Infant feeding

and
nutritional assessment
Content overview
 Infant feeding  Nutritional assessment
 Introduction  Definition
 Feeding behavior  Anthropometric
 Feeding in the 1st 6 months assessment
of life  Biochemical (biophysical)
 Feeding in the 2nd 6 method
months of life  Clinical Methods
 Problems associated with  Datary survey
feeding
 Statistics of breastfeeding
in Ethiopia
Introduction
Infancy- the period from 0month- 12month
This period is vital for the children because they are at
high risk of nutritional deficiency and growth
retardation.
The establishment of feeding practices that are
comfortable and satisfying for both the parents and
the infant is crucial not only for the emotional well-
being of both but also for ensuring adequate nutrient
intakes for the infant.
 
More growth occurs during the first year than at any
other time in a child's life.
 For the first few months, breast milk or formula is all
that is needed.
 As the baby grows, starting a variety of healthy foods
at the proper time is important for proper growth and
development.
 And, starting good eating habits at this early stage will
help set healthy eating patterns for life.
Feeding behaviour
One of the 1st decisions a new or expectant mother must
make—ideally, some time before the infant is born—is
whether the infant will be breast-fed or formula-fed.
Feedings should be initiated as soon after birth as
possible, depending on the infant's ability to tolerate
enteral nutrition.
 This helps maintain normal metabolism during the
transition from fetal to extrauterine life.
 Most infants can start breast-feeding immediately after
birth, almost always within 1–4 hr.
Most infants will have established a suitable and
reasonably regular schedule by 1 mo of age.

By the end of the 1st wk of life, most healthy infants

will be taking 60–90 mL/feeding and want 6–9
feedings/24 hr.

Feeding can be considered to have progressed

satisfactorily if the infant is no longer losing weight by
the end of the 1st wk of life and is gaining weight by the
end of the 2nd wk.
 Most infants will wake for a middle-of-the-night
feeding until 3–6 wk of age.

 Between 4–8 mo of age, many infants will lose interest

in the late evening feeding and, by 9–12 mo of age,
most will be satisfied with 3 meals/day plus snacks. All
infants do not conform to these general guidelines.
 FEEDING DURING THE 1ST
6 MONTH OF LIFE

Exclusive Breast feeding or formula feeding is the best

nutritional supply for infants at this age.
Breastfeeding
Colostrum and mature milk
colostrum mature milk
comparisson
colostrum Mature milk
 First milk (late pregnancy to 4-6 After 4-6 days pp
days)
Low fat ,CHO and potassium High fat CHO and
High protein potassium
It has a mild laxative effect Low protein: lactalbumin
contain immunoglobulin such as
IgA, IgG, and IgM in mammals Dochosahexaeonic acid
High amount of vitamin A, and (DHA) : Tissue in brain
sodium chloride devt
Contains cytokines and growth
hormones. Contain lactose Iron and
Lactobacillus bifidus VIT.D
Brast milk composition
In one nursing the breast produces three type of milk
Fore milk- 60% of the total volume
- resemble skim milk
Hind milk- 35% of the total volume
- similar to whole milk
Final milk- like cream
- high fat content
Advantages of breast feeding
It is the best natural food for babies with the best
combination of:-
 Sugar
 Fat
 Proteins
 Minerals
 Vitamins
 Bacterial and viral antibodies, IgA
 Lactoferrin- 1/3 saturated
 Etc…
Continued…
It is easy to digest and it is well absorbed
Provide the infant with adequate supply of water
Clean and available for 24 hours a day.
It creates bonding b/n Mum and baby
It protects against allergy
It provides an efficient contraceptive method for
the first six months.
It reduce the risk of PPH
It prevents breast engorgement and its
consequence.
Cases when breast milk is considered
disadvantageous
Unknown intake
Transmission of infection
CMV, hepatitis, HIV, TB
Transmission of drugs- antithyroid , anticancer
Nutritional inadequacies- prolonged BF without
introduction of solids lead to poor weight gain and
rickets
Vitamin k deficiency -hemorrgic disease of newborn
Mothers preparation for breast feeding
The physician who is interested in helping the
prospective mother breast-feed successfully should
discuss the advantages of breast-feeding with her as
early as the mid-trimester of pregnancy or whenever
the mother begins planning for her infant.   
Provide all pregnant women with information and
counseling.  
Recommended breastfeeding practice
 Good breastfeeding skills must be attained by the
mother. Proper position of the baby on the breast is
important:
 Position
Infants head and body must be straight
Facing the breast
Infants body closer to mums body
Mum should support the whole body

  
Attachment
More of the areola is visible above the
babies upper lip than below the lower
lip
Baby's mouth is wide open
Baby's chin touches the breast
The lower lip is turned outward
Expression of milk if needed
Assessment of the infant's nutritional status
Exclusive breastfeeding for 6 months
Refer to lactation consultation if any concerns arise.
Infants should go to the breast at least 8–12 times/24 hr, day
and night. There should be frequent on demand feeding
Avoid time limits on the breasts; offer both breasts at each
feeding.
Do not give sterile water, glucose, or formula unless
indicated.
Breastfeeding should increase in frequency if the infant is ill

  
The mother should be adviced on:
A. HYGIENE
B. MATERNAL DIET
C. DRUG INTAKE
D. TECHNIQUE OF BREAST-FEEDING
E. DETERMINING THE ADEQUACY OF MILK
SUPPLY
F. EXPRESSION OF BREAST MILK
G. FREQUENCY AND FEEDING CUES
COMMON PROBLEMS OF BREASTFEEDING
1. Retracted nipple:

this is a condition that is mostly noted at time of

pregnancy. It is not a total contraindication.
the solution is: daily manual breast-pump suction
during the latter weeks of pregnancy.
inverted nipples may be helped by the use of milk
cups, starting as early as the 3rd month of pregnancy
Continued…
2. Sore nipple:
 This conditions are caused by wrong attachment of
baby’s mouth or from candidiasis
 The solution for these is:
 Exposing the nipples to air,
 Avoiding soap and other drying agents
 changing disposable nursing pads frequently
 nursing more often
 Treating the candidiasis
 nursing in different positions, and keeping the breast
dry
Continued…
3. Mastitis and abscess:
 These are caused by- cracks, untreated ductal
obstruction, engorgement
 Treat by- antibiotics and drainage of the abscess
- breast hygiene
-treat obstructed ducts and breast engorgement
Continued…
4. Poor production of milk:
 Three possibilities should be excluded before assuming
that a mother cannot produce sufficient milk:
(1) errors in the feeding technique;
(2) remediable maternal factors related to diet, rest, or
emotional distress;
(3) physical disturbances of the infant that interfere with
nursing or weight gain.
If the above are ruled out: the mother should
 increase frequency and properly position the child
Formula feeding
Formula feeding
Sometimes it is better for the mother to choose other
methods of feeding when mother has:
HIV or active tuberculosis,
Drugs , alcohol intake, or who have a history of
these situations,
Mood stabilizers and migraine medicines
All marketed formulas must contain minimum
amounts of all nutrients known or thought to be
required by infants, and increasing emphasis is
being placed on not exceeding a reasonable
maximum content of each nutrient.
It is rarely necessary to feed more than 1 qt (960
mL) of formula/day.
Techniques of Formula Feeding
The setting should be similar to that of BF
 Mothers position
 Infants position
 Infant should be hungry , fully awake, warm and dry.
 Should be held as though being BF
 Bottle milk should be warmed to body temp.
FEEDING DURING THE 2nd 6 MO OF
LIFE
Complementary feeding
These is started after 6 month. But this does not mean
that the mother should stop breastfeeding.
The food must contain:
High in energy
Good in variety
Easy to digest and clean
Inexpensive
Recommended quality and quantity
 2-3 meals per day at 6-8 month
 3-4 meals per day at 9-12 month + 1-2 snacks
 3-4 meals per day at 12-24 month + 2 snacks
 we must also diversify the food as the child grows
and increase its content
 the mother should actively feed her child
 There should also be IRON and VIT.A supplement.
Cow's milk
It is recommended to avoid intake of bovine milk
before at least one year of age.
Infants fed bovine milk on average ingest roughly
 3x recommended intake of protein
 50% more sodium than the upper limit of the safe range.
 2/3rd of recommended intake of Fe
 ½ of the recommended intake of lenoleic acid
 Fat which is not digestible by young infant
 Contains many allergenic proteins
 Composition of different milks
Energy Protein Fat (g/L) Carbohy Mineral
(Kcal/L) (g/L) drate (g/L)
(g/L)
Human milk 750 11 45 70 2

Cow milk whole 670 36 36 49 7

Cow milk skim 360 36 1 51 7

Casien/whey based 670 14-16 34-36 72 3

formula

Soybean-protien based 670 16-20 36 67 4

formula

Predigested protein 670 18 26-37 68-89 1

Transition formula 670 17 or 25 33 75 3

Problems encountered at time of infant feeding
Under feeding
 Suggested by restlessness,
 Crying
 Failure to thrive

Its treatment depends on accurate identification of the

cause
Inadequate dietary intake---most common
Diet restriction
Over Feeding
Regurgitation and vomiting are the most frequent
symptoms
Regurgitation – less forceful, natural
Vomiting - emptying of stomach, more pathological
Stool of breast fed infants is naturally softer
 Causes
Use of laxatives or ingestion of certain foods by the mother
Excessive intake of breast milk
Constipation is uncommon
 COLIC
COLIC
- The etiology usually is not apparent, but in some
infants, the attacks seem to be associated with
hunger or with swallowed air that has passed into
the intestine.
manifestation - paroxysmal abdominal pain
- severe crying
Breastfeeding in Ethiopia
In Ethiopia breast feeding are suboptimal
 According to 2000 DHS survey
54% are exclusively breastfed
57% b/n 6 and 9 month are sub-optimally fed
24% of infant death are due to poor breast feeding
Infant feeding and HIV
Breast feeding transmission is associated with:
 High maternal plasma HIV viral load
 Low maternal CD4 count
 Duration of breastfeeding
 Mastitis
 Acute maternal HIV infection
Risk of transmission
Early antenatal + antenatal = 5-10%
Labor and delivery = 10-20%
Postnatal by breastfeeding = 25-50%
 So it is better to use supplement than breastfeeding in this
patients. But the replacement should be:
 (dr. abady--- breast feeding---5 – 20%
 Overall without bf—15—30
 EBF for 6 mo—25-35
 Bf for 18 to 24 months ---30--45
 AFASS CRITREIA
Acceptable
Feasible
Affordable
Sustainable
Safe
If the mother chooses to breastfeed then there
are option:
1.Option one (safe BF)
exclusive BF & avoid complementary mixing
 stop BF as soon as complementary feeding is
acceptable
maintain breast health
Stop BF from infected breast
2.ption two ( wet nursing)
3.option three
heat treated breast milk- within 1hr
4.option (mother choice not to BF)
- exclusive replacement feeding(don’t mix)
-hygienic preparation
if cow’s milk is used for artificial
.1st 15day= dilute by 50%
.2wks-6month= 2:1
.after 6 month undiluted
Nutritional assessment
Definition
 Is an interpretation of the anthropometric,
biochemical( laboratory), clinical and dietary survey
data to determine the nutritional status of an
individual or group of people
 Is the primary step in the evaluation of chilidren
growth and should be linked with evaluation and
management of children with acute and chronic
disease
Cont…
 Includes collection of nutritional data
using the ABCD method
Anthropometric method
Biochemical method
Clinical method
Dietary method
Anthropometric assessment
Definition.
 Anthropometry came from two words:
Anthropo = human
metry = measurement.
 Measurement of variation of physical dimension and
gross composition of human body at different levels &
degrees of nutrition.
 Used in - clinical
- field set ups
Choice of anthropometric measurements
Depends on
 The purpose of making the measurement
Anthropometric measurements to assess growth and degree
of nutrition
Anthropometric measurements to assess body composition
 Target population supposed to be measured
Anthropometric measurements of growth
and degree of nutrition
Length or height
 Length or stature is the most useful indicator of growth
status.
 In infants and children younger than 2 years the
measurement length is used
 The requirements to perform this measurement :
Two people
Measuring table or board
 movable board
Fixed tape meter
Proper skill of measurement
Cont…
Height
 Is measured for children older than 2 years.
 The requirements to perform this measurement:
Measurement must be made with the child feet bare
The child should stand erect with the heels, buttocks,
shoulders, and head all touching the measuring board or
the wall
The feet should be positioned at 90 degree
Child axis of vision should be horizontal
External auditory meatus and lower margin of the orbit
aligned horizontally.
Stature is recorded to the nearest 0.1 cm.
Cont…
Weight
 Various types of apparatus, such as infant scales, beam-
balance scales and read out scales are available
 Spring balance or Salter scale is used for measurement
of weight in children < 2 years, and measurement is
performed to the nearest 10g.
 in adults and children > 2 years, beam balance is used,
and measurement is performed to the nearest 0.1 kg.
Cont…
Head circumference ( HC)
 Is the circumference of the head along the supra
orbital ridge anteriorly and occipital prominence
posterioriy.
 Measured using flexible, non-stretchable measuring
tape around 0.6cm wide, and measurement is
performed to the nearest 1mm.
 HC is useful in assessing chronic nutritional problems
in < 2 years b/c after two years the brine growth is
sluggish it is not useful.
 Values below the -3 standard deviation(SD) are
labeled as microcephally and above +3 SD as
macrocephally.
Mid- upper arm circumference
 Is the circumference of the left upper arm is taken at
mid point while the arm is hanging by the side.
 Is used as age independent criterion for detecting
malnutrition in children of age one to five years.
 A MUAC of 12.5cm indicates malnutrition and when less
than 11cm, severe malnutrition.
Indices
Combination of two measurement
 Indices derived from growth measurement
Head circumference- for- age (HCA)
Weight - for- age (WA)
Height - for- age (HA)
Weight/ height ratios (WH)
 Other indices include
Body mass index ( Quetelet’s index)
 Weight/( heghtin meters)2
Ponderal index
 Weight/ (height in meters)3
Weight for age
 We take the percentile of the ratio b/n our measurement
and the ideal wt of reference child of same age obtained
from the NCHS graph.

 WA= Wt X 100
wt. of reference
child of same age
 Then we interpret our result using different modalities
 Classification for interpretation of nutritional
status
Gomez classification (weight for age)
%tag of NCHS Level of
Malnutrition
90-100 normal

75-89 Mild(grade one)

60-74 Moderate(grade
two)
<60 Severe (grade
three)
Cont…
The Gomez system
 Used in public health screening and to evaluate the
impact of public health interventions.
 Shortcomings
90% --- too high
Edema---- ignored
Age ----- difficult to know in developing countries, and is
usually un reliable.
It fails to differentiate acute vs chronic malnutrition
It fails to differentiate b/n types of severe PEM
Well come classification (weight for age)

Level of malnutrition
%tage of edema No edema
NCHS

60-79 Kwashiorkor undernourish

ed
<60 Marasmic- marsmus
Kwashiorkor
Cont…
The welcome system
 Wt for age measured by the Harvard curve
 Is preferable for clinical setups to distinguish different
forms of PEM.
 Shortcomings
Relies on age
Dose not consider height
Dose not differentiate acute vs chronic malnutrition
Height- for- age
 We take the percentile of the ratio of our ht
measurement with that of Ht of reference child of same
age taken from NCHS graph.
 HA = Ht X 100
Ht of reference
child of same age
 Is an indicator of past undernutrition or chronic
malnutrition, it can not measure sort term changes in
mal nutrition
Cont…
Depending up on age we can modulate the name as,
length- for- age for children below 2 years of age.
Defecates in length- for- age or height -for- age is
called stunting, it is and indicator of past growth
failure.
Weight - for - height
 We take the percentile of the ratio of the actual weight
to the weight of the normal child of the same age taken
from NCHS graph.
 WH = Wt X 100
Wt of reference
child of same Ht
 It is referred to as wt for length in children under 2 years
of age.
Cont…
It helps to identify children suffering from current or
acute under nutrition or acute under nutrition or
wasting.
Is also useful when exact ages are difficult to
determine.
It can be used to differentiate stunting growth from
wasting and is independent of age.
Wasting results from acute or subacute nutritional
deprivation and by acute medical conditions such as
diarrhea.
The interpretation of our result will be based on Water
low classification(height for age and weight for age).
Waterlow classification
(height for age and weight for age)
Wt. for ht. Nutritional Height for Nutritional
Status age status

90-100% Normal >90% Normal

85-90% Mild wasting 90-95% Mild

stunting
75-85% Moderate 85-90% Moderate

<75% Severe <85% Severe

wasting stunting

In general
 WA & WH indices – sensitive to acute changes to
nutritional status
 HA indicates nutritional status in long run
 Anthropometric measurements to
assess body composition
Our body made up of two compartments
 Fat mass
 Fat free mass
Assessment of body fat
 Skin fold thickness test – in 5 places
% of body fat level
General popn athletes

M F M F

lean <12 <17 <7 <12

acceptable 12-21 17-28 7-15 12-25

Moderately 21-26 28-33

over Wt

Over Wt >26 >33 >15 >25

WH ratio
Waist to hip circumference ratio
Ratio >1 in male & >0.87 in
female ----high risk of coronary
heart diseases

` acceptable Not acceptable

excellent Good average high extrime

M <0.87 0.85-0.9 0.9-095 0.95-1 >1

F <0.75 0.75-0.8 0.8-0.85 0.85-0.9 >0.9

Anthropometric measurements in general
dose have advantages and disadvantages

Advantages  Disadvantages

 Quick  Difficulty of selecting

 Cheap appropriate cut of point
 Limited diagnosis relevance
 More accepted by the
 Need for reasonably precise
community
 Not invasive age in children, it difficult to
 Objective
know in agrarian society
 Considerable potential for
 Give gradable results
inaccuracy
Biochemical (biophysical) method
Definition
 measurement of either total amount of the nutrient in
the body or its concentration in particular storage site in
the body or in the body fluid.
 Indicate defecate on intermediary metabolism on other
words they occur when there is biochemical
lesion(depletion).
Parts
1, static biochemical test
 Measure a nutrient or its metabolite in pre-selected
biological materials.
2, functional biochemical test
 To determine the sufficiency of nutriture which is
required to perform the intended nutrient dependent
biological function
 Useful for subclinical deficiency state
 Are based on measurements of functional impairment
 Have greater biological value & significance than static
test
Cont…
Types of functional tests
1. Abnormal metabolic products in urine & blood
2. Changes in enzyme activities in the blood
3. In vitro tests of in vivo function
4. Load and tolerance tests
5. Spontaneous in vivo responces
6. Growth and developmental response. etc
Cont…
Factors affecting the interpretation of result of
biochemical tests
 Physiological – homeostatic
 Physiological state
 Pathological
 Analytical
 Biomarkers of nutrients
(lab. Tests for nutrients & metabolites)
nutrients Most sensitive Less sensitive Least sensitive
protien Plasma AA, Serum albumin Total serum
transferin urine urine protein
3- methyl hydroxyproline
histidine etc
Lipids Serum HDLP Serum
cholestrol ,TG
Vit. A Serum vit. A
retinol binding
protein
Vit. D Serum 25(OH)D3 Serum alkaline Serum Ca &P
phosphatase
Vit E Serum tecoferol
Vit K S-prothrombin Bleeding
&coagulation
time
Vit C Whole blood AsA S-AsA
Cont…
B1 ETk Urine B1 Blood pyruvate
B2 EGR Urine B2
B3 Urine N1 MN
Folic acid E-folate S-folate BM film&TBF
B6 Tryptophan laod E-
test& P&U B6 glutamic ,pyruvate
&Ox Tsae
B12 S-B12& TS U-methyle BmF&TBF
malonic Acid
Iron S-ferritin &Fe in S-Fe BF
BM saturation&TR
iodine T3&T4 S-protein bound I2 U-iodine
Cont…
Advantages
 Detect subclinical
malnutrition  Disadvantage
 Give gradable nutritional  Lack of biological
info. material
 Are more objective  Some times low values
may not reflect presence
of pathological lesions
 Invasive
 Need skilled stuff
Clinical Methods
Used to detect deviations from the normal state of
nutrition just by observing and interpreting signs
and symptoms.
It focuses on skin, hair, eyes, mouth & MSS
It must be interpreted in conjunction with other
method of nutritional ass’t.
 Physical signs & symptoms associated
common with under nutrition
1.Protein-energy malnutrition
Kwashiorkor -
• loss of appetite
• Growth retardation
• Bilateral pitting edema
• Muscle wasting with sc fat preserved
• Moon face
• Hair changes-red or brown straight sparse easily &painlessly pluckable
-Forest sign
-Flag sign
• Skin changes- depigmentation
- flaky paint dermatitis
• Hepatomegaly
• Psychomotor disturbance
Cont…
Marasmus
• Characterized by emaciation
• Growth failure
• Wasting of muscles & sc fat
• Old man face
• Increased appetite, hungry
• Alert but miserable
• Sunken eye balls
• Mood changes –always irritable
• Paggy pant appearance
2.Micronutrient deficiency
Vitamin A deficiency -night blindness
-bitot’s spot
-follicular hyperkeratosis
-xerophtalamia
-keratomalacia
Vitamin C deficiency -spongy bleeding gums
- easy bruising of skin
-scorbutic rosary
-poor wound healing
Cont…
Vitamin D deficiency -craniotabes
wide wrist
-

-rachitic rosary
-delayed fontanel closure
-Harrison's groove
-skeletal deformity
Anemia- easy fatigability, dyspnea headache loss of appetite
-pale conjunctiva and palm
Iodine deficiency –mental retardation,goiter
DIETARY SURVEY
Assessment of past or current intakes of nutrients
from food by individual or group to know their
nutritional status
At national level
 Estimation of food available for consumption per capita
for a year is called FBS/NFDD/Food Going into
Consumption.
 It can be used as one of the indicators for food self
sufficiency but not for food security
Cont…
 At house hold level
 House hold food inventory method—by gathering data
on the amount of food available for consumption
 Food account methods—by gathering data on the
amount of income spent for purchasing food
 At group or individual level
 Methods used to assess the current intake
Weighed record method
Observed weighed method
Food diary method
Weighed record method
 Advantage
 More accurate
 No respondent memory loss
 Disadvantage
 High respondent burden
 Change of dietary habit during the survey due to fear of
burden
 Needs literate respondent
 costly
Observed weighed method
Investigator records the amount, type of food
consumed by the study subjects over a specified period
of time.
Usually applied for disabled people ,infants& children,
mentally ill people or patients admitted to hospital.
Adv- as weighed record method
Food diary method

 Advantage
 Give relatively accurate estimate of nutrient intake if
done properly
 Disadvantage
 high respondent burden
 needs literate respondent
Methods used to assess past intake
24 hrs dietary recall
Dietary history
Food frequency questionnaire
24 hrs dietary recall
 Advantage
 Cheap
 Quick
 Less respondent burden
 No chance for respondents to change their dietary habit
 Disadvantages
 Does not indicate individuals unless conducted for
number of days
 Respondent memory laps
 Social desirability bias
 Less precision
Dietary history
Used to asses the nutrient intake from food over a longer
period of time, usually the association between diet &
disease .
 Advantage
 Give dietary habits of an individual or a group of people over a
long periods of time
 Is possible to target the questions specific dietary habit or
intake of specific nutrients
 Less respondent burden
 Disadvantage
 It over emphasizes the regularity of dietary pattern
 Needs highly trained interviewer
Food Frequency Questionnaire
Is based on the local staple diet & its administration so
as to determine the frequency of consumption of a
particular nutrient.
FFQ frame
Food Portio
list n size
Frequency of consumption consu
med
daily weekly fortnightly monthly quarterly biannually

A
B
C
D
Cont…
 Advantage
Is usually used for areas where there is
geographically widely scattered study population
Less costly esp. if self administered
Less respondent burden
Disadvantage
Very difficult to develop esp. in multicultural society
where different staple foods are consumed
Needs literate subjects
Thank you
Thank you