of INFANT NUTRITION

FOR OPTIMUM

GROWTH and DEVELOPMENT

Presented By: Dr. Sai Kiran Dalai

Pediatric speciality, DHH
Jharsuguda, Odisha-768201
ABCDS INFLUENCING INFANT
NUTRITION
Anthropometric assessment

β-Palmitate Science

Constipation and gut health

Dietary red flags to watch

out
ANTHROPOMETRIC
ASSESSMENT
High prevalence of stunting, underweight and wasting: Influencing the
need for anthropometric assessment

The minimum incidence of stunting in Indian children <5 years of

age is reported to be 25.1%

The minimum incidence of underweight in Indian children <5 years

of age reported at 13.5%

The minimum prevalence of wasted children (<5 years of age) in

India was 10%

Rural areas of Gujrat, Meghalaya, Bihar

and DNH & DD have reported incidence of
>40% of children (<5 years of age) with
stunted growth & are underweight

Fact Sheets: Key Indicators (22 STATE,S,/UTs FROM PHASE I) . [Internet]. [cited 2021 Feb 28] Available from:http://rchiips.org/nfhs/factsheet_NFHS-5.shtml
 Need for anthropometric assessment: Triple burden of malnutrition
NFHS-5 data reflected that there was an increase in the number of overweight and obese children between
the 2015-16 and 2019-20, these being components of what is termed as triple burden of malnutrition
(overweight, obesity and micronutrient deficiency)1

The prevalence of overweight/obesity is high as Micronutrient deficiency is a major health

most states/union territories had reported 1 of
problem in the country, with anaemia
every 5 persons obese as per the recent NFHS
affecting almost 50% - 60% of the
data.2
population.3
Andaman and Nicobar
Islands report the highest
prevalence of
overweight/obesity (45.3%
in men and 38.1% in
women), followed by
Lakshadweep, Kerala and
Goa

NFHS: Nat ional Family Health Survey

Nutritional assessment and Anthropometry: An introduction

Nutritional assessment is the interpretation of

data to determine whether a person or group of
people are well-nourished or malnourished
(over-nourished or malnourished).1
The Bright Futures/AAP Periodicity
Schedule recommends that for infants
Anthropometry is the measurement of physical <2 years of age, anthropometric
dimensions such as height or weight, as well as measurements (weight, length, head
circumference, and plot of
fat mass composition of the human body to
weight/length) be obtained at each
provide information about a person’s visit to the healthcare facility.2
nutritional status.1

AAP: American Academy of Pediatrics.

1. Nut rition Module: 5. Nut ritional Assessment. [Internet]. [cited 2021 Feb 23] Available from:https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=318&printable=1
2. ANTHROPOMETRIC MEASUREMENTS. [Internet]. 2020 [cited 2021 Feb 19] Available from: https://www.dhcs.ca.gov/services/chdp/Documents/HAG/4AnthropometricMeasure.pdf.
Commonly used anthropometric assessment in children
A series of quantitative measurements of the muscle, bone, and adipose tissue used to assess the
composition of the body.

Height Weight Body mass index (BMI)

Body circumferences
Skinfold thickness
(head, waist, hip, and
limbs)

Casadei K, Kiel J. Anthropometric Measurement. [Internet]. 2020 [cited 2021 Feb 18] Available from: ht tps://www.ncbi.nlm.nih.gov/books/NBK537315/
 Clinical significance of anthropometric assessment

In infants, indications for anthropometric assessment include stunting, wasting, and being
underweight.1

BMI is an index of nutritional status and used as a gauge of malnutrition in

infants.1

• Abnormal linear growth or weight gain can indicate a variety of medical,

psychological, or socioeconomic problems.2
• For infants, measuring the head circumference helps in identifying
microcephaly.1
• The lengths of extremities are related to chronic diseases, shorter upper leg
length associated with high prevalence of metabolic syndrome, while those
with short upper arm length have shown higher prevalence of diabetes. 1
BMI: Body mass index.
 Clinical significance of anthropometric assessment (Cont.)

Index Cut-off value based on standard deviation (SD)/percentage What it indicates?

Weight for age Less than –2 and more than –3 Moderate underweight

Weight for age Less than –3 Severe underweight

Moderate acute malnutrition
Height for age Less than –2 and more than –3 (i.e., 70–79.99% of the norm
(MAM)
Less than –3 (i.e., less than 70% of the norm) and/or bilateral Severe acute malnutrition
Height for age
pitting edema (SAM)

An indicator is an index combined with

Indicators which can help in determining
specific cut-off values that help in
the nutritional status include weight for age
determining whether a child is underweight
and height for age.3
or malnourished.3

BMI: Body mass index

1 Casadei K, Kiel J. Anthropometric Measurement. [Internet]. 2020 [cited 2021 Feb 18] Available from: ht tps://www.ncbi.nlm.nih.gov/books/NBK537315/
2. ANTHROPOMETRIC MEASUREMENTS. [Internet]. 2020 [cited 2021 Feb 19] Available from: https://www.dhcs.ca.gov/services/chdp/Documents/HAG/4AnthropometricMeasure.pdf.
3. Nut rition Module: 5. Nut ritional Assessment. [Internet]. [cited 2021 Feb 23] Available from:https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=318&printable=1
Clinical significance of anthropometric assessment: Measurement of
muscle or
fat-free mass (Cont.)
An accurate way to measure fat-free mass is to measure the mid upper arm circumference (MUAC)
midway between the shoulder tip and the elbow tip on the left arm. A low MUAC indicates loss of muscle
mass.

MUAC is a good screening tool in determining the risk of mortality among children [Figure 1].

The tape has three colors, with the red indicating severe acute malnutrition, the yellow indicating moderate
acute malnutrition, and the green indicating normal nutritional status.

Figure 1: MUAC measuring tape

Nut rition Module: 5. Nut ritional Assessment. [Internet]. [cited 2021 Feb 23] Available from:https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=318&printable=1
Considerations demanding follow-up

Short stature
Abnormal head circumference Infants and toddlers with a length-for-
An abnormal head growth is age that is <2nd percentile on the WHO
defined as head circumference growth charts are classified as having
>98% or <2% the mean for a given short stature. Further assessment is
age and gender. required when infants have
inadequate linear growth velocity.

Underweight
Infants and toddlers with a weight
for length that is <2nd percentile on Overweight
the WHO growth charts are Infants and toddlers with a weight for
classified as low weight for length. length that is > 98th percentile are
classified as high weight for length.
Inadequate weight gain
Infants and toddlers with poor
weight gain velocity require
additional assessment and should
be monitored closely.

ANTHROPOMETRIC MEASUREMENTS. [Internet]. 2020 [cited 2021 Feb 19] Available from: https://www.dhcs.ca.gov/services/chdp/Documents/HAG/4AnthropometricMeasure.pdf.
 What is your take?

How does stunting affect development of a child?

Nut rition Module: 5. Nut ritional Assessment. [Internet]. [cited 2021 Feb 23] Available from:https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=318&printable=1
β-Palmitate science- A
special focus on lipids
 LIPIDS: THE UNSUNG HERO OF INFANT NUTRITION

Role of lipids
in infant Lipids in human breast milk (HBM)
growth,
developme
nt, and
health:1
1%
4%
HBM composition2 Energy supply to
Modulate gastrointestinal function
infants through HBM2
7% 60% 50%
50% 40%
40%
Lipoprotein metabolism 30%
20% 10%
10%
0%
Membrane composition and 88%
function

Water Carbohydrates Proteins Fats

Signaling pathways

1. Delplanque B, Gibson R, Kolet zko B, Lapillonne A, St randvik B. Lipid Quality in Infant Nutrition: Current Knowledge and Fut ure Opportunities. J Pediatr Gastroenterol Nutr. 2015 Jul;61
2. Kim SY, Yi DY. Components of human breast milk: from macronutrient t o microbiome and microRNA. Clin Exp Pediatr. 2020 Mar 23;63(8):301–9.(1):8-17.
 WHY ALA AND LA ARE IMPORTANT FOR INFANT DEVELOPMENT?

α -linolenic acid (ALA) and

ALA represents as a precursor of
linoleic acid (LA) are essential
DHA that is essential for a proper
for the proper growth and
brain development of infants. 2
development of children.1

Furthermore, LA and ALA are

precursors for AA and EPA that
are important for the modulation Therefore, LA and ALA should be
on blood pressure, vascular provided in proper quantities
reactivity, inflammation, platelet and proportions.2
aggregation, immune function,
allergy and cytokine release.3

1. Bresson et al. ALA and LA and growth and development of children. The EFSA Journal. 2008:783:1-9
2. Delplanque B, Du Q, M artin J, et al. Lipids for infant formulas. OCL. 2018; 25(3), D305.
3. Uauy R, Castillo C. Lipid requirements of infants: implications for nutrient composition of fortified complementary foods. J Nutr. 2003 Sep;133(9):2962S-72S
 ALA AND LA AS PRECURSORS OF AA AND EPA SYNTHESIS

Linoleic acid Arachidonic acid Eicosapentaentaenoic acid α- Linolenic acid

n-6 PUFA n-3 PUFA

Membrane phospholipids

Arachidonic acid and

eicosapentaenoic acid

Prostaglandins Prostacyclin Thromboxane Leukotrienes

Inflammation Immune Thrombosis Bronchoconstriction
Cytokines response Bronchoconstrict Chemotaxis
Vascular ion Inflammation
reactivity

Uauy R, Castillo C. Lipid requirements of infants: implications for nutrient composition of fortified complementary foods. J Nutr. 2003 Sep;133(9):2962S-72S
 COMPONENTS OF BREAST MILK FAT1,2

Milk fat globule

Breast membrane
Phospholipid bilayer
milk (0.26%–0.8%)

Triglycerides

(98.1%–98.8%)
Saturated fatty acid content in HBM 1
Colostrum Transitional Mature
Caprylic acid (C8:0) 0.07–0.19 0.2–0.31 0.2–0.3

Capric acid (C10:0) 0.5–1.04 1.2–1.6 1.5–1.8 Human breast milk contains 70–
75% of palmitic acid, which is
Lauric acid (C12:0) 2.8–3.5 5.4–6.6 5.7–6.5
esterified at the sn-2 position of
Myristic acid (C14:0) 5.4–6.0 6.6–7.5 6.5–7.1 the triglycerides (β-palmitate).
Palmitic acid (C16:0) 24.3–25.5 21.9–23.3 21.7–22.7
Stearic acid (C18:0) 6.2–6.6 6.1–6.7 6.3–6.6
Arachidic acid
0.19–0.25 0.20–0.32 0.20–0.26
(C20:0)
 Factors influencing the composition of milk fat globules in breast milk1

1. Lee H, Padhi E, Hasegawa Y, et al. Compositional Dynamics of t he Milk Fat Globule and Its Role in Infant Development. Frontiers in Pediatr ics. 2018;6:313.
 Β-PALMITATE IN SCIENTIFIC FEEDS
Hydrolysis of unsaturated fatty acids at sn-1 and sn-3 positions

UFA UFA
Triglyceride

Glycerol
Palmitic acid Palmitic acid
Ca Ca
UFA
UFA cannot form complex with
Hydrolysis by pancreatic lipase calcium β-Palmitate gets absorbed
(calcium gets absorbed)
Hydrolysis of palmitic acid at sn-1 and sn-3 positions

Palmitic acid
Ca
Triglyceride

Palmitic acid
Loss of calcium and
UFA palmitic acid
Palmitic acid Ca
Palmitic acid
Low availability of calcium and
Hydrolysis by pancreatic Formation of insoluble calcium palmitic acid
soap
UFA: Unsat urated fatty acid. lipase

Bronsky J, Campoy C, Emblet on N, et al. Palm Oil and Bet a-palmitate in Infant Formula: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and
Nut rition (ESPGHAN) Committee on Nut rition. J Pediatr Gastroenterol Nutr. 2019 May;68(5):742-760.
 WHY NOT COW’S MILK? 1,2
Component Human milk Cow milk Impact of household milk boiling practices
Calories (kcal/L) 747 701
Protein (g/100 mL) 1.1 2.8
Casein 3.7 25.0
Boiling of milk Loss of nutrients
Fat (g/1,000 mL) 4.5 4.4
Cholesterol (mg/L) 139 120 Heating of
Decrease in milk for 15
Carbohydrate (g/1,000 mL) 6.8 4.7 min has Reduction in
the
been vitamins B2 ,
concentrati
reported to B3 , B12, and
Calcium (mg/dL) 34 118 on of fat-
folic acid
soluble result in 24%
Phosphorus (mg/dL) 14 93 vit amin A losses of
Calcium/phosphorus ratio 2.4:1 1.3:1 vitamin B12
Loss of fat -
Reduction soluble
Sodium (g/dL) 0.512 (7 mL Eq/L) 0.768 g/L in vitamins vitamin D
B2 , B3 , B12, due to
and folic
Vitamin D 4–40 IU/L 47–100 IU acid
intermittent
boiling and
Vitamin K 0.9–6.9 mg/L 19 mg/L storage

Microwave heating of milk has been reported to cause 30–

• Has a high a solute load
• High casein – Difficult to digest
40% losses in vitamin content of the bovine milk
• High amount of sodium and phosphorus
 Benefits of β-Palmitate in infants

Improved
comfort
Less
crying

Night Softer
Sleep Stools

Fat
Absorptio Healthy
n Gut
calcium Bacteria
intake
Healthy Bone Intestinal
Growth Enhanced
Strength Health Immunity

Havlicekova Z, Jesenak M, Banovcin P, et al. Bet a-palmitate - a natural component of human milk in supplemental milk formulas. Nutr J. 2016 Mar 17;15:28
WHAT IS YOUR TAKE?

What are the implications of low fat in infant’s growth and development?
Constipation and gut health
STOOL COLOR AND FREQUENCY: IMPORTANT INDICATORS OF AN INFANT’S
HEALTH
Average stool frequency of Indian
children

Age Frequency of
defecation
<1 month 3–4 times/day
1 month to 1 year 1.5–2 times/day
1–2 years 1–2 times/day
Older than 2 years 1 time/day
Yachha SK, et al. Indian Pediatr. 2018;55(10):8

Sissons C. Baby poop color: Causes and when to see a doctor [Internet]. 2019 [cited 2021 Feb 15]. Available from: https://www.medicalnewstoday.com/articles/327218.
CONSTIPATION: A GROWING CONCERN IN INDIAN INFANTS

 Childhood functional constipation is a common problem worldwide with

estimated prevalence of about 3%.1
 In India, the incidence of functional constipation is found to be approximately
30%.2,3

Definition of Constipation in Indian children4

Presence of ≥2 of the following symptoms:

Duration of more
than 4 weeks for all
ages
• Defecation frequency
• Fecal incontinence
• History of excessive stool retention
• History of painful or hard bowel movements
1. Poddar U. Indian Pediatr. 2016;53(4):319-27.
• Presence of a large mass in or on the rectum 2. Vishal, et al. International Journal of
Cont emporary Medical Research. 2018;5(10).
3. Kondapalli CS, et al. Int J Contemp Pediatr.
2018;5(1):6-13.
4. Yachha SK, et al. Indian Pediatr.
2018;55(10):885-92.
FACTORS CONTRIBUTING TO FUNCTIONAL CONSTIPATION

Premature initiation of Drugs and inter- Quick and abrupt transition Change in local
toilet training current illnesses of diet e.g., liquid to solid, environment (start of
breastfeeding to bottle schooling) and
feeding psychosocial factors

Evaluation of constipation

Red flags indicative of

organic constipation:
• Delayed passage of
meconium
• Onset in early infancy
Dietary history Clinical features Examination • Ribbon or pellet stools
✓ Detailed dietary history ✓ Age at onset of ✓ Thorough • Bilious vomiting, etc.
should be taken constipation examination should
✓ Stool be conducted to rule
characteristics out an organic
etiology

Yachha SK, et al. Indian Pediatr. 2018;55(10):885-92.

WHAT IS YOUR TAKE?

How do you differentiate functional constipation in infants in your clinical practice?

HOW DOES 100% LACTOSE PREVENT CONSTIPATION?

Lactose contributes to a major part of the energy intake of

healthy, breast fed infant s.1

It induces a prebiotic effect on the gut microbiota and positive

impact on mineral absorption in infants.1

It has the potential to attract water into the intestinal

lumen and produce an osmotic laxative effect.2

It is also found that the intestinal absorption of

elements, calcium and magnesium was reduced in
infants given lactose-free milk.3

1. Grenov B, et al. Food Nut r Bull. 2016;37(1):85-99.

It enhanced calcium and magnesium levels in infants who
2. Kesavelu D, et al. Clin Epidemiol Glob Health. 2018; 6(1):5-9. were given proprietary milk containing lactose and lactase.3
3. Kobayashi A, et al. Am J Clin Nut r. 1975;28(7):681-3.
 Dietary red flags to
watch out in children
 DIETARY RED FLAGS – 0-6 MONTHS

0–6
Consumes water, juice, herbal teas or months
other liquids

Consumes cow’s or goat’s milk, plant-

based beverages (soy, rice, almond),
Introduces complementary foods too evaporated milk or homemade
early (before infant is showing signs of formula
developmental readiness), including
adding cereal to a bottle

Aqui C, At kinson L, Cardinal M, et al. Pediatric Nutrition Guidelines (Birth t o Six Years) for Health Professionals. Ontario Dietitians in Public Health (ODPH) –
Family Healt h Nutrition Advisory Group. 2019
 DIETARY RED FLAGS – 6-12 MONTHS

Consumes cow’s or goat’s milk or plant-

based beverages (soy, rice, almond) as
6–12 months Does not consume iron-rich foods
main milk source daily

By 9 months, lumpy textures have not Consumes fruit juice, fruit drinks/punch,
been introduced or consumed sports drinks, pop or beverages containing
artificial sweeteners or caffeine (coffee,
tea, hot chocolate)

Consumes > 750 mL (24 oz) of cow’s or

Consumes raw or unpasteurized milk or goat’s milk a day by the age of 9-12
milk products or unpasteurized juice months

Aqui C, At kinson L, Cardinal M, et al. Pediatric Nutrition Guidelines (Birth t o Six Years) for Health Professionals. Ontario Dietitians in Public Health (ODPH) – Family Health Nutrition Advisory
 DIETARY RED FLAGS – 12-24 MONTHS

Does not eat a variety of textures and

family foods including iron-rich foods 12–24 months Dietary fat intake is
each day restricted

Consumes skim or partly skimmed (2% or

1% M.F.) cow’s or goat’s milk or plant-
based beverages (soy, rice, almond) as
main milk source Consumes fruit drinks/punch, sports
drinks, pop or beverages containing
artificial sweeteners or caffeine
Consumes raw or unpasteurized milk or milk (coffee, tea, hot chocolate)
products or unpasteurized juice

Consumes > 750 mL (24 oz) cow’s or

Consuming beverages in excessive goat’s milk a day and/or > 175 mL (6 oz)
amounts displaces complementary of juice a day
foods

Aqui C, At kinson L, Cardinal M, et al. Pediatric Nutrition Guidelines (Birth t o Six Years) for Health Professionals. Ontario Dietitians in Public Health (ODPH) – Family Health Nutrition Advisory
COMMON NUTRITIONAL DEFICIENCIES IN INDIAN INFANTS

Calcium and vitamin D 2

Affect bone
Leads to Iron, vitamin B12, folate, and health2
anemia1 ferritin deficiency1

Zinc1

Affects growth and

immune function3
Vitamin A deficiency1
Leads to nutritional
1. Gonmei Z, Tot eja GS. Micronutrient status of Indian population. Indian J Med Res. 2018;148(5):511-
blindness1 521.
2. From Indian Academy of Pediatrics ‘Guideline for Vitamin D and Calcium in Children’ Committee.,
Khadilkar A, Khadilkar V, et al. Prevention and Treatment of Vit amin D and Calcium Deficiency in
Children and Adolescents: Indian Academy of Pediatrics (IAP) Guidelines. Indian Pediatr. 2017 Jul
15;54(7):567-573.
3. Dror DK, Allen LH. Overview of Nut rients in Human Milk.Adv Nutr. 2018;9(suppl_1):278S-294S.
WHAT IS YOUR TAKE?

What are the current recommendations for the prevention of nutrition

deficiencies in infants?
THANK YOU!