Recommended Feeding and Dietary Practices to Improve ... · Recommended Feeding and Dietary Practices to Improve Infant and Maternal Nutrition is a publication of the LINKAGES (Breastfeeding,

Recommended Feedingand Dietary Practices toImprove Infant andMaternal Nutrition

February 1999

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Recommended Feeding and Dietary Practices to Improve Infant and MaternalNutrition is a publication of the LINKAGES (Breastfeeding, Complemen-tary Feeding, and Maternal Nutrition Program) Project. LINKAGES is sup-ported by the G/PHN/HN, Global, U.S. Agency for InternationalDevelopment, under Cooperative Agreement No. HRN-A-00-97-00007-00and managed by the Academy for Educational Development. The opin-ions expressed herein are those of the author(s) and do not necessarilyreflect the views of the U.S. Agency for International Development.

The LINKAGES ProjectAcademy for Educational Development1825 Connecticut Avenue NWWashington, DC 20009Tel: 202-884-8000Fax: 202-884-8977E-mail: [email protected]

First Printing, February 1999Second Printing, December 1999

Table of Contents iii

Table of ContentsAcknowledgments ......................................................................................................... v

Executive Summary ..................................................................................................... vii

Introduction ................................................................................................................... 1

I. Recommended Feeding Practices to Improve the Nutrition of Infants 0 to 6 Months ... 3

II. Recommended Feeding Practices to Improve the Nutrition of Children 6 to 24Months .......................................................................................................................... 6

III. Recommended Dietary Practices to Improve the Nutrition of Adolescent Girls andWomen of Reproductive Age ........................................................................................15

Conclusion ....................................................................................................................24

Summary of Recommended Readings .........................................................................25

References ...................................................................................................................25

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v

AcknowledgmentsThis paper benefitted from the contributions and advice of many individuals. Sandra

Huffman and Luann Martin were major contributors. Special thanks are extended to JayRoss for his insightful comments, to Roy Miller for presentation of DHS data, and to EllenPiwoz of the SARA Project for her contribution to the section on complementary feeding.LINKAGES and AED staff who participated in review meetings and provided commentson draft documents included Jean Baker, Rolando Figueroa, Mary Lung’aho, PeggyParlato, Maryanne Stone-Jiménez, Vicky Quinn, and Victor Aguayo. Other individualswho contributed to this document are Stephanie Gabela from Wellstart International whoprovided helpful comments on an earlier draft, Erika Lutz for examples of diets for chil-dren and pregnant women, Soe Lin Post for graphics, and Kimberly Ferguson and CindyArciaga Lauer for layout. The support, technical advice, review, and constructive feed-back on various drafts by Susan Anthony, Mihira Karra, Miriam Labbok, and ShelleySnyder are greatly appreciated.

Acknowledgments

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vii

Executive SummaryMalnutrition can start before birth and can persist throughout life. Many babies are

born with low birth weight and micronutrient deficiencies. Poor feeding practices duringthe first two years of life have immediate and often long-term negative consequences ongrowth and development. Nutritional stress during adolescence and the reproductiveyears affects the health of women and, consequently, the next generation. This paperidentifies a set of recommended feeding and dietary practices to break this cycle of poorhealth and nutrition that passes from generation to generation. It also provides the scien-tific evidence to support the recommendations.

Exclusive breastfeeding for about six months ensures that the young infant receivesmaximum health and nutritional benefits from breastmilk. Exclusively breastfed infantsare at a much lower risk of infection from diarrhea and acute respiratory infections thannon-breastfed infants. When other foods or fluids are consumed, there is an increasedrisk of exposing the young infant to pathogens that cause sickness, leading to decreasednutrient intake and death.

Children are at greatest risk of nutritional deficiency and growth retardation betweenthe age of 6 and 24 months. Around six months of age, introduction of complementaryfoods, along with sustained breastfeeding, is required. Appropriate complementary feed-ing helps promote growth, prevent stunting, and increase a child’s chances for a healthy,productive life as an adult. Improving complementary feeding requires a combination ofstrategies. Energy intake can be increased by breastfeeding more frequently, feedingcomplementary foods more often, providing energy-dense foods, practicing active feed-ing, and increasing food portion sizes. If locally available foods are inadequate, micronu-trient supplementation may be needed.

Another period of nutritional stress is adolescence and the reproductive years. Addi-tional energy is needed to support adolescent growth, fetal growth during pregnancy,and milk production during lactation. While pregnancy represents an important opportu-nity for health and nutrition interventions, nutritional problems must also be addressedat other times in a woman’s life. Adequate energy and micronutrient intake is critical atall stages. For adolescents and women of reproductive age, improved energy intake, adiversified diet, and increased micronutrient intake through food fortification can help toimprove their health and nutrition, as well as birth outcomes. When appropriate foodsare not available, micronutrient supplements can improve nutritional status.

The recommendations presented in this paper and listed on the following pages fo-cus on feeding and dietary practices and not on other important determinants of nutri-tional status such as household food security, health services, and environmental factors.They are grouped into several categories: children 0 to 6 months, children 6 to 24months, and adolescent girls and women of reproductive age. The goal is for healthywomen to give birth to healthy babies who receive optimal nutrition, first through theirmothers’ breastmilk and then, from around 6 months to 24 months and beyond, throughbreastmilk and appropriate complementary foods.

These recommendations can serve as guidelines for program planners andpolicymakers to use in setting policies and designing communication, service delivery,and training activities. LINKAGES suggests that program planners collaborate with com-munication specialists in determining how to present this advice in a culturally appropri-ate way to different groups that influence feeding and dietary practices. Localassessments will help determine the emphasis to give each practice. LINKAGES also rec-ommends that program planners collaborate with local nutrition specialists to “translate”caloric requirements into local foods and measurements.

Executive Summary

viii

Summary of Recommended Feeding and Dietary Practices

Executive Summary

Infants0 to 6Months

Initiate breastfeeding within about one hour of birth.

Establish good breastfeeding skills (good positioning and attach-ment).- Baby should be held close to mother, facing the breast, with the

baby’s ear, shoulder, and hip in a straight line.- Infant’s mouth should open wide just before attaching so the

nipple, and as much of the areola as possible, are in the mouth. Ifproperly attached, the lips are rolled outward, with the tongueover the lower gum.

- Signs of effective feeding include visible jaw movement drawingmilk out, rhythmical suckling with an audible swallow, and nodrawing in of cheeks.

Breastfeed exclusively (no prelacteal feeds, no other foods, nowater or other liquids) for about the first six months.

Practice frequent, on-demand feeding, including night feeds (8–12 breastfeeds per 24 hours, every 2–3 hours, or more frequently ifneeded).

In areas where vitamin A deficiency occurs, mothers should takea high-dose vitamin A supplement (200,000 IU) as soon as pos-sible after delivery, but no later than eight weeks postpartum, toensure adequate vitamin A content in breastmilk.

Continue frequent, on-demand breastfeeding, to 24 months andbeyond.

Introduce complementary foods beginning around six months ofage.- Breastfeed before each feeding of complementary food.

Increase food quantity as the child ages while maintaining fre-quent breastfeeding.- Provide 6- to 8-month-old infants approximately 280 kcal per day

from complementary foods.- Provide 9- to 11-month-old infants approximately 450 kcal per day

from complementary foods.- Provide 12- to 24-month-old children approximately 750 kcal per

day from complementary foods.

Increase complementary feeding frequency as the child ages, us-ing a combination of meals and snacks.- Feed complementary foods to 6- to 8-month-old infants 2–3 times

per day.- Feed complementary foods to 9- to 11-month-old infants 3–4 times

per day.- Feed complementary foods to 12- to 24-month-old children 4–5

times per day.

BreastfedChildren6 to 24Months

ixExecutive Summary


BreastfedChildren6 to 24Months(con't.)

Gradually increase food thickness and add variety as the child ages,adapting the diet to the child’s requirements and abilities.- Feed mashed and semi-solid foods to infants, starting around 6

months of age.- Feed energy-dense combinations of foods to 6- to 11-month-olds.- Introduce “finger foods” (snacks that can be eaten by children alone)

at about 8 months of age.- Make the transition to the family diet at about 12 months of age.

Diversify the diet of both the breastfeeding mother and the child byincluding fruits, vegetables, fortified foods, and/or animal productsto improve quality.- Feed fruits and vegetables daily, especially those rich in vitamin A

and other vitamins.- Feed meat, poultry, fish, or other animal products daily or as often as

possible (if feasible and acceptable).- Use fortified foods, such as iodized salt, vitamin A-enriched sugar,

iron-enriched flour, or other staples, when available.- Give vitamin-mineral supplements when animal products and/or forti-

fied foods are not available.

Practice active feeding.- Feed infants directly and assist older children when they feed them-

selves.- Offer favorite foods and encourage children to eat when they lose in-

terest or have depressed appetites.- If children refuse many foods, experiment with different food combi-

nations, tastes, textures, and methods for encouragement.- Talk to children during feeding.- Feed slowly and patiently and minimize distractions during meals.- Do not force children to eat.

Practice frequent and active feeding during and after illness.- During illness, increase fluid intake by more frequent breastfeeding,

and patiently encourage children to eat favorite foods.- After illness, breastfeed and give food more often than usual, and en-

courage children to eat more food at each sitting.

Practice good hygiene and proper food handling.- Wash caregivers’ and children’s hands before food preparation and

eating.- Keep all food preparation surfaces clean; use clean utensils to pre-

pare and serve foods.- Cook food thoroughly.- Avoid contact between raw foodstuffs and cooked foods.- Serve foods immediately after preparation; avoid storing cooked

food.- Wash fruits and vegetables.- Use safe water.- Use clean cups and bowls; never use feeding bottles.- Protect foods from insects, rodents, and other animals.- Store non-perishable foodstuffs in a safe place (separate from pesti-

cides, disinfecting agents, or other toxic chemicals).

x Executive Summary

Recommended at all times

Increase food intake, if underweight, to protect adolescentgirls’ and women’s health and establish reserves for preg-nancy and lactation.

Diversify the diet to improve the quality and micronutrient in-take.- Increase daily consumption of fruits and vegetables.- Consume animal products, if feasible and acceptable.- Use fortified foods, such as vitamin A-enriched sugar and

other products and iron-enriched and vitamin-enriched flouror other staples, when available.

Use iodized salt.

If micronutrient requirements cannot be met through availablefood sources, supplements containing iron, vitamin A, zinc,and other nutrients may be needed to build stores and im-prove women’s nutritional status.

Recommended during periods of special needs:

At certain times, girls and women have heightened nutritional re-quirements. During these times, they should follow the above rec-ommendations plus those listed below.

During adolescence (between 10 and 19 years of age)Increase food intake to accommodate the adolescent “growthspurt” and to establish energy reserves for pregnancy and lac-tation.

During pregnancyIncrease food intake to support fetal growth and future lacta-tion.Take iron/folic acid tablets daily.

During lactationEat the equivalent of an extra meal per day.In high-risk areas, take a high dose vitamin A capsule(200,000 IU) as soon after delivery as possible, but no laterthan 8 weeks postpartum, to build stores, improve breastmilkquality and reduce maternal morbidity.

During the interval between the cessation of lactation and thenext pregnancy

Allow adequate time (at least six months) between the cessa-tion of lactation and the next pregnancy to replace and buildup energy and micronutrient reserves.


Adolescentgirls (10–19Years) andWomen ofReproductiveAge

1Introduction

IntroductionThe overall objective of the LINKAGES

Project is to improve breastfeeding and re-lated complementary feeding and mater-nal dietary practices. The Project cutsacross traditional boundaries betweenhealth/nutrition and population programs,emphasizing the overlapping benefits offour health-related practices: optimalbreastfeeding, timely introduction of familyplanning, including the Lactational Amenor-rhea Method (LAM), timely and appropri-ate complementary feeding, and bettermaternal nutrition.

Together, these practices contribute tofertility reduction, improved reproductivehealth, and child survival. Listed below areexamples of the overlapping benefits ofthe four health-related practices.

A well-nourished mother provides opti-mal nutrition to her fetus and is lesslikely to give birth to a premature in-fant or to a low birth weight, full-termbaby. She is also able to provide opti-mal nutrition to her exclusivelybreastfed infant.The Lactational Amenorrhea Method(LAM) and improved breastfeedingpractices extend birth spacing.Optimal breastfeeding and comple-mentary feeding behaviors promotehealth, growth, and development andincrease a child’s chances for ahealthy, productive life as an adult.Good feeding practices during the firsttwo years greatly reduce the risk thata girl will reach maturity stunted andat risk of obstetric complications andthe delivery of a low birth weightbaby.

The LINKAGES Project, in consultationwith technical experts and program man-agers, identified a set of recommendedfeeding and dietary practices to improvenutritional status at various points in thelife cycle: birth to about six months, sixmonths to 24 months, and adolescenceand the reproductive years. This paperpresents the technical justification for therecommendations. Policymakers and pro-gram planners can use them as guidelines

for developing messages and programsappropriate to prevailing local conditions.

When viewed within a larger concep-tual framework (Figure 1), LINKAGES’ rec-ommendations are part of maternal andchild care, one of three major underlyingdeterminants of nutritional status. Feedingpractices affect both dietary intake andhealth status, which are the immediate de-terminants of nutritional status. The impactof LINKAGES’ activities on improving feed-ing and dietary practices will be greater ifthey are supported by determinants of nu-tritional status that are outside LINKAGES’scope of work. These determinants includehousehold food security, health services,environmental factors, and other care is-sues such as physical workloads. A fewexamples illustrate the importance of foodsecurity, health services, reduced physicalworkloads, and family planning.

Access to food: Poor-quality diets maybe due to poverty, the unavailability ofnutrient-rich foods, and inequitable dis-tribution of food within a household.Access to preventive and curative healthservices:- Hookworm infection contributes to

anemia and anorexia.- Malaria tends to worsen nutritional

status by destroying red blood cells,resulting in anemia.

- Illness often suppresses appetite andpredisposes children to malnutrition.For example, diarrhea causes de-creased nutrient absorption and de-creased dietary intake.

Reduced physical workloads: Heavyphysical labor and high levels of en-ergy expenditure that are not compen-sated for by increased food intakeundermine nutritional status. In astudy in Ethiopia, the caloric intakes ofpregnant women participating in highand low levels of physical activitywere compared. Both groups con-sumed approximately the same num-ber of calories. Women who engagedin low levels of physical activitygained, on average, nearly three kilo-grams more than women involved inheavy labor. Their infants weighed

2

about 200 grams more than the othergroup (Tafari et al., 1980).Delay of first pregnancy: Teenage preg-nancy increases the risk that a babywill be born with low birth weight. In astudy in urban areas of Mali andBurkina Faso, teen mothers were al-most twice as likely to give birth tolow birth weight babies as older moth-ers (LeGrand and Mbacké, 1993).Birth spacing: Frequent childbearing in-creases a woman’s risk of malnutritionbecause of the nutritional demands ofpregnancy and lactation. Extended birthintervals also benefit the child. A childborn less than two years after the pre-vious child is two times more likely todie before the age of five than a childborn after an interval of two years ormore (Hobcraft, 1991).

Introduction

The remainder of this paper focuseson feeding and dietary practices as under-lying determinants of nutritional status.The paper does not address issues sur-rounding infant feeding and HIV/AIDS.These issues are discussed in a separateLINKAGES publication, Frequently AskedQuestions on Breastfeeding and HIV/AIDS.For a discussion of interventions to pro-mote and support LINKAGES’ recom-mended practices, the reader is referredto two papers developed for LINKAGES:

Improving breastfeeding behaviors: Evi-dence from two decades of interventionresearch (Green, Forthcoming) andInterventions to improve complementaryfood intakes of 6–12 month old infants indeveloping countries: What have we beenable to accomplish? (Caulfield, 1998).

Figure 1. Causes of Malnutrition

InadequateEducation

Political and Ideological Superstructure

Economic Structure

BasicCauses

Potential Resources

Resources & ControlHuman, Economic &

Organizational

UnderlyingCauses

ImmediateCauses

Manifestations

InsufficientHousehold

Food Security

InadequateMaternal &Child Care

Insufficient HealthServices & Unhealthy

Environment

InadequateDietary Intake

Disease

Malnutrition

UNICEF, 1992.

3Nutrition of Infants 0 to 6 Months

Box 1. Recommended Feeding Practices to Improve theNutrition of Infants 0 to 6 Months

Initiate breastfeeding within about one hour of birth.Establish good breastfeeding skills (proper positioning and attachment).Breastfeed exclusively (no prelacteal feeds, no other foods, no water or otherliquids) for about the first six months.Practice frequent, on-demand feeding, including night feeds (8–12 breastfeedsper 24 hours, every 2–3 hours, or more frequently if needed).In areas where vitamin A deficiency occurs, mothers should take a high-dosevitamin A supplement (200,000 IU) as soon as possible after delivery, but nolater than eight weeks postpartum, to ensure adequate vitamin A content inbreastmilk.

Note 1Full or nearly fullbreastfeeding in-cludes exclusivebreastfeeding, “al-most exclusive” (vi-tamins, mineralwater, juice, or ritual-istic feeds given in-frequently inaddition tobreastfeeds), and“high” levels ofbreastfeeding (thevast majority offeeds arebreastfeeds). Inter-vals should not ex-ceed four hoursduring the day andsix hours at night.Supplementationshould represent nomore than 5–15 per-cent of all feedingepisodes. (Labbok etal., 1994)

I. Recommended FeedingPractices to Improve theNutrition of Infants 0 to 6Months

The benefits of breastfeeding for infanthealth and survival, child growth and de-velopment, and maternal health are welldocumented. These benefits are summa-rized in a LINKAGES publication, Quantify-ing the Benefits of Breastfeeding: AnAnnotated Bibliography (Lutter, 1998). Thischapter discusses six key practices, listedin Box 1, that support optimal nutritionduring the first six months of life. Exclusivebreastfeeding, with frequent, on-demandfeedings, also contributes to child spacingand lower total fertility rates. A womanwho is amenorrheic, less than six monthspostpartum, and fully or nearly fullybreastfeeding1 is more than 98 percentprotected against pregnancy, as demon-strated in clinical trials of the effectivenessof the Lactational Amenorrhea Method(LAM) for birth spacing (Labbok et al.,1997).

Initiate breastfeeding within about onehour of birth

The first step to optimal breastfeedingis to put the baby to the breast within thefirst hour of birth. Initiation during the firsthour takes advantage of the newborn’s in-tense suckling reflex and alert state(Righard, 1990). Early initiation also stimu-lates breastmilk production; fostersmother-child bonding; and immediately

provides the infant the enhanced anti-bac-terial, anti-viral, and nutritional propertiesof colostrum (the first milk).

Establish good breastfeeding skills(proper positioning and attachment)

A key factor to initiating successfulbreastfeeding is the establishment of goodbreastfeeding skills during the first days.Proper positioning and attachment in-crease the infant’s suckling efficiency, fa-cilitating effective removal of milk fromthe breast, adequate milk intake, and theproduction of breastmilk. Proper position-ing and latch-on also reduce friction on themother’s nipples that can cause pain andresult in sore or cracked nipples (Shragoand Bocar, 1990).

Signs of proper positioning and attach-ment include:

Baby should be held close to mother,facing the breast, with the baby’s ear,shoulder, and hip in a straight line.Infant’s mouth should open wide justbefore attaching so the nipple, and asmuch of the areola as possible, are inthe mouth. Once attached, the lipsshould be rolled outward, with thetongue over the lower gum.Signs of effective feeding are: visiblejaw movement drawing milk out,rhythmical suckling with an audibleswallow, and no drawing in of cheeks.

Suckling at the breast differs fromsucking from a bottle. Use of a bottle tofeed expressed breastmilk can result in

4

less effective suckling at the breast,“nipple confusion,” the introduction ofpathogens through unsterile feedingbottles, and, in the most extreme cases,refusal of the breast (Newman, 1990). Toavoid these problems, expressed breast-milk should be fed by cup.

Pacifiers (dummies) and other artificialteats can also interfere with breastfeedingand serve as a vehicle for contaminants.One study in Brazil reported that the pro-portion of children who were no longerbreastfed at six months of age was signifi-cantly higher among babies who usedpacifiers at one month of age than amongthose who did not use pacifiers (Victora etal., 1993).

Breastfeed exclusively (no prelactealfeeds2, no other foods, no water or otherliquids) for about the first six months

A randomized trial conducted in Hon-duras suggests that babies who are exclu-sively breastfed for six months grow aswell as those who receive complementaryfoods from the age of four months (Cohenet al., 1994). Given the risks of infectiondue to food-borne pathogens, most ex-perts now recommend exclusive breast-feeding for about the first six months.Exclusive breastfeeding ensures that theyoung infant receives the maximum healthand nutritional benefits from breastmilk. Astudy (Duncan et al., 1993) in Tucson, Ari-zona, of more than 1,000 babies foundthat babies who were exclusively breast-fed for four months or more had 40 per-cent fewer episodes of acute ear infectionsthan breastfed babies who received otherfoods before four months.

There is also clear evidence that theexclusively breastfed child is at a muchlower risk of infection from diarrhea andacute respiratory infections than infantswho receive other foods (Brown et al.,1998; Popkin et al., 1990; Lutter, 1997). Forexample, in the Philippines, the risk of diar-rhea among infants four months of age

who received complementary foods was 6–13 times greater than for exclusivelybreastfed infants (Popkin et al., 1990). Eventhe addition of water or other non-nutritiveliquids doubled the risk of diarrhea com-pared with exclusively breastfed infants.

Water supplementation is both unnec-essary and dangerous because it can intro-duce contaminants and reduce nutrientintake. In India use of non-nutritive liquidswas associated with a decline in breast-milk consumption (Sachdev et al., 1991).Six studies that examined the water re-quirements of exclusively breastfed infantsin diverse climates reported that healthyinfants who consumed enough breastmilkto meet their energy needs also satisfiedtheir fluid requirements, even in hot anddry climates (WHO, 1991). The studieswere conducted in Argentina, Israel, India,Jamaica, and Peru.

Practice frequent, on-demand feedings,including night feeds (8–12 breastfeedsper 24 hours, every 2–3 hours, or morefrequently if needed)

Frequent feedings increase breastmilkproduction and maintain supply. They helpto prevent problems, such as breast en-gorgement, that might discourage awoman from breastfeeding. Newbornswho are breastfed on demand generallyregain their birth weight sooner than thosefed on a schedule (de Carvalho et al.,1983). Indicators of infant hunger are in-creased alertness, mouthing, and rootingfor the nipple. Crying is a late sign of hun-ger (Anderson, 1989).

Some babies, such as passive, sleepybabies, may seldom cry or “demand” tobe fed. Mothers should be informed thatfor optimal nutrition, babies need to bebreastfed 8–12 times per 24 hours, every2–3 hours, or more frequently as neededduring the first months. During the firstfew days after birth, many babiesbreastfeed more frequently and often forlonger periods than when breastfeeding isfully established.

Note 2Prelacteal feeds in-clude water, otherliquids, or ritualfoods given to a babybefore breast-feeding is initiated.

Nutrition of Infants 0 to 6 Months

5

In areas where vitamin A deficiencyoccurs, mothers should take a high-dosevitamin A supplement (200,000 IU) assoon as possible after delivery, but nolater than eight weeks postpartum, toensure adequate vitamin A content inbreastmilk

The concentration of vitamin A inbreastmilk depends on a woman’s vitaminA status and the changing needs of hergrowing infant. Preterm milk is higher invitamin A concentration than term milk.During the first two weeks of lactation, thevitamin A concentration in breastmilk isnearly double the concentration at onemonth. The mature breastmilk of womenwith relatively good maternal health andnutritional status provides enough vitaminA for at least the first six months and pos-sibly the first year (Newman, 1993).

In areas where vitamin A deficiency isendemic, women may have low vitamin Aconcentration in their breastmilk, increas-ing a child’s risk of becoming clinically de-ficient during illness. Preterm infants are atparticular risk of vitamin A deficiency be-

Nutrition of Children 0 to 6 Months

cause they have virtually no reserves ofretinol in their livers (Greene, 1991). Pro-viding a high-dose vitamin A supplementto the mothers of at-risk infants soon afterdelivery will improve their vitamin A statusand, in turn, the vitamin A content of theirmilk. In a study in Bangladesh (Roy et al.,1997), a group of mothers of breastfed in-fants received a single oral high-dosesupplement of vitamin A soon after birth.Their infants had significantly fewer daysof illness from respiratory infections duringthe first six months of life than infants ofmothers from the same socio-economicgroup who were not given the supplement.

The earlier the single dose (200,000 IUorally) is given to a lactating woman, thesooner the vitamin A status of her breast-fed child will be improved (WHO, 1997). Ahigh-dose vitamin A supplement can beharmful to a fetus (WHO/MI, 1997). There-fore, it should not be given during preg-nancy or anytime beginning around eightweeks after childbirth when women are atheightened risk of pregnancy (especially ifthey are not fully breastfeeding).

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II. Recommended FeedingPractices to Improve theNutrition of Children 6 to 24Months

Children are at highest risk of nutri-tional deficiency and growth retardationbetween the ages of 6 and 24 months. Theprevalence of malnutrition within a popula-tion, as measured by growth retardation,usually peaks in children 12 to 24 monthsof age. As illustrated in Figure 2, theprevalence of stunting (low height-for-age)approaches 40 percent among children inthis age group and is only slightly higher inolder groups of children.

Short-term nutritional deficiencies, asevidenced by wasting (low weight-for-height), are also most prevalent in the 12-to 24-month age group. Although wastingdrops off sharply in the third year, childrenare unable to compensate for their earlypoor feeding and continue to be stunted forthe rest of their lives. By age 2–3 years,

children’s weights may become appropri-ate for their lower heights, but little can bedone to bring these children up to the stat-ure of well-nourished children. For girls,the consequences of stunting are height-ened risks of obstructed labor during child-birth since stunting affects the size of thebirth canal (pelvic size). In addition, astunted woman is more likely to give birthto a low birth weight baby.

Underwood (1985) describes the pe-riod between 6 and 24 months as a criticaltransition period when the “exposure toenvironmental pathogens is most intense,the likelihood of inadequate nutrient intakemost probable, and the emotional traumaof less intimate maternal infant contactmost stressful.” The recommended prac-tices to improve the nutrition of childrenbetween 6 and 24 months address theserisks. These practices, listed in Box 2, fo-cus on optimal feeding behaviors, ad-equate dietary intake, hygienic foodpreparation, and the caregiver’s attentive-ness to a child’s needs.

0

10

20

30

40

50

Figure 2. Malnutrition Prevalence in 15 Countries by Age (average prevalence)

% D

efic

ien

t

<6 6–11 12–23 24–35 36–47 48–59

Age in Months

Underweight (low weight-for-age)

Stunting (low height-for-age)

Wasting (low weight-for-height)

% Deficient refers to the percentage of malnourished children below -2 Standard Deviations.

Source: Demographic and Health Surveys, 1991–1995.

Note: All DHS countries with anthropometric data in the 1991–1995 surveys were included: Cameroon, Colombia, DominicanRepublic, Egypt, Guatemala, Jordan, Madagascar, Malawi, Namibia, Niger, Nigeria, Pakistan, Peru, Tanzania, and Zambia.

4

9

3

2021

7

31

40

10

29

42

5

24

44

4

23

42

4

Nutrition of Children 6 to 24 Months

7Nutrition of Children 6 to 24 Months

Many of the recommendations areaimed at increasing energy intake. Thiscan be done by:

breastfeeding more frequently,feeding children complementary foodsmore often and/or providing more en-ergy-dense foods,making portion sizes larger (up to thelimit of a child’s hunger and stomachcapacity), andpracticing active feeding (adapting thefeeding method to the child’s changingpsychomotor abilities, actively encour-aging the child to eat, and providing asupervised environment).Micronutrient intake can be increased

by diversifying the diet to include fruits,vegetables, and animal products; usingfortified foods; and/or giving micronutrientsupplements. Choosing food combinationsthat enhance micronutrient absorption isalso important. Improving the micronutri-ent content of the maternal diet will im-prove the quality of a woman’sbreastmilk.

In many areas, local, cultural, and en-vironmental constraints make it difficult topractice all of the recommended practices.Adaptations will need to be made; how-ever, a child’s nutritional status is likely tobe compromised unless most of thesepractices are adopted. Programs to im-prove complementary feeding should re-

view existing studies and conduct local as-sessments to understand the multiple fac-tors that affect feeding practices. Theseassessments will determine the appropri-ate emphasis to give to each of the recom-mended practices. Local studies shouldidentify local diets and current good prac-tices to be supported, test options for im-proving the traditional diet and changingrelated feeding practices, and identify tar-get audiences and effective strategies forreaching them.

A discussion of each of the recom-mended feeding practices to improve thenutrition of breastfed children 6 to 24months of age follows.

Continue frequent, on-demandbreastfeeding, including night feedingfor infants

There are several reasons for recom-mending frequent, on-demand breastfeed-ing of older infants and toddlers.

Breastmilk remains an importantsource of energy and fat. Breastmilkis relatively high in fat compared withmost complementary foods. Based onestimates, breastfed infants need only25 percent of their calories from fat incomplementary foods compared with35–45 percent for non-breastfed in-fants (Brown et al., 1998). Whencomplementary foods are low in fat,

Box 2. Recommended Feeding Practices to Improve theNutrition of Breastfed Children 6 to 24 Months

Continue frequent, on-demand breastfeeding, to 24 months and beyond.Introduce complementary foods beginning around six months of age.Increase food quantity as the child ages while maintaining frequentbreastfeeding.Increase complementary feeding frequency as the child ages, using a combi-nation of meals and snacks.Gradually increase food thickness and add variety as the child ages, adaptingthe diet to the child’s requirements and abilities.Diversify the diet of both the breastfeeding mother and the child by includingfruits, vegetables, fortified staple foods, and/or animal products to improvequality.Practice active feeding.Practice frequent and active feeding during and after illness.Practice good hygiene and proper food handling.

8 Nutrition of Children 6 to 24 Months

the fat in breastmilk may be essentialfor the utilization of vitamin A.Breastmilk’s contribution to the sup-ply of vitamins and high-quality pro-tein may be substantial, dependingon the levels in complementaryfoods. Studies in Bangladesh reportedthat breastmilk contributed nearly halfof the protein intake and 60 percent ofdaily energy and vitamin A intake inthe diet of children over two years ofage (Brown et al., 1982). In a study ofrural West African children over oneyear of age, Prentice and Paul (1990)reported that breastmilk was the mostimportant source of vitamin A and fat.Breastfeeding is extremely importantduring illness. Children often continuebreastfeeding even when they areanorexic and refuse other foods.Breastmilk continues to reduce therisk of infection. Besides providingyoung children with an important,high-quality food, breastfeeding contin-ues to reduce the risk of infection (es-pecially diarrhea, including shigellosis),even in the older infant and youngchild (Ahmed et al., 1992; Mobak etal., 1994; Clemens et al., 1986). Sus-tained breastfeeding also reduces therisk of childhood cancer (Davis, et al.,1988).Breastfeeding helps to suppress fer-tility. Breastfeeding can significantlyreduce fertility beyond the first sixmonths among populations where con-traceptive use is limited. Women whobreastfeed their infants at frequent in-tervals over prolonged periods of timehave lower fertility than women whobreastfeed infrequently and for shorterdurations (VanLandingham et al.,1991).

Introduce complementary foodsbeginning around six months of age

By about six months of age,breastmilk alone cannot meet most ba-bies’ total energy and vitamin/mineral re-quirements. At this time complementaryfeeding should begin. Complementaryfeeding refers to the period when otherfoods or liquids are provided along with

breastmilk. Complementary foods are anynon-breastmilk foods given to young chil-dren during this period.

In many countries, nutrition guidelinescontinue to recommend introducingcomplementary foods between four andsix months based on the assumption thatbreastmilk alone may not be adequate tosupport the growth of some infants duringthis period. Some have suggested thatcomplementary feeding should begin be-fore six months to get infants used to eat-ing other foods. However, a study inHonduras (Cohen et al., 1995) showed thatearly initiation does not result in improvedgrowth velocities or food acceptance. Thestudy compared food consumption pat-terns and growth of infants who werestarted on foods at four months to the con-sumption patterns and growth of thosewho began eating complementary foods atsix months. There were no differences infood acceptability or food consumption at9–12 months between the two groups. In-fants consumed similar amounts and vari-eties of foods whether or not they hadsolids prior to six months of age.3

Several studies in Thailand, Peru, Hon-duras, and the United States have docu-mented that early initiation (<6 months)of complementary foods replaces breast-milk and does not increase caloric intake(Brown et al., 1998). None of these studiesreported any benefits for the child’sgrowth of early complementary feeding.Because breastmilk is generally higher innutritional value than the complementaryfoods and liquids fed to children in devel-oping countries, replacing it can negativelyaffect the fat, energy, and micronutrient in-take of young infants.

Even when breastfeeding frequencyremains high, the total amount obtainedfrom each breastfeed decreases whenother foods are fed. The implications aretwofold: (1) maintain high levels ofbreastfeeding when introducing comple-mentary foods, and (2) ensure thatcomplementary foods are as high in nutri-ents as possible.

Many breastfeeding counselors recom-mend that women breastfeed before feed-ing complementary foods, especially until

Note 3Frongillo andHabicht (1997) raisesome concernsabout the study, par-ticularly the highnon-random drop-out rate among theexclusive breast-feeding group andan inadequatesample size to showsignificant differ-ences in weight andlength.


the child is 10 to 12 months of age. Thisrecommendation is intended to maximizebreastmilk consumption and stimulatebreastmilk production. A review by Arm-strong (1993) indicated that there is no sci-entific evidence showing that breastfeedingprior to complementary feeding negativelyaffects infant growth. Armstrong terms therecommendation to breastfeed first“speculative,” a “common-sense position”that communicates the importance ofbreastmilk for infant health and nutrition.

Breastfeeding before each comple-mentary feeding is also promoted for itsrole in fertility reduction. This practice isone of the criteria for extended use (ninemonths rather than six months) of the Lac-tational Amenorrhea Method. Breastfeed-ing before complementary feeding helps tomaintain the frequency and intensity ofbreastfeeding necessary for the effective-ness of the Lactational AmenorrheaMethod (Cooney et al., 1996). The othercriterion for extended LAM is amenorrhea.If these criteria are not met, the chance ofpregnancy is increased.

Increase food quantity as the child ageswhile maintaining frequentbreastfeeding

Adequate energy intake can be en-sured through age-appropriate, energy-dense foods, frequent feedings, andcontinued breastfeeding. Table 1 illustratesthat the energy needed from complemen-tary foods depends on the child’s age andthe level of breastmilk intake. As the childages and breastmilk intake decreases,complementary foods must meet agreater proportion of the energy require-ments.

Listed below are estimates of the rec-ommended daily energy intake fromcomplementary foods for various agegroups. They represent average require-ments for breastfed children. Local re-search is needed to determine the bestcombinations of foods and feeding prac-tices to achieve these levels of energy in-take. Individual children may require moreor fewer additional calories and nutrientsdepending on their nutrient stores, activitylevels, and growth requirements.

Table 1. Energy Needed from Complementary Foods toMeet Daily Requirements by Level of Breastmilk Intake

Level of Breastmilk Intakea

Age in months Daily energy High breast- Average breast- Low breastmilkrequirement milk intakec milk intakec intakec

(kcal)b (Mean +2 S.D.) (Mean - 2 S.D.)

Kilocalories needed from complementary foods

6–8 680 75 270 4659–11 830 230 450 675

12–23 1090 490 750 1000

Source: Brown et al., 1998.a Figures have been rounded.b Estimates of average breastmilk intake are: 410 kcal for a 6- to 8-month-old, 380 kcal for a 9- to

11-month-old, and 340 kcal for a 12- to 23-month-old. These estimates need to be adjusted for thesize of the infant.


General feeding guidelines for breast-fed children with average breastmilk in-take (defined in the footnote to Table 1),and sample daily diets are shown below.

Provide 6 to 8-month-old infants ap-proximately 280 kcal per day4 fromcomplementary foods.(Example: ½ cup rice, 1½ tablespoonsmung dal [lentils], 3 tablespoons darkgreen leafy vegetables, and 1 tea-spoon groundnut oil)5

Provide 9 to 11-month-old infants ap-proximately 450 kcal per day fromcomplementary foods.(Example: 1½ cups plain maize pap,½ banana, ½ cup rice and beans, lladle palm oil/tomato/pepper stew, 1½tablespoons chopped chicken, and 1fried bean cake)6

Provide 12 to 24-month-old childrenapproximately 750 kcal per day fromcomplementary foods.(Example: 1 cup rice, 3 tablespoonsdal [lentils], 1 teaspoon oil, a smallpiece of fish, ½ cup boiled potato, 1tablespoon coconut, 2 tablespoons mo-lasses, and 1 small mango)7

All three of these diets provide, in ad-dition to breastmilk, sufficient calories,protein, and vitamin A for the specific agegroup. However, because these diets arelow in animal products, their iron and zinccontent is inadequate. For children 6 to 24months, it is difficult to obtain sufficientamounts of these nutrients without fortifiedfoods or micronutrient supplements.

Increase feeding frequency as the childgets older, using a combination of mealsand snacks

Guidelines on feeding frequenciesshould take into account the energy den-sity and the amount of various foodsserved to a child. The continuation of fre-quent, on-demand breastfeeding is impor-tant to ensure that complementary foodsdo not displace breastmilk. Breastmilkshould be the sole source of nutrition in thefirst six months and the primary source inthe second six months.

Recent estimates (Brown et al., 1998)of energy requirements and breastmilk in-

takes suggest the following complemen-tary feeding frequencies, using a combina-tion of meals and snacks:

Feed complementary foods to 6 to 8-month-old infants 2–3 times per day.Feed complementary foods to 9 to 11-month-old infants 3–4 times per day.Feed complementary foods to 12 to 24-month-old children 4–5 times per day.

Differences in local foods and recipesand variations in breastfeeding practices un-derscore the need to develop local guide-lines on the types and quantity of foodchildren should consume at different agesas well as the feeding frequency needed tomeet their energy requirements. Local dietswill also need to be assessed for their mi-cronutrient content. Tools such as Designingby Dialogue (Dickin et al., 1997) can help inthe development of recommendations forfeeding practices and appropriate localfoods for young children.

Gradually increase food thickness andvariety as the child gets older, adaptingthe diet to the child’s requirements andabilities

As the gastrointestinal tract and im-mune system mature and other develop-mental changes occur, a child is ready toingest a variety of foods. The foods con-sumed should change in consistency andcomposition, becoming thicker and moreenergy dense. Initially, porridge and othersemi-solid foods are suitable first foods be-cause infants are physiologically ready toaccept them. They are also more calori-cally dense than liquids, such as soups.

When infants are capable of eatingthicker semi-solid foods, such as mashedbananas, these foods should be introducedbecause they tend to be more caloricallydense than purées. One disadvantage,however, is that thicker semi-solid foodsusually take longer to feed than purées,until the child reaches about 10 months ofage (Gisel, 1991). By 10–12 months of age,most infants can pick food up by hand andare ready to eat solid foods, such asbread. At this age, the variety of foodsshould be increased by feeding mashedfamily foods and various fruits and

Note 4The difference fromthe number shownin Table 1 is due torounding.

Note 5Adapted fromCameron andHofvander, 1983.

Note 6Dickin et al., 1997.

Note 7Wollinka et al., 1997.


vegetables (Dickin et al., 1997). At about12 months, most children are ready tomake the transition to the family diet.

Guidelines for the introduction ofvarious foods are summarized below.

Feed mashed and semi-solid foods(softened with breastmilk, if possible)to infants, beginning around sixmonths of age.Feed energy-dense combinations ofsoft foods to 6–11 month olds.Introduce “finger foods” (snacks thatcan be eaten by children alone, suchas grated vegetables and bread strips)at about eight months of age.Make the transition to the family dietat about 12 months of age.

Diversify the diet to improve quality

Optimal feeding of children 6 to 24months and older requires adequate pro-tein and micronutrient intake8 as well asenergy intake to ensure growth and propermetabolic functions of the body. This canbe done in the following ways:

Feed fruits and vegetables daily, espe-cially those rich in vitamin A and othervitamins.Feed meat, poultry, or fish daily or asoften as possible (even small quanti-ties help).Use fortified foods, such as iodizedsalt, vitamin A-fortified sugar or othervitamin A-fortified products, and iron-enriched flour or other staples, whenavailable.

When animal products, fortified foods,and/or vitamin A-rich foods are not avail-able, vitamin-mineral supplements, contain-ing appropriate levels of micronutrients,should be given to children to prevent ane-mia, zinc deficiency, vitamin A deficiency,and other micronutrient deficiencies.

FFFFFeed fruits and veed fruits and veed fruits and veed fruits and veed fruits and vegetegetegetegetegetables dailyables dailyables dailyables dailyables daily,,,,,especially those rich in vitamin Aespecially those rich in vitamin Aespecially those rich in vitamin Aespecially those rich in vitamin Aespecially those rich in vitamin A

The ability of food sources to preventvitamin A deficiency depends on the con-tent of vitamin A compounds in differentfoods, the amount of vitamin A that can beabsorbed and utilized, and the vitamin Astatus of the person consuming the food

(Sommer and West, 1996). Provitamin Acarotenoids are found in fruits and veg-etables. Dark green leafy vegetables are agood source of provitamin A carotenoids,but orange/yellow fruits and vegetablesare an even better source. Provitamin Acarotenoids in orange/yellow fruits(mango, papaya) and yellow/red veg-etables (pumpkin, sweet potatoes) aretwice as effective in enhancing serum vita-min A levels as those found in dark greenleafy vegetables (Bloem et al., in press).

Because vitamin A and its precursorsare fat soluble, vitamin A can be morefully utilized when fruits and vegetablesare mixed or eaten with a fat source, thusenhancing their absorption and increasingthe energy density of the foods withoutsacrificing nutrient density. For the samereason, breastmilk, which is a majorsource of fat in the diet, may help to im-prove vitamin A status. As noted earlier,breastmilk is also a good source of vitaminA. For example, a breastfed child who is9–11 months old could meet all of the dailyvitamin A requirements by eating a quar-ter of a mango. A non-breastfed child, onthe other hand, would require a wholemango (USDA, 1997).

FFFFFeed meat, poultryeed meat, poultryeed meat, poultryeed meat, poultryeed meat, poultry, fish, or other, fish, or other, fish, or other, fish, or other, fish, or otheranimal products daily or as often asanimal products daily or as often asanimal products daily or as often asanimal products daily or as often asanimal products daily or as often aspossible, if feasible and acceptablepossible, if feasible and acceptablepossible, if feasible and acceptablepossible, if feasible and acceptablepossible, if feasible and acceptable

In developing countries, where mostdiets are based on staple grains and le-gumes, micronutrient deficiencies are verycommon. The vitamin A, iron, and zincfound in grains and vegetable sources areless available and less efficiently storedthan those found in animal products. Dailyor frequent consumption of animal prod-ucts helps to avert deficiencies of these es-sential micronutrients.

Retinol, a vitamin A compound, isfound only in animal sources (eggs, milk,cheese, liver, and fish oils). To replace 1 µgof retinol available in animal products, 6µg of beta-carotene (in orange and yellowfruits and vegetables) and 12 µg of otherprovitamin carotenoids (such as in darkgreen leafy vegetables) are needed(Olson, 1995). Only 1.4 percent of the ironin spinach and 7 percent in soybeans can

Note 8Micronutrients arefrequently classifiedas Type I and Type IInutrients (Golden,1995). Althoughgrowth continues inthe early stages ofType I nutrient defi-ciencies, characteris-tic clinical signs andsymptoms develop.Health workers aretrained to recognize,diagnose, and treatsuch Type I deficien-cies as anemia (iron),beri-beri (thiamin),scurvy (vitamin C), xe-rophthalmia (vitaminA), and iodine defi-ciency disorders. Defi-ciencies in Type IInutrients, on theother hand, exhibitno specific clinicalsigns but can result ingrowth failure andanorexia. Whengrowth failure occurs,it is difficult to deter-mine which nutrientsmight be responsible.Zinc, magnesium,phosphorus, and po-tassium are amongthe Type II nutrients.In addition to theseminerals, protein isclassified as a Type IInutrient. (Note: Addi-tional micronutrientssuch as riboflavin, nia-cin, B

6, and B

12, may

also be deficient insome populations.)


be absorbed, compared with 20 percent ofiron from red meat (Scrimshaw, 1991).

Use fortified foods, when available; giveUse fortified foods, when available; giveUse fortified foods, when available; giveUse fortified foods, when available; giveUse fortified foods, when available; givevitamin-mineral supplements whenvitamin-mineral supplements whenvitamin-mineral supplements whenvitamin-mineral supplements whenvitamin-mineral supplements whenanimal products, fortified foods, and/oranimal products, fortified foods, and/oranimal products, fortified foods, and/oranimal products, fortified foods, and/oranimal products, fortified foods, and/orvitamin A rich foods are not availablevitamin A rich foods are not availablevitamin A rich foods are not availablevitamin A rich foods are not availablevitamin A rich foods are not available

Although animal products are excellentsources of micronutrients, they are oftenunavailable, unaffordable, or unacceptable(such as to a vegetarian population). More-over, it is difficult to meet the iron require-ments of a rapidly growing child evenwhen animal products (flesh meats) areconsumed regularly.

If young children are unable to meetall of their micronutrient requirementsthrough the consumption of animal prod-ucts and vitamin A-rich fruits and veg-etables, they should eat fortified foods,such as iodized salt, vitamin A-fortifiedsugar or other vitamin A-fortified products,and iron-enriched flour or other staples,when available. If fortified foods are notavailable, the following supplements maybe needed:

Iron: UNICEF recommends oral ironsupplements daily (12.5 mg per day)to infants 6 months to 1 year of age. Asolution of 25 mg/ml of iron can begiven to an infant by dropper with 10drops (0.5 ml) per dose. It would befeasible to add 10 mg of zinc to thispreparation (Nestel and Alnwick,1997).9 If the prevalence of anemia isknown to be very high (40 percent ormore), supplements should be contin-ued until 24 months of age. Low birthweight infants are at particular risk ofiron deficiency and may need to takeoral iron supplements (12.5 mg/day)starting from three months of age andcontinuing for at least nine months(UNICEF/WHO, 1995).Vitamin A: Bi-annual dosing with high-dose vitamin A as retinol (100,000 IUfor children 6–11 months and 200,000IU for those 12–60 months of age) canenhance vitamin A stores in areaswhere vitamin A deficiency occurs(WHO, 1997). Consumption of dietarysources of vitamin A is often inad-equate to eliminate marginal defi-

ciency in the population (de Pee et al.,1995).Iodine: If the soil is low in iodine andseafood sources are lacking, iodinemust be obtained through fortificationor supplements. Consumption of saltfortified with iodine will prevent iodinedeficiency in pregnant women, chil-dren, and other vulnerable groups.Breastfeeding mothers who consumeiodized salt will have sufficient iodinein their breastmilk.Other micronutrients: Depending onthe local diet and health status, othersupplements or multiple vitamin-min-eral tablets may be necessary. For ex-ample, some young children are B6

and B12 deficient because of malab-sorption in the gut or a deficiency inthe child’s diet or the diet of the lactat-ing mother. Riboflavin is low in dietsthat contain few animal products, andvitamin C is often only seasonallyavailable. Zinc intake is generally lowwhen iron intake is low. Zinc has beenshown to enhance growth and reduceinfection in young children.

Practice active feeding

Active feeding refers to caregiver be-haviors that may help to increase a child’sfood intake. These behaviors are listed be-low.

Feed infants directly and assist olderchildren when they feed themselves.Offer favorite foods and encouragechildren to eat when they lose interestor have depressed appetites.If children refuse many foods, experi-ment with different food combinations,tastes, textures, and methods for en-couragement.Talk to children during feeding.Feed slowly and patiently and mini-mize distractions during meals.Do not force children to eat.

Positive reinforcement, persistence,and supervised feedings are characteristicsof active feeding. Children of caregiverswho are passive and non-responsive totheir needs are more likely to be malnour-ished than children of attentive caregivers.

Note 9The impact of such apreparation on ironand zinc status is onlynow being tested.


In addition to nutritional benefits, activefeeding stimulates a child’s verbal andcognitive development (Engle et al., 1997).

A major problem that can be ad-dressed by active feeding is the highprevalence of anorexia observed amongyoung children. Depressed appetites areoften associated with diarrhea and feverbut are also prevalent in children who arenot ill. Many caregivers only encouragechildren to eat when they are sick, but notat other times. Encouragement is needed,even when children do not appear hungryor refuse new foods. This can be done byoffering additional food or second helpings,showing children how to eat, and talking tothem while they eat.

Adequate time for feeding, thecaregiver’s knowledge of the amounts ofdifferent foods that a child needs to eat,and self-confidence contribute to activefeeding. If a child refuses food, a self-confi-dent caregiver does not assume that thechild “knows best” but realizes that thefood should be offered numerous timesuntil the child becomes accustomed to eat-ing it. Some caregivers may feel that ac-tive feeding is too time-intensive. Theyneed to be assured that this time-intensiveperiod is normal and relatively brief.

Practice frequent and active feedingduring and after illness

Illness affects both dietary intake andnutrient utilization. Due to loss of appetite,sick children frequently reject food or con-sume only small quantities. Even whenthey eat food, nutrients are often lost be-cause the illness inhibits their absorption ordrains them away through diarrhea andvomiting. The following advice is offered tocaregivers of children 6 to 24 months ofage.

During illness, increase breastfeeding,increase fluid intake, and patiently en-courage children to eat their favoritefoods.After illness, feed children more oftenthan usual and encourage children toeat more food at each sitting.

Breastfeeding is particularly criticalduring illness because breastmilk, a nutri-

tious, easily digestible food, reduces pro-tein and caloric loss at a time when chil-dren frequently lose their appetite forother foods and liquids. For example, stud-ies in rural Peru found that during diarrhealepisodes, breastfed children maintainedtheir breastmilk intake; however, total ca-loric intake from other foods decreased by10–20 percent (Brown et al., 1990). Be-sides helping to maintain energy intake,breastfeeding helps prevent dehydrationand comforts the sick child.

Practice good hygiene and proper foodhandling

To ensure that foods given to childrenare safe and transfer nutrients, not patho-gens, caregivers should:

Wash caregivers’ and children’s handsbefore food preparation and eating.Keep all food preparation surfacesclean; use clean utensils to prepareand serve foods.Cook food thoroughly.Avoid contact between raw foodstuffsand cooked foods.Serve foods immediately after prepa-ration; avoid storing cooked food.Wash fruits and vegetables.Use safe water.Use clean cups and bowls; never usefeeding bottles.Protect foods from insects, rodents,and other animals.Store non-perishable foodstuffs in asafe place (separate from pesticides,disinfecting agents, or other toxicchemicals).Keep all food preparation premisesclean.

These optimal practices are based onprinciples set forth by the World Health Or-ganization (1996). Program planners andcommunicators will need to determinewhich of these recommended practices de-serve emphasis within a specific socioeco-nomic and environmental context.

One of the causes of high rates ofmalnutrition among children 6 to 24months is the introduction of pathogens incontaminated feeding bottles and foods.Contamination is also the result of poor ba-


sic hygiene, sanitation, and methods offood preparation. Food is often preparedseveral hours before it is consumed andthen stored at temperatures that promotethe growth of pathogens. Insufficient cook-ing or reheating of food can also result infood-borne illnesses. Foods should becooked thoroughly and fed as soon as theyare cool enough to eat. Foods for infantsshould not be stored, unless they can bekept cold (below 10o C) or hot (above 60o

C) and in clean, covered containers (WHO,1993). Because bottles are particularlyhard to clean, they should not be used forinfant feeding.

Acidified foods (such as yoghurt) orfermented foods are less subject to con-tamination since the acid helps prevent thegrowth of bacteria. Foods that do not need

to be cooked, such as a banana peeled im-mediately prior to consumption, are an-other way of providing foods free fromcontamination. Fruits and vegetablesshould be washed and peeled if possible.Those that cannot be peeled should becooked to kill bacteria.

Hand washing can help reduce con-tamination and the risk of diarrhea. Keep-ing children’s hands clean is importantbecause children put their hands in theirmouths many times when feeding them-selves. Caregivers need to wash their ownhands with soap before feeding children, apractice requiring substantial behaviorchanges in places where hand washingwith soap is infrequent. Providing a cleansurface for the child to feed him/herself isalso important.

15

III. Recommended DietaryPractices to Improve theNutrition of Adolescent Girlsand Women of ReproductiveAge

As noted in the previous chapter, nutri-tional neglect during the first two years oflife has immediate and often long-termnegative consequences on growth and de-velopment. This chapter examines the im-pact of nutritional stress duringadolescence and the reproductive years inwomen and the next generation. As illus-trated in Figure 3, the following risks to nu-tritional status are present throughout life:food insecurity, micronutrient deficiencies,infections and parasites, gender inequities,and heavy physical labor. The outer circleshows additional risks during differentstages of the life cycle.

In most developing countries, womenspend a larger proportion of their repro-ductive years pregnant, lactating, or preg-

nant and lactating. McGuire and Popkin(1990) estimate that on average, womenin Africa and Asia between the ages of 15and 45 are pregnant or lactating 30–48percent of their time. The cumulative ef-fect of frequent, closely spaced pregnan-cies, negative energy balance, andmicronutrient deficiencies can lead to acondition known as “maternal depletionsyndrome” (Winkvist et al., 1992).

Recommendations for improving thenutrition of adolescent girls and women ofreproductive age, set forth in Box 3, focuson dietary practices that affect energy andmicronutrient intake at different points inthe life cycle: adolescence, the non-preg-nant/non-lactating period, pregnancy, andlactation. At all stages, energy is neededfor body maintenance. Additional energy isneeded to support adolescent growth, fetalgrowth during pregnancy, and milk produc-tion during lactation. Energy demands areat a maximum level when an adolescentgirl is pregnant and lactating.

Figure 3. Risks to Female Nutritional Status duringDifferent Periods of Life

Source: Baker et al., 1996

Infancy and Early Childhood (0–24 months)

Suboptimal breastfeeding practicesInadequate quality and quantity of weaning dietInfrequent feedings

Lactation

Higher caloric andmicronutirentrequirements

Pregnancy

Higher caloric, protein, iron,vitamin A and other micro-nutrient requirements

Adolescence (10–19 years)

Increased nutritional demandsduring growth periodGreater iron needs with onsetof menstruationEarly childbearing

Childhood (2–9 years)

Poor diets

Lifetime Risks

Food insecurityMicronutrient deficienciesInfections and parasitesGender inequitiesHeavy physical labor

Nutrition of Adolescent Girls and Women of Reproductive Age

16

Micronutrient requirements alsochange at various points in the life cycle.Adolescent growth, menstruation, preg-nancy, and lactation can exacerbate micro-nutrient deficiencies. For somemicronutrients, such as vitamin A, lacta-tion puts greater demands on maternal re-serves than pregnancy. In the case of iron,the period of lactational amenorrhea is the

time of lowest iron loss for women of re-productive age.

LINKAGES’ recommended dietarypractices address women’s changing nutri-ent requirements. While pregnancy repre-sents an important opportunity for healthand nutrition interventions, nutritionalproblems must also be addressed at othertimes in a woman’s life, for the sake of

Box 3. Recommended Dietary Practices to Improve theNutrition of Adolescent Girls and Women of ReproductiveAge

Recommended at all times

Increase food intake, if underweight, to protect adolescent girls’ and women’sown health and establish reserves for pregnancy and lactation.

Diversify the diet to improve the quality and micronutrient intake.- Increase daily consumption of fruits and vegetables.- Consume animal products, if feasible and acceptable.- Use fortified foods, such as vitamin A-enriched sugar and other products and

iron-enriched and vitamin-enriched flour or other staples, when available.

Use iodized salt.

If micronutrient requirements cannot be met through available food sources,supplements containing iron, vitamin A, zinc, and other nutrients may beneeded to build stores and improve women’s nutritional status.

Recommended during periods of special needs

At certain times, girls and women have heightened nutritional requirements.During these times, they should follow the above recommendations plus thoselisted below.

During adolescence (between 10–19 years of age)Increase food intake to accommodate the adolescent “growth spurt” and toestablish energy reserves for pregnancy and lactation.

During pregnancyIncrease food intake to support fetal growth and future lactation.Take iron/folic acid tablets daily.

During lactationEat the equivalent of an extra meal per day.In high risk areas, take a high-dose vitamin A capsule (200,000 IU) as soon af-ter delivery as possible but no later than 8 weeks postpartum to build stores,improve breastmilk quality, and reduce maternal morbidity.

During the interval between the cessation of lactation and the next pregnancyAllow adequate time (at least six months) between the cessation of lactationand the next pregnancy to replace and build up energy and micronutrient re-serves.


17Nutrition of Adolescent Girls and Women of Reproductive Age

both the woman and her children. Asshown in Box 3, some of the recommen-dations apply to all women; others applyto periods of special needs.

Increasing Food Intake

Women of reproductiveWomen of reproductiveWomen of reproductiveWomen of reproductiveWomen of reproductive age,age,age,age,age, if if if if ifunderweight,underweight,underweight,underweight,underweight, should increase food should increase food should increase food should increase food should increase foodintake to protect their own health andintake to protect their own health andintake to protect their own health andintake to protect their own health andintake to protect their own health andestablish reserves for pregnancy andestablish reserves for pregnancy andestablish reserves for pregnancy andestablish reserves for pregnancy andestablish reserves for pregnancy andlactationlactationlactationlactationlactation

In developing countries chronic energydeficiency is very common among womenof reproductive age. Many women are toothin (Body Mass Index10 less than 18.5) orunderweight (weight less than 45 kg).Over 60 percent of women are under-weight in South Asia, over 40 percent inSouth East Asia, and about 20 percent insub-Saharan Africa (Gillespie, 1997). Func-tional consequences of chronic energy defi-ciency include heightened susceptibility toinfection, reduced activity levels, andlower productivity (Shetty and James,1994).

There is a strong association betweenlow pre-pregnancy weight and intrauterinegrowth retardation,11 as shown in a meta-analysis of 25 studies of maternal anthro-pometry and pregnancy outcome from 20countries (WHO, 1995). Most low birthweight in developing countries is due to in-trauterine growth retardation, which is pri-marily the result of maternal malnutritioneither before conception or during preg-nancy. Achieving the weight gain neces-sary in pregnancy to ensure adequate fetalgrowth and favorable birth outcomes maybe difficult for women who enter preg-nancy underweight and continue to engagein heavy physical labor. Increased energyintake by underweight women between re-productive cycles can improve birth weightand maternal health.

Adolescent girls should increase foodintake to accommodate the adolescent“growth spurt” and to establish energyreserves for pregnancy and lactation

During adolescence (the period be-tween 10 and 19 years), girls experiencerapid physical growth and sexual matura-tion. Growth occurs faster in adolescence

than at any other time, with the exceptionof the first year of life. Nutritional statuscan be undermined if adolescent girls’ in-creased nutritional demands are unmet.

Adolescent girls’ “growth spurt” occursabout 12–18 months before their firstmenstrual period, usually between 10 and14 years of age. They continue to grow inheight for up to seven years after the on-set of menstruation (menarche). A well-nourished adolescent girl may reach fullheight as early as 16 years, whereas amalnourished girl, whose menarche hasbeen delayed, may achieve full height aslate as 23 years (Roche and Davila, 1972).

Adolescent girls are capable of con-ceiving before their body is fully devel-oped. Completion of the development ofthe birth canal occurs two to three yearsafter full height is reached (Moerman,1982). Pelvic bone immaturity increasesthe risks of prolonged labor, pre-eclamp-sia, and cephalopelvic disproportion. Preg-nancy puts adolescent girls at high risk ofmalnutrition, complications of pregnancy,and poor birth outcomes, including death.For adolescent girls under the age of 18,the risk of dying in childbirth is three timesgreater than for women between the agesof 20 and 29 (UNICEF, 1995). A key strat-egy for maintaining or improving the nutri-tional status and survival of adolescentgirls is, therefore, to delay the first preg-nancy.

Pregnant womenPregnant womenPregnant womenPregnant womenPregnant women should increase food should increase food should increase food should increase food should increase foodintake to support fetal growth andintake to support fetal growth andintake to support fetal growth andintake to support fetal growth andintake to support fetal growth andfuture lactationfuture lactationfuture lactationfuture lactationfuture lactation

The nutritional demands during preg-nancy are multiple. Maternal fat stores areneeded to support fetal growth and futurelactation. The amount of weight thatshould be gained during pregnancy de-pends on several factors, such as pre-pregnancy weight, activity level, and bodysize.

The average woman should gain about10 kilograms during pregnancy, but manywomen in developing countries, particu-larly in South Asia, gain barely half thisamount (McGuire and Popkin, 1990). Forwomen who enter pregnancy with goodnutritional status, the additional food intake

Note 10The Body Mass Index(BMI) is an expressionof the height inmeters divided byweight in kilogramssquared.

Note 11Intrauterine growthretardation is evidentin full-term babieswho are born small-for-date. Low birthweight is also com-mon among infantswho are premature(born before 37weeks).

18

required is the equivalent of about 200kilocalories per day (Institute of Medicine,1990). Examples of a 200 kilocalorie snackare listed below.

1 medium tortilla, 2 tablespoonsrefried beans, and ½ tablespoon oil =194 kilocalories or1 small orange, ¼ cup split peas, and½ cup rice = 206 kilocalories or1 piece of boiled cassava and 12ground nuts = 197 kilocalories

For women who enter pregnancy un-derweight, more calories than shown inthe above examples are needed toachieve adequate weight gain.

Inadequate weight gain during preg-nancy is often the result of excessive de-mands on women’s time and energy. Somewomen are unaware of the need for addi-tional food during pregnancy. Others delib-erately restrict their diet because they fearthat a large baby will increase obstetricrisks. Low caloric intake or weight gain dur-ing pregnancy is a major factor influencingbirth weight, the single most important de-terminant of a child’s chances for survival.Low birth weight, in turn, is an indirect indi-cator of women’s nutritional status.

Trials in a number of countries haveexamined the effects of food supplementson weight gain and birth outcomes. Al-though differences in study designs makeit difficult to generalize, a recent review byLINKAGES of the evidence from these stud-ies concludes that increased caloric intakeamong severely (<45 kg and BMI <18.5)and moderately malnourished women(<50 kg and BMI <23) may lead to in-creases in birth weight. In moderatelymalnourished women, food supplementsmay not result in further improvements inbirth weight because a larger proportion ofweight gain is directed to the mother thanto the fetus. For better-nourished women(>50 kg and BMI >23), food supplementsare unlikely to affect maternal weightchange or infant birth weight. Hence, thebenefits of food supplements for maternalnutritional status and infant birth weightare greatest for undernourished women,particularly at times of the year when foodis scarce and/or workload is high (Rasmus-

sen, 1998), as recently demonstrated in astudy in the Gambia (Ceesay et al., 1997).In the Gambian study, the number of lowbirth weight babies declined by almost 40percent among pregnant women who re-ceived high-energy biscuits which providedaround 1,000 kcal/day after 20 weeks ofpregnancy. Still birth and perinatal mortal-ity rates were almost cut in half whensupplements were targeted at at-risk preg-nant women.

Lactating womenLactating womenLactating womenLactating womenLactating women should eat the should eat the should eat the should eat the should eat theequivalent of an extra meal per dayequivalent of an extra meal per dayequivalent of an extra meal per dayequivalent of an extra meal per dayequivalent of an extra meal per day

The National Academy of Sciences’ Sub-committee on Nutrition during Lactation (In-stitute of Medicine, 1991) recommends thatbreastfeeding mothers consume around2700 kcal per day (about 500 kcal per daymore than a non-pregnant, non-lactatingwoman). The recommendation assumesthat women can draw from fat stores accu-mulated during pregnancy. Malnourishedwomen with few fat stores and a poor dietneed more calories than the recommendedlevel to meet their energy requirements dur-ing lactation. For underweight women andwomen with low weight gain during preg-nancy, the National Academy of Sciencesrecommends a 650 kcal/day increase in en-ergy intake during the first six months of lac-tation. This is about the equivalent of anextra meal and more than triple the esti-mated 200 kcal/day additional requirementduring pregnancy. In transitional societieswhere obesity is a problem among certainpopulations, women may need fewer addi-tional calories; however, they still require thesame high levels of micronutrients.

Mothers with adequate fat stores pro-duce milk higher in fat content; conse-quently, their infants need to suckle less toobtain sufficient energy. Both well-nour-ished and mildly malnourished womenproduce breastmilk of adequate quantityand high energy and protein quality. Defi-ciencies of some vitamins and mineralswill result in lower levels of these nutrientsin breastmilk (Prentice et al., 1994). Onlyunder extreme conditions, such as famine,are the protein and energy composition ofbreastmilk significantly affected (Perez-Escamilla, 1995). While most malnour-



ished women can breastfeed successfully,their own health and nutritional status canbe compromised if their nutritional storesare depleted to nourish their infants.Breastfeeding and maternal nutrition is thesubject of a separate LINKAGES publication(forthcoming).

Non-pregnant/non-lactating mothersNon-pregnant/non-lactating mothersNon-pregnant/non-lactating mothersNon-pregnant/non-lactating mothersNon-pregnant/non-lactating mothersshould allow an adequate period (atshould allow an adequate period (atshould allow an adequate period (atshould allow an adequate period (atshould allow an adequate period (atleast six months) between the cessationleast six months) between the cessationleast six months) between the cessationleast six months) between the cessationleast six months) between the cessationof lactation and the next pregnancy toof lactation and the next pregnancy toof lactation and the next pregnancy toof lactation and the next pregnancy toof lactation and the next pregnancy toreplace and build up energy andreplace and build up energy andreplace and build up energy andreplace and build up energy andreplace and build up energy andmicronutrient reservesmicronutrient reservesmicronutrient reservesmicronutrient reservesmicronutrient reserves

Overlap of lactation and pregnancy iscommon. Nearly half of the women stud-ied in the Philippines experienced overlap(Siega-Riz and Adair, 1993). In a study inGuatemala, more than 50 percent ofwomen breastfed during pregnancy, with asubstantial number (44 percent) breast-feeding into the second trimester (Mer-chant et al., 1991). Increasing birthintervals and allowing at least six monthsbetween the cessation of lactation and thenext pregnancy can help to replace andbuild up energy and micronutrient re-serves. Besides improving women’s im-mediate nutritional and health status,building up micronutrient and fat reservesbetween pregnancies can affect pregnancyoutcomes, as discussed earlier.

Improving Micronutrient Intake

At all times, At all times, At all times, At all times, At all times, adolescent girls and womenadolescent girls and womenadolescent girls and womenadolescent girls and womenadolescent girls and womenof reproductive ageof reproductive ageof reproductive ageof reproductive ageof reproductive age should diversify should diversify should diversify should diversify should diversifytheir diet to improve quality andtheir diet to improve quality andtheir diet to improve quality andtheir diet to improve quality andtheir diet to improve quality andmicronutrient intakemicronutrient intakemicronutrient intakemicronutrient intakemicronutrient intake

Micronutrient deficiencies contribute towomen’s undernutrition. They also accountfor maternal and childhood deaths, blind-ness, and mental retardation. Less severedeficiencies impair intelligence and reduceworking capacity and productivity. The twoprimary factors contributing to micronutri-ent deficiencies are inadequate intake ofmicronutrient-rich foods and inadequateutilization due to disease or some otherfactor in the diet. Inadequate consumptionmay be a result of cost, limited or sea-sonal availability of food, and inequitableintra-household distribution of food.LINKAGES’ efforts are concentrated on im-

proving variety in the family diet. Dietaryapproaches for improving micronutrient in-take include the following:

Increase daily consumption of fruitsand vegetables. Increased daily con-sumption of fruits and vegetables willimprove micronutrient status of vita-mins A, C, and B6, as well as calcium(National Research Council, 1989). In-creased vitamin C consumption fromfruits and vegetables will enhance theiron bioavailability from other foods.Consume animal products, if feasible.As noted earlier, animal products areexcellent sources of protein, fat, andmicronutrients. Many micronutrientsare more easily absorbed and/or uti-lized by the body than those found infruits and vegetables. The cost of ani-mal products, however, may limittheir consumption.Use fortified foods, such as vitamin A-fortified sugar, other vitamin A-fortifiedproducts, iron-enriched flour, vitamin-enriched flour, or other fortifiedstaples, when available.12 As stated ina World Bank publication (1994), “Suc-cessful fortification of a staple foodmay be one of the most equitablehealth interventions available—espe-cially if the slight cost of the additionalnutrients is absorbed by the govern-ment—because it reaches everyone,including the poor, pregnant womenand young children, populations thatsocial services can never cover com-pletely.”Use iodized salt. In some areas of theworld, nearly everyone is at risk of amicronutrient deficiency. This is thecase in areas where iodine is absentfrom the soil. Around 250 millionwomen suffer from iodine deficiency,increasing the chances of miscarriage,stillbirth, and prematurity. During theearly months of pregnancy, iodine de-ficiency can result in cretinism andmental retardation. Iodine deficiency isthe single most common cause ofmental retardation in the world. InBangladesh, infants of women withgoiter suffer twice as many neonataldeaths as infants of normal women.

Note 12Data from theUnited States illus-trate the impor-tance of fortificationeven for an industri-alized country. In1977 only 5 percentof women 19–51years of age met theRecommended Di-etary Allowance(RDA) for iron. Whenthe additional ironin fortified foods wasincluded, 12 percentmet the RDA (Popkinet al., 1996). The dif-ferences were evengreater for thiamin,riboflavin, and niacin(12 percent vs. 35percent, 27 percentvs. 43 percent, and34 percent vs. 52percent, respec-tively).

20

(PROFILES, 1993). The irreversibledamage resulting from iodine defi-ciency can be prevented by the intakeof minuscule amounts of iodine in io-dized salt.

If micronutrient requirements cannotIf micronutrient requirements cannotIf micronutrient requirements cannotIf micronutrient requirements cannotIf micronutrient requirements cannotbe met through available food sources,be met through available food sources,be met through available food sources,be met through available food sources,be met through available food sources,adolescent girls and women ofadolescent girls and women ofadolescent girls and women ofadolescent girls and women ofadolescent girls and women ofreproductive age reproductive age reproductive age reproductive age reproductive age may need to takemay need to takemay need to takemay need to takemay need to takesupplements containing iron, vitamin A,supplements containing iron, vitamin A,supplements containing iron, vitamin A,supplements containing iron, vitamin A,supplements containing iron, vitamin A,zinc, and other nutrients to build storeszinc, and other nutrients to build storeszinc, and other nutrients to build storeszinc, and other nutrients to build storeszinc, and other nutrients to build storesand improve women’s nutritional statusand improve women’s nutritional statusand improve women’s nutritional statusand improve women’s nutritional statusand improve women’s nutritional status

Some micronutrients are concentratedin a few foods. If a woman does not haveaccess to these foods, cannot afford them,or does not have a taste for them, micro-nutrient deficiencies are likely to occur un-less she eats fortified foods or takesmicronutrient supplements. Because oflow caloric intake and the limited numberof fortified foods, fortification may not re-sult in substantial increase in the propor-tion of women with adequate dietaryintakes.

Although pregnant women and, insome programs, postpartum women aregenerally the target populations for supple-mentation, these efforts are often too late,too short, or too limited to bring about thedesired improvements.

Micronutrient supplementation thatbegins during pregnancy is often toolate. Folic acid and iron illustrate theproblem of supplementation that be-gins in pregnancy.Folic Acid: Some defects in fetal devel-opment begin within the first fewweeks of pregnancy, before mostwomen start taking supplements(Perez-Escamilla, 1995). Recent evi-dence indicates that improving folatestatus prior to pregnancy reduces neu-ral tube defects (such as spina bifida).Defects must be prevented by the27th day of gestation when the poste-rior neural tube closes. This meansthat neural tube defects will occur be-fore a woman knows she is pregnantand begins taking prenatal supple-ments (Molinari, 1993). For this reasonthe United States Public Health Service

recommends that women of reproduc-tive age in the United States who arecapable of becoming pregnant take400 µg (0.4 mg) of folic acid dailythrough fortified foods and supple-ments.Iron: As mentioned earlier, in develop-ing countries iron deficiency is themost common micronutrient defi-ciency among women, resulting in ahigh prevalence of anemia. Duringearly adolescence, iron requirementsincrease as girls experience a growthspurt and the onset of menses. An es-timated 50 million pregnant and 320million non-pregnant women in devel-oping countries are anemic (Stoltzfus,1995). Anemia causes extreme fatigueand reduces physical activity, produc-tivity, and possibly a woman’s capac-ity to care for her children. Whileanemia can be cured by daily ironsupplementation throughout preg-nancy, building iron stores to reducethe less severe but important levels ofiron deficiency is difficult when supple-mentation is provided only duringpregnancy. Pre-pregnancy supplemen-tation, in addition to improving ironstores, can prevent poor birth out-comes (Klebanoff et al., 1991).The period of supplementation is of-ten too short. In endemic areas, vita-min A is another micronutrient thatmay require longer-term approachesto improving micronutrient status andbuilding stores. The Nepal Nutrition In-tervention Project-Surlahi II study(NNIPS-II) found that provision of vita-min A for at least three months priorto pregnancy and throughout preg-nancy was still associated with lowlevels of vitamin A in infants at sixmonths of age (West et al., 1997).A study in Bangladesh showed thatwhile supplementation of postpartumwomen with high-dose vitamin A wasassociated with improved breastmilkcontent at three months, high propor-tions of infants still had low vitamin Alevels. The increased vitamin A in thebreastmilk was unable to reverse vita-min A deficiency in many infants.



These infants probably were born withlow vitamin A stores because theirmothers were vitamin A-deficient dur-ing pregnancy (Rice et al., 1997).Limiting supplementation to one ortwo micronutrients diminishes effec-tiveness. Many women consume lowlevels of micronutrients and experi-ence multiple micronutrient deficien-cies throughout their reproductiveyears. Treating only one micronutrientdeficiency may be less effective in im-proving overall nutrient status becauseof the interactions among nutrients.Addressing multiple deficiencies priorto pregnancy and lactation will im-prove women’s current health and es-tablish reserves to draw on duringpregnancy and lactation.

The promotion of micronutrientsupplements first requires an understand-ing of the levels of nutrients that should beincluded in the supplement and then an as-sessment of the quality control of appropri-ate supplements. In some places multiplemicronutrient supplements, although avail-able, are not suitable. For that reason, it isnot yet appropriate to promote their wide-spread use unless adequacy and qualitycan be assured.

LINKAGES supports programs that pro-vide women with iron/folic acid tablets dur-ing pregnancy and a high-dose vitamin Acapsule soon after childbirth. At the same

time, LINKAGES is encouraging dialogue onthe potential for an appropriate multiple vi-tamin-mineral supplement for women andthe development of international standardsfor such a supplement.

The reader is referred to a separatepaper developed by LINKAGES, titled TheCase for Promoting Multiple Vitamin/MineralSupplements for Women in Developing Coun-tries (Huffman et al., 1998), for an exten-sive discussion of the role of multiplevitamin/mineral supplements.13

Pregnant womenPregnant womenPregnant womenPregnant womenPregnant women should take iron/folic should take iron/folic should take iron/folic should take iron/folic should take iron/folicacid tablets dailyacid tablets dailyacid tablets dailyacid tablets dailyacid tablets daily

The need for additional iron duringpregnancy is widely recognized. Iron re-quirements increase significantly duringthe second and third trimester of preg-nancy because of the growth of the fetusand placenta and expansion of themother’s blood volume. In the third tri-mester, about 300 mg of iron are trans-ferred from mother to fetus (WHO, 1994).

In developing countries, approximately40 percent of women of reproductive ageare anemic. During pregnancy the rate ofanemia rises to 50 percent in many coun-tries and much higher in some Asian coun-tries, as shown in Figure 4. Severe anemiaincreases the risk of hemorrhage duringchildbirth, with an estimated 20 percent ofmaternal deaths attributed to anemia(Ross and Thomas, 1996).

0

20

40

60

80

100 Figure 4.PregnancyAnemia Rates(hemoglobin <11mg/dl) inCountries withover 3 MillionBirths a Year

Note 13The LINKAGESProject believes thatit is important totest delivery strate-gies for micronutri-ent supplements.Along with Popula-tion Services Inter-national (PSI),LINKAGES is testingthe social marketingof a multiple-micro-nutrient supple-ment in Bolivia. Atthe same time,LINKAGES is promot-ing long-term solu-tions to improvingmicronutrient status,including dietary di-versity and con-sumption of fortifiedfoods.

India Pakistan Nigeria China Indonesia Bangladesh Brazil United States

Source: WHO, unpublished data (from surveys 1985–1990) reported in The Progress of Nations 1994.

83

74

6562 60

4237

17

Per

cen

tag

e

22

The recommended dosage for iron/folic acid during pregnancy is as follows:

Pregnant women should take a dailysupplement of iron/folic acid (60 mg ofiron and 250–400 µg folic acid) for sixmonths of pregnancy (or 120 mg ofiron/folic acid for three months ifwomen are not reached earlier)(Stoltzfus and Dreyfuss, 1998). Folicacid is included in the supplement be-cause it helps to prevent anemia andreduces the risk of obstetric complica-tions. Folic acid deficiency is known tocontribute to anemia in some parts ofIndia, western Africa, and Burma(Sloan et al., 1992).

Recent and current studies are helpingto define the impact of improving the sta-tus of other micronutrients on pregnantwomen and their infants. Box 4 illustratesthe potential impact of maternal deficien-cies in folic acid and iron, as well as iodine,vitamin A, and zinc on health outcomes ofmother and child.

Recent evidence suggests that in areaswhere iron deficiency exists, zinc defi-ciency is also common because zinc andiron are found in similar foods (animalproducts). Zinc deficiency during preg-nancy has been associated with an in-creased incidence of low birth weight,preterm delivery, prolonged labor, prema-

Box 4. Potential Impact of Micronutrient Deficienciesduring Pregnancy on Health Outcomes of Mother and Child

Deficiency Impact on pregnant woman Impact on fetus/infant

Folic acid Increases risk of anemia Increases risk of pre-term delivery, low birth weight, and neurological defects

Iodine Reduces physical capacity by Increases risk of spontaneous abor- causing lethargy and fatigue tions, stillbirths, impaired fetal brain Causes goiter development, infant deaths, cretin- Reduces mental capacity ism, and congenital abnormalities

Iron Increases risk of death from Increases chance of prematurity, low hemorrhage, spontaneous abor- birth weight, and infant mortality tion, stress of labor, and other Possibly lowers iron status in newborns delivery complications Reduces work capacity and

economic productivity Heightens fatigue and apathy Diminishes ability to fight infection

Vitamin A Impairs immune system; in- May increase risk of infant vitamin A creases severity of illness deficiency and reduce birth weight Increases risk of maternal death Increases risk of anemia in infants Increases risk of anemia Inhibits normal iron utilization Increases risks for some kinds of

infections Causes corneal disease, dry eyes,

and night blindness

Zinc Increases risk of prolonged labor, Increases risk of spontaneous abortion, intra- and postpartum hemor- low birth weight, intrauterine growth rhage,and hypertension retardation, prematurity, and deformities



ture rupture of the membranes, and ma-ternal lacerations (Caulfield, 1996). In astudy in Peru, 60 percent of women exhib-ited low zinc levels (Zavaleta et al., 1997).Studies in Guatemala, Nigeria, and Nepalalso report low intakes of zinc (less thantwo-thirds of the Recommended DietaryAllowances) (Gibson, 1994). As in the caseof iron, it is difficult to meet zinc require-ments during pregnancy through dietarysources, unless animal products are con-sumed or foods are fortified. This problemmay be addressed through a multiple vita-min-mineral supplement during pregnancy.

Pregnant women and their infantsmay also benefit from low-dosage vitaminA supplementation. High rates of vitamin Adeficiency during pregnancy have been re-ported in many developing countries. Insome areas, night blindness (an inability tosee in dim light or at dusk) is considered anormal condition of pregnancy, often de-veloping during the third trimester. Around10–20 percent of pregnant women in ruralSouth and Southeast Asia are estimated toexperience night blindness during preg-nancy. The extent of night blindness in Af-rica and Latin America is unknown (IVACG,1997).

In the Nepal Nutrition InterventionProject, women suffering from night blind-ness were more likely to be anemic andunderweight and at increased risk of infec-tions and death than those without symp-toms of night blindness (UNICEF, 1998).The results of the Nepal Nutrition Interven-tion Project showed that low-dose (23,300IU) weekly supplementation of vitamin Aor beta-carotene for at least three monthsprior to and during pregnancy lowered ma-ternal mortality by an average of 44 per-cent (West et al., 1997), reduced nightblindness by 38 percent in the vitamin Agroup and 16 percent in the beta-carotenegroup (UNICEF, 1998), and improved ironstatus among both pregnant and postpar-tum women (Stoltzfus et al., 1997). Basedon a study in Indonesia, Suharno et al.

(1993) estimate that about one-third of thehemoglobin decline during pregnancy inthe study population could be attributed tovitamin A deficiency. They estimate thatdaily low-level supplementation of vitaminA could eliminate anemia in one-fourth ofanemic women.

Lactating womenLactating womenLactating womenLactating womenLactating women should take a high- should take a high- should take a high- should take a high- should take a high-dose vitamin A capsule (200,000 IU) asdose vitamin A capsule (200,000 IU) asdose vitamin A capsule (200,000 IU) asdose vitamin A capsule (200,000 IU) asdose vitamin A capsule (200,000 IU) assoon after delivery as possible but nosoon after delivery as possible but nosoon after delivery as possible but nosoon after delivery as possible but nosoon after delivery as possible but nolater than eight weeks postpartum tolater than eight weeks postpartum tolater than eight weeks postpartum tolater than eight weeks postpartum tolater than eight weeks postpartum tobuild stores, improve breastmilkbuild stores, improve breastmilkbuild stores, improve breastmilkbuild stores, improve breastmilkbuild stores, improve breastmilkqualityqualityqualityqualityquality, and r, and r, and r, and r, and reduce maternal morbidityeduce maternal morbidityeduce maternal morbidityeduce maternal morbidityeduce maternal morbidity

Vitamin A supplementation of lactatingwomen was discussed in Chapter II as away of improving the vitamin A status ofinfants. A high-dose vitamin A capsule issafe during the first eight weeks postpar-tum and can help to improve breastmilkconcentrations and maternal stores. In arural low-lying area in Nepal, a study con-ducted in 1991 found that night blindnessoccurred in twice as many breastfeedingwomen as pregnant women (16 percentvs. 8 percent) (Katz et al., 1995).

In addition to vitamin A, maternal defi-ciencies in Group 1 nutrients (thiamin, ribo-flavin, iodine, selenium, B6, and B12) resultin lower concentrations in breastmilk andcan negatively affect infant health (Allen,1994). The micronutrient status of abreastfeeding woman and the concentra-tion of Group 1 micronutrients in herbreastmilk can be improved if she eatsmore fruits, vegetables, and animal prod-ucts; consumes fortified foods; and/ortakes a micronutrient supplement.

For Group 2 micronutrients (folic acid,vitamin D, calcium, iron, copper, and zinc),micronutrient supplementation has little ef-fect on breastmilk concentrations. Thesemicronutrients are maintained in thebreastmilk at the expense of the mother’sown stores. Improving the intake of Group2 micronutrients is more likely to benefitthe mother than the infant.

24

ConclusionThe premise of this paper is that nutri-

tional status reflects a cumulative process.In the case of severe malnutrition, the con-sequences are often immediate and obvi-ous. But in many cases, the consequencesof nutritional neglect may not be readilyapparent until they appear in the next gen-eration.

Nutritional deficiencies often begin be-fore birth and persist throughout life. Forthat reason, this paper recommends prac-tices from conception through the repro-ductive years. To some, therecommendations may seem simplistic:breastfeed, eat more, and eat better. How-ever, the following statistics testify to thechallenge of converting these recommen-dations into practices.

Exclusive breastfeeding rates in mostcountries are very low. It is estimatedthat approximately 1–2 million infantdeaths from diarrhea and acute respi-ratory diseases could be averted annu-ally if more women breastfedexclusively for about six months andcontinued breastfeeding through thefirst year or more (Huffman et al.,1991).

Poor maternal nutrition perpetuates acycle of malnutrition. Approximately19 percent of infants in developingcountries are born with low birthweight (WHO, 1992). As a result of io-dine deficiency in the maternal diet,around 28 million children are borneach year at some risk of mental im-pairment (UNICEF, 1997).Micronutrient deficiencies persist be-cause of inadequate intake of micronu-trient-rich foods and inadequateutilization due to disease or someother factor in the diet. WHO esti-mates that 183 million children (ex-cluding those in China) under fouryears of age are anemic. Between theages of 6 and 18 months, iron defi-ciency tends to peak (Lozoff, 1990).

Improving infant and maternal nutri-tion will require personal behaviorchanges, increased community recognitionand support for interventions to improvematernal nutrition, strategies for reachingyoung people and involving men, andgreater availability of quality health ser-vices.

Conclusion

25

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Caulfield L. Presentation at Zinc for Child HealthMeeting. Johns Hopkins University. Decem-ber 1996.

Caulfield L, Huffman SL, Piwoz E. Interventionsto improve complementary food intakes of6–12 month old infants in developingcountries: What have we been able to ac-complish? Paper prepared for theLINKAGES Project. Washington, DC, 1998.

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Cohen RJ, Landa Rivera L, Canahuati J, et al..Delaying the introduction of complemen-tary food until six months does not affectappetite or mother’s report of food accep-tance of breastfed infants from 6–12months in a low income Honduran popula-tion. Journal of Nutrition 1995; 125: 2787–92.

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Summary List ofRecommended ReadingsCaulfield L, Huffman SL, Piwoz E. Interventions

to improve complementary food intakes of6–12 month old infants in developingcountries: What have we been able to ac-complish? Paper prepared for theLINKAGES Project. Washington, DC, 1998.

Dickin K, Griffiths M, Piwoz E. Designing by dia-logue: A program planner’s guide to consul-tative research to improve young childfeeding. Washington DC: Academy for Edu-cational Development, 1997.

Green CP. Improving breastfeeding behaviors:Evidence from two decades of interventionresearch. Paper prepared for the LINKAGESProject. Washington, DC: Academy for Edu-cational Development, Forthcoming.

Huffman SL, Baker J, Shumann J, Zehner ER.The case for promoting multiple vitamin/mineral supplements for women in devel-oping countries. Paper prepared for theLINKAGES Project. Washington, DC: Acad-emy for Educational Development, 1998.

Labbok M, Cooney K, Coly S. Guidelines:breastfeeding, family planning, and theLactational Amenorrhea Method—LAM.Washington, DC: Institute for ReproductiveHealth, 1994.

LINKAGES. Frequently asked questions onbreastfeeding and HIV/AIDS. Washington,DC: Academy for Educational Develop-ment, 1998.

LINKAGES. Frequently asked questions onbreastfeeding and maternal nutrition.Washington, DC. Academy for EducationalDevelopment, forthcoming.

LINKAGES. Facts for feeding on maternal foodsupplementation, forthcoming.

Lutter C. Quantifying the benefits of breastfeed-ing: An annotated bibliography. Preparedfor the LINKAGES Project. Washington, DC:Academy for Educational Development,1998.

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26

duction of complementary foods on infantbreast milk intake, total energy intake, andgrowth: a randomized intervention study inHonduras. Lancet 1994; 344:288–93.

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Recommended Feeding and Dietary Practices to Improve ... · Recommended Feeding and Dietary Practices to Improve Infant and Maternal Nutrition is a publication of the LINKAGES (Breastfeeding,