Monday, July 18, 2016

How to wean a baby - a guide to complementary feeding for Doctors - Dr Ashwini Bhat at Docplexus

As community physicians, we are hit by malnutrition among under five children so hard on the face that our heart starts aching. Under nutrition is worst in the age group of 6 months to one and half years. This is not just because of a delay in the introduction of weaning foods but also due to the poor quality of foods combined with inappropriate practice of feeding. According to the NFHS 3, only 21% of the children in India were offered any semi-solid food between 6 and 23 months. How tragic! At the time of maximum growth, the child is deprived of essential nutrition. 
Who is at fault? Is it the mothers or the doctors? An intervention in Haiti taught mothers to use inexpensive local foods to prepare nutritious food for their children. This was highly successful in helping mothers rehabilitate their malnourished children: the children of the mothers who received demonstration-education had under-nutrition related mortality rates that were 68% of the same as experienced by children of the mothers who had received growth-monitoring but no demonstration-education. So let’s take the blame on us now. We are no doubt emphasising growth monitoring as a tool to tackle under nutrition but at the same time we are getting so busy that we aren’t counselling the mothers regarding weaning foods and feeding practices. Here is what WHO has told us long ago. 
We should make it a point to spend at least 10 minutes counselling one mother who is about to wean her child irrespective of we sit in our offices or work in the field, irrespective of whether we are the busiest or we have all time on earth. World Health Organisation’s guidelines for appropriate complementary feeding is as follows - Continue frequent, on-demand breastfeeding until 2 years of age or beyond. Breastfeeding should continue besides complementary feeding up to 2 years of age or beyond. It should be on demand, as often as the child wants. Breast milk can provide one half or more of a child’s energy needs between 6 and 12 months of age, and one third of energy needs and other high quality nutrients between 12 and 24 months. Breast milk continues to provide higher quality nutrients than complementary foods, and also protective factors. Breast milk is a critical source of energy and nutrients during illness , and reduces mortality among children who are malnourished. Practise responsive feeding, applying the principles of psychosocial care. Feeding time is the period of learning and love. Mother ought to give her undivided attention to the child while feeding the tiny tots because as important as what is fed is how and where the child is fed. More active style of feeding can improve dietary intake. Mother should find a way of interacting with her child and drawing the tot’s attention towards her like singing or telling a story or showing attractive books or photos and videos etc. 
Patience is of utmost importance. If children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement. A mother must always talk to children during feeding, with eye-to-eye contact. Practise good hygiene and proper food handling. Microbial contamination of complementary foods is a major cause of diarrhoeal disease, which is particularly common in children 6 to 12 month’s old. This can be prevented by safe preparation and storage of food. Keep all utensils, such as cups, bowls and spoons used for an infant or young child’s food thoroughly washed. 
Hand washing is of paramount importance, before preparing the food as well as feeding the child. Mother’s hands as well as child’s hands need to be washed thoroughly.  Keep raw and cooked foods separate. Cook thoroughly so that even the centre of the food roll boils. Keep food at safe temperatures. Bacteria multiply rapidly at room temperature. So, the foods need to be refrigerated if they are to be kept for long. If refrigeration is not possible, then it is important to finish the food within 2 hours. Infants should preferably be fed with freshly prepared food. Use safe water and raw materials. Start at 6 months of age with small amounts of food Start with liquid foods like cow’s milk or clear fruit juices or cereal porridges. Initiate with 2–3 tablespoonfuls per feed. Such 2–3 meals per day may be offered. Gradually increase the food consistency, quantity and the number of times that the child is fed complementary foods as the child gets older. Gradually thicken the consistency of the cereal porridge so that it can stay on spoon without dripping off. Also start giving pureed or well mashed foods. 
Foods that are thicker are more energy- and nutrient-dense than the liquid foods. Increase the quantity to half of a 250 ml cup per meal till 8 months and 3/4th of the same cup then on. Depending on the child’s appetite, 1–2 snacks can be added. Bring in more variety in food as the infant grows older, adapting to the infant’s requirements and abilities. Once the child starts to accept cereal based diet, gradually add pulses, vegetables and animal foods one by one. Feed a variety of nutrient-rich foods to ensure that all nutrient needs are met. Cook with less water and make a thicker porridge, replace some (or all) of the water with milk. Add extra energy and nutrients to enrich the thick porridge. 
For example add milk powder and sugar (or margarine or ghee); or add groundnut paste (peanut butter) or sesame seed paste. Adding fatty / oily foods makes thick porridge softer and easier to eat. Toast cereal grains before grinding them into flour. Toasted flour does not thicken much, so less water is needed to make porridge. By 8 months, most infants can also eat finger foods. By 12 months, most children can eat the same types of foods as consumed by the rest of the family. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed Unfortified complementary foods that are predominantly plant-based generally provide insufficient amounts of certain key nutrients (particularly iron, zinc and vitamin B6). Inclusion of animal-source foods can meet the gap in some cases, but this increases cost and may not be practical for the lowest-income groups. 
Furthermore, the amounts of animal-source foods that can feasibly be consumed by infants are generally insufficient to meet the gap in iron. Hence, foods fortified at the point of consumption with a multi-nutrient powder or lipid-based nutrient supplement may be necessary. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, favourite foods. After illness, give food more often than usual and encourage the child to eat more. 
During an illness, the need for fluid often increases but the child’s appetite for food often decreases. At that time breast milk may become the main source of both fluid and nutrients. A child should also be encouraged to eat some complementary food to maintain nutrient intake and enhance recovery. Intake is usually better if the child is offered his or her favourite foods, and if the foods are soft and appetizing. Child must be given more frequent, smaller meals. When the infant or young child is recovering, and his or her appetite improves, the mother should offer an extra portion at each meal or add an extra meal or snack each day. Reference: Infant and young child feeding Model Chapter for textbooks for medical students and allied health professionals. Geneva, World Health Organization, 2009. 

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