract Don’t give up on new foods children from eating. • Patience is the key. • It also takes time away from • One may have to offer child a talking as a family. new food 10 or 15 times before Healthy eating and exercise he/ she will eat it. go hand in hand Viscosity of Complementary Food Make active play a part of Foods that are thick enough to stay everyday family life. in the spoon. 24
  • 25. Nutritional Deficiencies • Encourage children to Deficiencies in the diet are : drink and eat during illness • Energy “Cocktail“ and provide extra food • Protein Metabolic interactions after illness to help them re • Iron should be kept in mind cover quickly. • Vitamin A • Iodine while giving a "cocktail" • Zinc of various micronutrients • Copper in clinical practice. • Others are still widespread and are common causes of excess morbidity & mortality. 25
  • 26. Proper Food Handling • Wash caregivers’ and • Encourage families to children’s hands before food continue breastfeeding if preparation and eating baby becomes ill • Use clean utensils, cups, and • Avoid medications or birth bowls to prepare, serve, and control methods that can store food disrupt or endanger • Avoid the use of feeding breastfeeding bottles • Encourage the use of spoons • Serve foods immediately after and cups for feeding preparation complementary foods, • Store foods safely expressed breast milk, or breast milk substitutes 26
  • 27. Metabolic Interactions Between Various Micronutrients There is evidence for metabolic inter-relationships between different micronutrients. • Ascorbic acid is known to enhance the • Selenium deficiency may impair absorption of non- haem iron. utilization of iodine because it is a key • High intake of zinc may interfere with component of the enzyme which is absorption of iron and copper. required to convert thyroxin to • Riboflavin has an important role in the triiodothyronine. absorption, metabolism and utilization of • Molybdenum intake may aggravate iron copper deficiency because it promotes • Vitamin A helps in iron transport, urinary excretion of copper. hemoglobin production and thus • Vitamin E has a sparing effect on Vitamin A improve the status of iron stores. and Ascorbic acid by protecting them from oxidation. • Dietary phytates and tannins are • Magnesium facilitates absorption of Calcium known to interfere with the absorption from gut. of iron. • Calcium helps in the absorption of Vitamin • Zinc deficiency may aggravate B12 from the ileum but hypovitaminosis A because zinc is it interferes with absorption of Zinc. required for transport of hepatic vitamin • All Anti- Oxidants in excess act as Pro- A to the target tissues. Oxidants. 27 27
  • 29. MILK MICROBIOTA COMPOSITION & MODE OF DELIVERY MODE OF DELIVERY (colostrum) MODE OF DELIVERY (6 months of breastfeeding) Cabrera-Rubio et al 2012 Am J Clin Nutr
  • 31. Approximate yield from milk (assuming no losses) Casein 32 kg Skim milk 889 kg Lactose 851 kg Casein whey 857 kg Cream 111 kg Whey whole milk 6 kg 1000 kg (=1 tonne)
  • 32. Food Pyramid 32 32
  • 33. B r a i n d e ve l o p m e n t 5 to 6 Weeks Forebrain 7 Weeks Neurons forming rapidly,1000’s/ mts Midbrain Hindbrain • 50,000 brain cells produced/second in developing fetal brain • 100 billion brain cells in adult • 1million billion connections between these brain cells: Determine IQ.
  • 34. Human Brain Development Synapse Formation Dependent on Early Experiences Required 3 Components 1. Nutrition 2. Prevention of infection 3. Psycho Social Stimulation Synaptic Connections 34
  • 35. Maturation Progression Maturation generally proceeds from the back of the brain to the front. Explains in part… – Preference for physical activity (back of brain) – More risky, impulsive behaviors (limbic system) – More moody at times (limbic system) – Less than optimal planning and judgment (PFC) – Poor recognition of negative consequences (PFC) Impact of Early Stress CHILDHOOD STRESS Hyper-responsive stress Chronic “fight or flight;” adrenaline /cortisol response; calm/coping Changes in Brain Architecture 35
  • 36. Eight Phases in Embryonic and Fetal Development at a Cellular Level 1. Mitosis 2. Migration 3. Aggregation 4. Differentiation 5. Synaptogenesis 6. Death 7.Rearrangement 8. Myelination Between 40 and 75 % of all neurons born in embryonic and fetal development do not survive.
  • 37. Brain Cell Connections in the Early Months newborn 1 month 3 months 6 months 6 Years Old 14 Years Old 37
  • 38. Out of Balance Prefrontal Cortex Amygdala Cold Cognition Hot Cognition Judgmental Emotional Reflective Reactive Calculating Impulsive Think about it Just do it Biological maturity by 24 Biological maturity by 18 Adapted from Ken Winters, Ph.D. 38
  • 39. Parenting as Primary Prevention of Ill Health Promoting Parenting Skills in the first 1000 days – Parenting is personal – makes pediatricians NERVOUS! – “Positive/Nurturing/Supportive” Parenting – Are parenting skills “teachable?” YES!! • Early maternal support exerts a positive influence on hippocampal development • The positive effect of maternal support on hippocampal volumes was greater in nondepressed children Lusby et al., 2012. Available at: www.pnas.org/cgi/doi/10.1073/pnas.1118003109 39
  • 40. Thanks Nation’s prospect depends on the Nutritional Status of People of that Country. 40