lndtam .7. Pedlat. 4~: 232, 197G

NUTRITIONAL

REQUIREMENTS OF INFANTS AND NEED EOR SUPPLi~MI~N/ MILK DIET WITH INFANT WEANING FOODS* BRI.JF,SH NARAIN AND

P.J.

DUBA,~H

Bombay

T h e first and the best natural |ood for h u m a n infants during the first year of life is h u m a n milk a n d in poor communities of I n d i a , it is the sheet-anchor of infant nutrition. Although few people argue about the "rightness" o f h u m a n milk for h u m a n babies, m u c h o f this thesis was, until recently, u n e x p l a i n e d in spite o f great overall advances in the science o f nutrition. O n e great question to which civilized m a n will p r o b a b l y never have an answer is, " H o w long is breast milk really i n t e n d e d to be the sole source o f n o u r i s h m e n t for human infants ?" Its i n a d e q u a t e iron c o n t e n t is one indication for early supplem e n t a t i o n (Moe 1"963~ C o m m i t t e e on N u t r i t i o n 1969). T h e present p r e v a l e n c e o f oral contraceptive usage in Western countries is perhaps t h e greatest d e t e r r e n t to successful breast feeding d u e to r e d u c e d milk flow. Infants being nursed by mothers on oral contraceptives gain in body weight at a rate approxim a t e l y two-thirds that of the n o r m a l breastfed infants ( F d e r 1970). T h e r e has been a m a r k e d decline in tl~e incidence o f breast feeding (Salber a n d Feinleib 1966, Filer 1970, 1971). It is recognized that h u m a n milk is i n a d e q u a t e in q u a n t i t y ( F o m o n a n d M a y 1958, G o p a l a n 1958, S o m e s w a r a R a o et al. 1959, G o p a l a n From the Food and Fermentation Section, University Department of Chemical Technology, Matunga, Bombay, 400 019. Received on March 22, 197fi.

a n d Narsinga R a o 1971) as well a s h quality ( G o p a l a n 1956, Gopalan Belavady 1960, V e n k a t a c h a l a m et al. l ~ t N I G o p a l a n a n d Narsing R a o 1971) g e n e r a ~ after 6 months of age. S o c i o - e u l t t u - l l restraints and physical difficulties e n c o U l ~ tered during breast feeding m a y h a l l contributed to the decline. Barnes e t , i 1953, Miller 1952, Call 1959). I n breast the q u a n t i t y of some nutrients remains r e ] l i tively constant despite various envixonxnetitll differences; o t h e r n u t r i e n t s , like v i t a m i n l l a p p e a r to vary with the m o n t h ' s intake the milk of mothers on a deficient d i e t not m e e t the y o u n g infants' total n u t r i t i o x i al d e m a n d s to the extent assumed. C o n s ~ quently, infants are w e a n e d on suitabt~ modified cow's milk, buffalo's milk anffm infant foods. I n f a n t foods based on b u f f a l o l milk in I n d i a are now well establish~! ( C h a n d r a s e k a r a e~ a/. 1957, M e y e r 1960)1 I n view of the high cost a n d short supplyj these are not within the range o f a larg~ section of our population. T h e projecte~ a n n u a l production of milk and its per capitil avai:ability in this c o u n t r y is given i~ T a b ! e 1. I n India, as in m a n y other countries oti the world, the diets of w e a n e d infants ott low socio-economic groups consist predomiJ nanttv of starchy foods which are poor i~ protective nutrients (Trowell et al. 195at| Jelliffe 1955, S o m e s w a r a R a o 1959). Thai spectre o f m a l n u t r i t i o n is a constant threal to n o r m a l d e v e l o p m e n t (Bengoa 1970]

~ARAIN AND DUBA,~H'--NUTR1T1ONAL REf)J;IREMENTS OF INFANTS

Treble I.

Prtjectcd awAlability of cow's milk and buffalo's milk at current level o[ production.

Projected annual milk production (million tonnes) C o w ' s Buffalo's

Population projected (millif,ns)

Year

Per c a p i t a a v a i l a b i l i t y o f m i l k per d a y

(g)

Cow's

Bufi~lo's T o t a l

1960-61

4.3g

7.87

10.75

40

67

116

1965-66

4.q2

P.59

12.13

4Y

(;P

116

1970-71

555

9.30

! 3.71

4-G

6~'

114.

1971-76

626

10.29

15.50

4;

4'~

! 13

"Taken from The Wealth of ItJdia (Ic.~70).

J o h n 1971, U d a n i 1971, C r a v i o t o etal. 1971) and even greater attention must be a c c o r d e d to t h e n u t r i t i o n a l needs o f these g r o w i n g i n f a n t s . I n view o f this urgency, c o n s i d e r a b l e w o r k has b e e n d o n e b o t h in the d e v e l o p e d a n d d e v e l o p i n g countries. I n o r d e r to p r o v i d e p r o p e r n u t r i t i o n to the i n f a n t s o f low s o c i o - e c o n o m i c groups, i n f a n t foods b a s e d on g r o u n d n u t a n d soy flour have b e e n s t a n d a r d i s e d in I n d i a ( C h a n d r a sekhara et al. 1966a, "1966b, 1969). T h e n u t r i t i o n a l v a l u e o f i n f a n t foods based on g r o u n d n u t p r o t e i n isolate a n d flour are almost as g o o d as m i l k food o f s i m i l a r c o m p o s i t i o n in p r o m o t i n g g r o w t h o f i n f a n t s ( S w a m i n a t h a n 1968; C h a n d r a s e k h a r a et al. 1966b). T h e s e i n f a n t foods a r e d e s i g n e d as substitutes to cow or buffalo milk. T h e ~atilization o f g r o u n d n u t for e d i b l e pro'poses has b e e n discussed in the w o r k s h o p on the 'utilization o f g r o u n d n u t a n d o t h e r oil.seeds Ilteld a t C.F.T.R.I., M y s o r e in 1971. k~though available milk substitutes give babies a f a i r c h a n c e o f survival a n d are '~seful u n d e r the pressure o f necessit.v, no

m i l k substitHte is r e c o m m e n d e d wimn h u m a n brea.ct or m a m m a l i a n m i l k is a v a i l able a n d c a n be d i g e s t e d satisfactorily by the infam. I n f a n t foods c a n be d i v i d e d into three m a i n groups as s h o w n in '-Fable 2. T h e w i d e s p r e a d a c c e p t a n c e of c o m m e r cially a v a i ! a b l e w e a n i n g i n f a n t foods and tee r e m a r k a b l e c h a n g e , nowadab-s, in th( p a t t e r n o f i n f a n t f e e d i n g , b,ave influenkec the t r e n d t o w a r d s the e a r ! l e t introductio~ o f these foods in t h e i n f a n t d i e t to assm adequate nutrition. American babies ithe first y e a r o f t h e i r life receive most r their n u t r i e n t s from s y n t h e t i c f o r m u l a e c mother's milk, precooked cereals ,an c a n n e d s t r a i n e d b a b y foods. T h e sales these b a b y tbods in th~ U.S.A. w e r e est m a t e d to be w o r t h S 344,70e,000 in 19; ( A n o n y m o u s 1972). A r e v i e w o f mi'.k-bast ini:ant t\mds has been p r e s e n t e d by C h a n d l s e k h a r a (1960). T h e present r e v i e w de~ w i t h the n u t r i t i o n a l r e q u i r e m e n t s o f i n f a n n o r m a l as well as p r e m a t u r e , a n d the ne for s u p p l e m e n t i n g t h e i n f a n t ' s m i l k diet

~34

INDIAN JOURNAL

VeL. 43, Nm

(')lv P E D I A ' I ' R I ( : ~

T a b l e 2. Group

T y p e r infant fi,ods |l

Infant foods. Purpose

I

A

Milk based

Used as a substitute for n o r m a l milk d l

B

W e a n i n g foods including strained baby foods

Used as s u p p l e m e n t a r y foods to milk d i l required to bridge tile c h a n g e from m i l l to a d u h tbods

(3

Special varieties including hypoallergenic toods

assure p r o p e r n u t r i t i o n to v u n l e r a b l e groups. Nntritional Requirements of Infants T h e revised r e c o m m e n d e d daily d i e t a r y a l l o w a n c e for r.ormal W e s t e r n ( N A S - - N R C , 1968) a n d I n d i a n infants ( I C M R 1968, Narsing R a o 1 9 6 9 ) a r e given in T a b l e 3 a n d T a b l e 4 respectively. T h e s e cover only a small p r o p o r t i o n of the m o r e t h a n sixty nutrients presently recognised as essential for h u m a n n u t r i t i o n . T h e requirem e n t s o f p r e m a t u r e infants h a v e been discussed by Ebbs (1966) a n d r e v i e w e d bv H u e t t i g 1969).

Calorie A daily intake of 120 calories per kg b o d y weight appears to be a d e q u a t e for infants u p to six m o n t h s but this requirem e n t drops to a b o u t 100 calories per kg b o d y weight at t h e e n d of the year ( F A O 1957). P r e m a t u r e infants will m a k e satisfactory gains if they receive 120-130 calories p e r kg b o d y w e i g h t a n d supervision of the f e e d i n g r o u t i n e o f these infants is of great i m p o r t a n c e ( G o r d o n 1947). T h e clinical a n d m e t a b o l i c a d v a n t a g e offered by early calorie a d m i n i s t r a t i o n to p r e m a t u r e infants a n d t h e risks i n v o l v e d have been r e v i e w e d

Used for allergic a n d m e t a b o l i c a l l y h a r i ~ c a p p e d infants

by B a r a t o n o a n d Grazia (1972). A : l placid infant m a y n e e d less but a n a ~ infant needs as m a n y as 130 calories p ~ body weight per d a y (Guthrie 1967). calorie r e q u i r e m e n t for weight g a i n / infants w i t h g r o w t h fa{lure is p r e d i C t ~ m (Krieger a n d C h e n 1969). An e x c ~ intake o f calories l e a d i n g to a r a p i d g a i n l m weight is u n d e s i r a b l e in infants. M a c k ~ (1963) has suggested that a baby h a v i n g t m weight o f 27 ib. (12.3 kg) at one year o f a ~ is m o r e likely to gTOW up tO be a n obeam adolescent or a d u l t t h a n one w e i g h i n g 1 ~ I n a study ( F o m o n et al. 1969) eonductem on infants, it was t e n t a t i v e l y c o n c l u d e d than lipid a p p e a r e d to a c c o u n t for a l a r p p e r c e n t a g e o f weight g a i n by infants recetl r i n g higher calorie from highly concentratedl formula intake. For a n e w b o r n , m i l k provides all tlig calories b u t m i l k diet alone c a n n o t m e e t thg caloric r e q u i r e m e n t o f large babies aftel one m o n t h , o f average babies after 4 mont]~ a n d for the smallest babies by the e n d o['/~ m o n t h s ( N a i m a r k 1957) ( T a b l e 5). P r o p ~ m a n a g e m e n t o f diet based on supl~llx m e n t a r y food is therefore essential to m ~ the a d e q u a t e calorie r e q u i r e m e n t o f tl~

I~ARAIN A N D

235

I ) U I ~ A t ; I I - - - N t J ' I R I ' F I O N A L RE~UIRE, MENT8 OF INFANTII

T a b l e 3.

R,,;comme,.deddaily dietary allowance Lfor American infants and young children.

Age

0-2 months --r'

W e i g h t (kg)

I

2-6 months

6- ! 2 months

I

1-2 years IIII

4

7

Height (era) Calories ( K c a l )

kg •

120

Protein (G)

kg •

2.2 a

-

9

63

O J

72

kg /, 110 kg /

2.0a

kg •

100

kg /

1.8'~

12 81 1100 25

V i t a m i n A. (I. U )

1500

1500

Vitamin D (I.U.)

400

400

400

400

V i t a m i n E (I.U.)

5

5

5

10

Vitamin C (rag~)

35

35

35

40

0.05

0.05

0.1

0.1

5

7

8

R i b o f l a v i n (mg)

0.4

0.5

O.B

0.6

T h i a m i n e (rag)

0.2

0.2

0.5

0.6

V i t a m i n B 6 (rag)

0.2

0.3

0,4.

0.5

V i t a m i n BI2 (meg)

1.0

1.5

2.0

2.0

C a l c i u m (rag)

400

500

600

700

Phosphorus (rag)

200

40')

500

700

I o d i n e (mcg)

25

40

45

55

6

!0

15

15

40

60

70

100

Folacin (mg)b Niacin ( m g eqn.)e

Iron (mg) M a g n e s i u m (rag)

1500

2000

8

Taken ti'om NAS--NRC (196S) a Assumes protein equivalent to that of human mi'k. if i~f.~n~ .,oung.:r than one year are being fed regular mixed d{e~, it woull be advisabie to apply ;he quaiicy correction factor of 1.43 to the lower allowance based on human milk protein. Pure forms of folacin effective in doses less than 88of RDA. i: Niacin equivalents include dietary sources of the v'tamin itself plus mg equivalent for each 60 rag. of dietary tryp~ophan.

256

iNDIAN JOURNAL OF PF,DIATRICg

Table

4.

V o I . . '~3, ~ 0

Daily dietary requirement as allowance for Indian infants and children,

Age

5 - 12 months

0 - 5

mortths

I

I

1--3 years

i

7-

Protein (G)

2.1 x kg t

1.7 x kgt

9

Calorie (Kcal)

120 x kg

110 • kg

1200

5.7

5.1

3.0

Nov (cal%) Minerals Calcium (mg)

500

Iron (rag)

- -

600

400 -- 500

1.0 X kg

15--

20

Vitamins Retinol (mcg)

400 a

/~ --carotene (mcg) T h i a m i n e (rag)

Riboflavina (nag) Niacin e

(rag)

Ascorbie acid (mg) a. b. c.

300 b

250

1200 b

1000 0.6 7 8

30--50

T a k e n from I C M R (1068), Narsing R a o ( 1 9 6 9 ) . R e q u i r e m e n t s f o r infants of 0-6 months of age. I~l~nl~ for infants of 6-12 months of age. ~do,l~! on the basis 0.5 mg/1000 cal.

d. Calculated on the basis of 0.55 mg/1000 cal. e. C4deulated on the basis of 6.6 rag/1000 cal. f. I n terms of milk protein.

infants. Filer and Martinet (1963) have reported that by six months of age, 70% of the energy should be provided by milk, with m e a t providing 10% and cereal, fruit and vegetables, each 5 %.

Protein T h e need for protein during the period of very rapid skeletal and muscular growth of early infancy is relatively high. FAO[

W H O group (1965) have accepted that tim requirement is of the order of 2-3 G. per kla body weight per day during the first months and decreases to 1-2 G.lkg. bod| weight/day at the end of the first year el life. The Committee is in agreement th~n breast milk supplies 7 % of the calories q protein which is an approximate requlr~ ment of infants for reference protei~

~ARAIN AND | ) I t B A S ; I - - N U r R t T I O N A L RE{~JIREMENT~I OF INFANTS

R e q u i r e m e n t o f protein t or n o r m a l infants Ilal been discussed by H o l t a n d S n y d e r m a n 0965). T h e r e q u i r e m e n t o f protein for p r e m a t u r e babies has been discussed by ~ a n y a u t h o r s (Holt 1959), G o r d o n a n d Oanzen 1959, D a v i d s o n 1960, G o r d o n 1961, Davidson a al. 1967) a n d a daily intake of 4 G. per kg. b o d y weigllt has been recomm e n d e d for satisfactory weight gain for infants fed on cow's milk. G o p a l a n a n d ~ a r s i n g R a o (1971) on the basis o f F o m o n and M a y ' s (1958) data, h a v e a p p r o x i m a t e d that the a m o u n t o f breast milk n e e d e d for satisfactory g r o w t h w o u l d be of the order of 850 ml. p e r d a y a n d 960 ml. per d a y in one m o n t h old a n d 6 m o n t h o l d n o r m a l I n d i a n infants respectively This a m o u n t o f milk is suflieie-nt to supply a d e q u a t e a m o u n t o f protein u p to A3 month~ o f t h e infant's life. However, i f t h e n e e d o f the i n f a n t is n o t fulfilled, s u p p l e m e n t a r y cow's m i l k or modified buffalo's m i l k should be i n c l u d e d in the i n f a n t ' s diet. T h e n u t r i t i v e value of protein of h u m a n a n d cow's m i l k has been reviewed ( H e n r y 1957, W i l l i a m s 1961). The biological value of h u m a n m i l k p r o t e i n is h i g h e r t h a n t h a t o f cow's m i l k p r o t e i n (90 c o m p a r e d to 75). Bullen et al. (1972) have observed t h a t breast fed babies are less prone to E . coli i n f e c t i o n t h a n bottle fed ~abies. T h e p r o t e i n lactoferrin, which is present in a h i g h e r c o n c e n t r a t i o n in h u m a n milk, possibly interferes w i t h iron m e t a bolism of the bacteria. Protein, if fed in excess, concentrates metabolites in urine a n d requires larger volume o f w a t e r for excretion. I f the ~aecessary a m o u n t o f w a t e r is n o t available, ~trea will a c c u m u l a t e a n d the i n f a n t m a y tronically suffer f r o m p r o t e i n o e d e m a (Guthrie 1967).

237

Amino acids

T h e a m i n o acid r e q u i r e m e n t o f t h e hum a n infant has been discussed by M c C a n c e and Widdowson (1964) a n d H o l t a n d S n y d e r m a n (1965). H u m a n milk p r o t e i n has been r e p o r t e d to p r o v i d e an a d e q u a t e margin of all the essential a m i n o acids over the quantities w h i c h are likely to be found in b o d y proteins at 6 m o n t h s of age. T h e c o m p o s i t i o n o f h u m a n a n d cow's milk protein has been g i v e n by Block a n d Mitchell (1946) a n d Morrison (1952). S u p p l e m e n t a t i o n of m i l k by tysine has been s t u d i e d (Albanese et al. 1955, 1956), b u t criticized by others as it m a y cause a m i n o acid i m b a l a n c e s ( S n y d e r m a n 1959). Fat

Wiese et al. (1958) have established that for n o r m a l n u t r i t i o n o f infants, 4 % o f the calories have to be s u p p l i e d by linoleie acid w h e n fat provides 4 2 % o f the total calories. T h e linoleic acid c o n t e n t o f breast m i l k is 4 to 5 times higher t h a n t h a t o f cow's milk ( H a n s e n et al. 1963). C o m b e r s et a!./~1962 ) s h o w e d that p r e m a t u r e 'infants receiving 4.5 % of their calories as linoleic acid h a d serum lipid values similar to those in infants fed on h u m a n milk. E v i d e n c e o f linoleic acid deficiency d e v e l o p e d in infants w h o received either a diet practically d e v o i d o f fat or one p r o v i d i n g 42 ~ o f t h e total calories as fat but e x t r e m e l y low in linoleic acid, p r o v i d i n g less t h a n 0.1% of the calories (Hansen et al. 1963). T h e p e r i o d a n d extent o f n e e d of fatty acids o f the linoleic a n d linolenic series necessary for brain developm e n t a n d the n e e d for o t h e r d i e t a r y factors, especially v i t a m i n E ~ h i c h can affect the need for essential fatty acids has been discussed by H o u t s m u l l e r ( 1971).

938

INDIAN JOUIllgAL O1' PIT,DIATlilfJS

T h e ilnl)ortar,ce o f |,,1than milk for the d e v e l o p m e n t of the infani'~ resistance to inlimtion has b,:en disc~_gsed in the past. For m a n y years Gyorgy et al. (1962) and A t h r e y a el al. (1964) have a n t i c i p a t e d an a d j u v a n t eff,.c-r ~,}"h u m a n milk in regard to the formation of specific antibodies in the course o f infection. T h e protective activity is believed to be due to a positional isomer of linolei~: acid which hat not yet been identified (Schmidt I.(t70). However, tat e x c h a n g e d infant formula is able to enhance specific a n t i b o d y production in ixtfants during inti-ction (Scilmidt 1970). Efforts should be m a d e to develop r.uch f o r m u l a e so that they c a n safely be i n c l u d e d in the inf~int's diet w h e n breast feeding is not possible to provide prophy!actic effect against i n f e c t i o n . . M a n y o f the other components o f breast milk provide specific and nonspeci.fic immunity.

Carboh)dr ates T h e higher content of lactose in h u m a n milk facilitates absorption o f c a l c i u m and m a g n e s i u m to a higher m i n e r a l content available for g r o w t h ( M a c y et al. 1953, Nelson 1959). I t also favours a m i n o acid absorption a n d nitrogen retention. T h e physiological effects o f lactose have been rek'iewed by D u n c a n (1955). Lactose provides galactose, a constituent o f eerebrosides present in tissues o f the newborn. T h e sugar o f h u m a n milk contains /3-lactose, a substance that inhibits the growth o f the colon bacillus, while cow's milk contain c~-lactose w h i c h favours the growth of the colon bacillus. T h e colon bacillus is an antagonist of the acidophihts intestinal bacilli w h i c h possess the faculty o f synthesizing m a n y o f the B vitamins (Dombrovskaya 1968). T h e L:ctobacillu~ bifidus factor

VOL.

43, b.r=

in h u m a n milk creates a m e d i u m i r l ~ gastrointestinal Iracl conducive t o ' i growth o f Lactobacil[usb~dus (Gyl!ett~ et al. 1953, Gyorgy et al. 1953). This m ~ organism, by providing acetic or l a c t i e ~ from lactose, depresses the g r o w ~ pathogenic organisms and decreases susceptibility of the inFant to i n f c . c t i 0 ~ this acid m e d i m n is cond~mive t o : ~ growth of fermentative ratlmr 9 putrefactive organisms (Guthrie 191~ Petuely (1957) has observed '.hat the 0{!11111 tos~-: protein ratio of 2 . 5 : 1 i'a n v ' c e s s a r g l i estab:ishing lactobacilllts flora in intestine of the infant by b i f i d o g e l ~ substances. Lactana-/3, a c o m m e r c i a l baby f o o i containing lactulose caused an i n h i b i t i o n i the process o f p u t r e f a c t i o n while a test f ~ without lactulose ';timnlated the p r o c e s ~ puzrefaction in the colon of the infa~u (Grutte et al. 197,9). T h e use o f s u p p l l m e n t a r y food containing lactulose s e e m s , ~ be beneficial for infants. MINERALS

T h e m i n e r a l composition of milk atlll its a d a p t a t i o n to tim mit:eval needs of young has been r e v i e w e d by Gt.eguea (lWl). a l d u m and Pt:o;pho~u~

Studies on breast milk composition ar~ optimal intake o f breast milk of" sati3factorll nutrient content indicate that an intake tll 300 m g calcium per d a y is a d e q u a t e fol satisfactory growth of infants (Gopa!an a~. Narsinga R a o t971). An allowance of 5011 --600 m g o f c a l c i u m per d a y has beet0 suggested for infants fed on formula dii~ ( F A O 1962). Poor b o d y stature of thU infants o f poor c o m m u n i t i e s is often attrll

~AI'/,A.tM ANI-J 13tltiASltf - - N ( : T R I V I O N A I , RF, OJ./IRtCMENT/t OF INFAN'F2,

buted to low c a l c i u m intak~r ( B e l a v a d y anti Gopalan 1959). Babies on breast milk retain a p p r o x i m a t e l y 600/0 of d i e t a r y CMciurn while those on cow milk formulae retain only 30'~, of the c a l c i u m (Fomon a al. 1963). S u p p l e m e n t a t i o n of calcium to the infants' diet has n - t p r o v i d e d any benefit a n d other d i e t a r y factors like calories', v i t a m i n A and vitamin D m a y have strong bearing on the beneficial effect of calciuin (Bansal e t a l . 1964, V e n k a t a chalam 1971). I n f o r m a t i o n on this aspect is meagre. T h e c a l c i u m : phosphorus ratio should be o f the o r d e r of 3:2. T h e daily d i e t a r y ,allowance o f phosphorus is estimated to be ,9_00 to 400 m g per d a y d u r i n g the first year of life ( N A S - N R C 1968).

A full t e r m i n f a n t having 250 m g o f total b o d y iron has 150 m g distributed in haemoglobin, 50 nag in tissue and 50 m g in liver ins iron stores (Bratteby 1968, Sjolin and X~,rranne 1968). T h e d i e t a r y iron absorption d u r i n g the first 2-3 months o f life is low due to lack o f erythropoietic stimulation a n d the use of released iron .~tores of growing tissues such as the liver. After 2-3 months, erythropoiesis a g a i n starts a n d iron is mobilised from the storage organs a n d helps in building up o f red cells continuously (Bratteby 1968, H a l l b e r g ~971). T h e n e e d for iron to cover the "demands o f growth a n d to balance the losses is entirely d e p e n d e n t on d i e t a W iron. rI'he diet of a n o r m a l infant after 2-3 fmonths of age should provide 1.0 m g iron I!er kg. b o d y weight per d a y to a m a x i n m m ~f: 15 m g per day. A s o m e w h a t g r e a t e r tallowance o f 2.0 m g iron per kg. body Melght b e g u n by the age o f 2 months to a

239

maximur, of 15 m g per d;ty is adxisable for p r e m a t u r e infants ( C o m m i t t e e on Nutrition 1969). Iron r e q u i r e m e n t d u r i n g infancy was r e v i e w e d by Sjolin and W r a n n e (1968). T o estimate the d i e t a r y iron r e q u i r e m e n t , an absorption o|" !0~ is .... ,',,reed (Schulz a n d Smith 195{'). Seruln iron saturation o f less than 15 ~/o is indicative o f iron depletion between 3-18 months of age. A haemoglobin level of aouut . . . . . . ,,.~ G. pcr 100ml or h e m a t o c r i t o f 36 ~o is considered optimal, btJt a value below this level is an indication of frank iron deficiency a n e m i a (Committee on Nutrition 1969). A review on iron deficiency anemi~t ~ a s prc~ented by M e h t a {1970). An a d e q u a t e a m o u n t o f iron is n e e d e d in the infant's diet a f t e r 2-3 months which must be absorbed by infants to supply the a m o u n t required after iron d e r i v e d from the high c o n c e n t r a t i o n of h a e m o g l o b i n at birth has been r e c l a i m e d for h a e m o g l o b i n synthesis. T h e a m o u n t o f iron which should be absorbed from the infant's diet has been estimated to be 0.8 m g per d a y on the basis of 10 % absorption ( A n d e l m a n a n d Elwood 1966). H u m a n a n d cow's milk c o n t a i n little iron (about 1.5 mg/litre and 0.05 m g l i t r e respectively) ( U S D A 1963. N R C 1953). About 480 ounces of cow's milk w~uld have to be c o n s u m e d by n o r m a l infants each d a y to provide enough iron to m e e t optimal requirements. O n the basis o f calorie r e q u i r e m e n t alone, w h e n milk account_~ for a large proportion o f the calories, the diet o f the infant wilt be gross]? deficient in iron. T r a c e elcmeuts

T r a c e elements are essential for growth, reproduction a n d m a i n t e n a n c e o f normal health ( C o m m i t t e e on Nutrition 1960).

~}40

INDIAN JOURNAl, OF PEDIATRI(:,q

Tlne daily r e q u i r e m e n t o f c o p p e r is 0.05 m g p e r kg. b o d y weight ( C o m m i t t e e on D i e t a r y Allowance.~ 1953). C o p p e r is a c o n s t i t u e n t of certain oxidati~,e enzymes in h u m a n beings ( W i n t r o b e 1958). T h e conc e n t r a t i o n o f c o p p e r in the baby's serum d u r i n g the first week after birth rises from the initial n e w b o r n level of 50 t~g per 100 ml to 150 t~g per 100 ml a n d r e m a i n s at this level t h r o u g h o u t c h i l d h o o d into adulth o o d ( H a g b e r g et al. 1953). C o p p e r deficiency occurs in infants whose stores were p r o b a b l y low o r d e p l e t e d (C,o r d a n o et al. 1964, C o r d a n o 1970). T h e body c o p p e r is e x c r e t e d in the bile a n d reabsorbed, but starvation, m a l a b s o r p t i o n , infection a n d d i a r r h o e a c a n interfere with the a b s o r p t i o n o f c o p p e r causing a p p a r e n t deficiency ( C a r t w r i g h t a n d W i n t r o b e 1964, S t e r n l i e b a n d J a n o w i t z 1964). A s e r u m level below 45/~g p e r 100 ml. lends strong s u p p o r t to the diagnosis w i t h a p p a r e n t d i s a p p e a r a n c e o f c e r u l o p l a s r r d n from the serum (Sternlieb a n d J a n o w i t z 1964, C o r d a n o 1970). T h e i n c i d e n c e o f c o p p e r deficiency at 7-9 m o n t h s suggests t h a t by this time, the n e o n a t a l stores o f c o p p e r c a n be d e p l e t e d by a c o m b i n a t i o n o f chronic intestinal losses a n d a very. poor i n t a k e from milk (Graham and C o r d a n o 1959, C o r d a n o 1970). H o w e v e r , a d i e t a r y deficiency of c o p p e r has n o t y e t been d o c u m e n t e d . Zinc. Z i n c is a p a r t of vital e n z y m e systems a n d o f insulin ( C o m m i t t e e on N u t r i t i o n 1960). Daily i n t a k e of 0.3-0.6 m g per kg. b o d y weight is a d e q u a t e (Hegsted n a t . 1945, V a l l e e 1958). Diets low in zinc are a d d i t i o n a l c o n t r i b u t o r y factors i n v o l v e d in beri-beri ( C o m m i t t e e or~ N u t r i t i e n 1960). S a n s t e a d et al. (1965) have f o u n d a low p l a s m a level o f zinc in k w a s h i o r k o r patients. T h e y f u r t h e r s p e c u l a t e d a b o u t the relationCo#per.

VoI,. 43, N o . ,

~hlp b e t w e e n zinc deficiency a n d grovan r e t a r d a t i o n f o u n d in preschool c h i l d r l suffering from protein-t:alorie m a l n u t r i t i O l t l Selenium. A daily s u p p l e m e n t o f 25 of selenium to m a l n o u r i s h e d J a m a i c a n c h i l l i ren showed gain in weight, but this w l a~+companied by an increase in fbod intall~ (Schwartz 1961, 1965, Majaj a n d Hopkit~[ 1966). Burk et al. (1967) s t a t e d that childr~l~ suffering from kwashiorkor have reduce~ selenium stores. No specific studies hard been m a d e so fac to assess the requiremeff~ of selenium for infants. Chromium. H o p k i n s et al. (1968) d e m o l ~ strated f r o m their study d a t a that malnott. Iishcd infants in some areas b e n e f i t t e d fron+ c h r o m i u m s u p p l e m e n t a t i o n b u t observe~ that not all cases of m a l n u t r i t i o n ar~ accompanied by c h r o m i u m d e f i c i e n c y H o w e v e r , the r e q u i r e m e n t o f c h r o m i u m for infants is still u n k n o w n . Cobalt.

T h e essential n a t u r e o f cobalt is

based u p o n its presence in the v i t a m i n ]312 mo"_ecule. T h e iat~er m u s t be synthesised by the intestinal flora using ingested cobalt or be o b t a i n e d p r e f o r m e d in the diet: ( C o m m i t t e e on _Nutrition 1960). Alar.ganese. T h e

daily d i e t a r y requirem e n t of m a n g a n e s e d u r i n g the first 6 months o f life has been r e c o m m e n d e d to be 2.5-2.7 ?g per kg. b o d y weight ( M c l e o d a n d Robinso~ 1972). This d e p e n d s u p o n the age, type o f milk a n d a m o u n t of solid foods consumed: No deficiency s y n d r o m e has been repoi'ted. lodzne. I o d i n e r e q u i r e m e n t in the neigh-

b o u r h o o d of 22-44#-g per d a y for infants is r e c o m m e n d e d ( U n d e r w o o d 1962). Increased intake of i o d i n e usually reverses the goitreogenic effect o f substances like arsenic a n d certain organic sulphur c o m p o u n d s in

~LAIN

AND D U H A S I t - - N U T R I T I O N A L

~tagetables o|" brassica a n d ~ a n - W y k el al. 1959).

bean

R E O UIREM~NTS OF INFANTS

t~tmilies

Water. The first need o f the body is for ~uid a n d the intake of w a t e r is crucial at a!] stages in life. T h e daily req airement for infants is a b o u t 150 ml per kg. body weight cold w e a t h e r and 180 ml in hot weather (Committee on Nutrition 1957). Water /equlrement is m e t if the diet supplies 150 ml o f w a t e r per 100 calories. I f the intake falls below 100 ml, the urine r rises m a x i m a l l y a n d m a y cause d a m a g e to the kidney. Human milk supplies a d e q u a t e a m o u n t of water as it provides 1"23 ml o f w a t e r per 100 calories {Bender 1973).

Vztamins. T h e Food and Nutrition Board, National A c a d e m y of Sciences N A S - N R C (1968) h a v e m a d e r e c o m m e n d a t i o n s on the amounts o f vitamins n e e d e d ,"or Western infants, while the Indian Council of Medical R e s e a r c h (1968) has not recommended a n y a l l o w a n c e for I n d i a n infants except for V i t a m i n A. For I n d i a n infants, the s u p p l e m e n t a t i o n o f the diet of lactating mother with vitamins has been recomm e n d e d to provide a d e q u a t e a m o u n t s to breast fed infants d u r i n g the first y e a r o f life. No specific studies have been m a d e so far to d e t e r m i n e the v i t a m i n r e q u i r e m e n t of Indian infants. However, G o p a l a n a n d Narsinga R a o (1971) on the basis of a d e q u a t e breast milk intake have c o m p u t e d the v i t a m i n intake of infants up to 6 months' of age for satisfactory growth. Vitamin A . T h e daily needs of infants for vitamin A till the age o f six months may, be considered to be b e t w e e n 30 a n d 60 p g (preformed) per kg. body weight, preferably nearer to the higher value ( P a t w a r d h a n [1971) or 450 t~g (1500 I . U . ) per d a y

241

(Bender 1373). F A O / W H O (1967) have m a d e a r e c o m m e n d a t i o n for 0-6 m o n t h - o l d infants a n d stated that breast feeding by a wel! nourished m o t h e r is the best w a y to satisfy the needs ot v i t a m i n A. V i t a m i n A content in breast milk o f mothers o f low socio-economic groups is a r o u n d 22 t~g per I00 mi (Belavady a n d G o p a l a n 1959, P a t w a r d h a n a n d K a m a l 1967) which is very low in comparison to 49 t~g per 1 0 0 m l of well nourished c o m m u n i t i e s ( M a c y el al. 1953). These studies suggest that infants especially o f m a l n o u r i s h e d mothers, require s u p p l e m e n t a t i o n of v i t a m i n A after 3-4 months a n d infants o f w e l l nourished mothers after 6 months. T h e a m o u n t o f vitamin A which is necessary for satisfactory growth, m a i n t e n a n c e o f liver stores a n d plasma level in an infant put on supplem e n t a r y diet with partial w e a n i n g c a n n o t be assessed, as no control studies have been m a d e to e v a l u a t e these aspects. Vitamin D. T h e need for v i t a m i n D is 400 I.U. per d a y . Since .both h u m a n a n d cow's milk a r e poor in the vitamin, supplementation with v i t a m i n D is necessary (Smith a n d Malthus 1962). P r e m a t u r e infants should be given s u p p l e m e n t a t i o n of vitamin D earlier t h a n n o r m a l infants. V i t a m i n D helps in the prevention of rickets, calcium transport in the intestine a n d mobilization of bone minerals (Morrii et al. 1967). T h e efficacy of v i t a m i n D in p r e v e n t i n g rickets, in p r o m o t i n g intestinal absorption o f calcium a n d in p r o m o t i n g liver growth is the concern of m a n y gtudies and has been discussed by the C o m m i t t e e on Nutrition (1963). A good deal o f progress has been a c h i e v e d in regard to the calcium transport c o m p o n e n t s of the intestine i n d u c e d by v i t a m i n D. N u m e r o u s studies (Wasserman

~/1'2

II',II)IANJOURNAl, OF I'~,DIATIIIeS

a n d T a y l o r 1966, T a y l o r a n d Wasserman 1967, W a s s e r m a n et at. 1968) h a v e sugg*;sted that the protein bound c a l c i u m ion which appears in the c y t o p l a s m i c fraction a f t e r v i t a m i n D administration, plays some r o l e in all absorption processes o f ealchxm. T h e current view of intestinal absorption of calcium i n d u c e d by v i t a m i n D in the intestine is possibly through a molecular m e c h a n i s m (Deluea 1970) bt, t is not yet fully defined. Any i m p a i r m e n t in the conversion o f v i t a m l n D to the biologically i m p o r t a n t 1 ~-25-hydroxy d e r i v a t i v e or a n y inhibition o f its binding to the nuclear membrane affects c a l c i u m absorption (Deluca 1970, Scriver 1970, Blunt and D e l u c a 1969). L a r g e r doses o f v i t a m i n D produce h y p e r c a l c e m i a which in its severe form is associated with mental retardation ( C o m m i t t e e o n Nutrition 1963). Babies f e d w i t h higher doses o f v i t a m i n D , however, showed increased absorption o f c a l c i u m but w i t h clinical s y m p t o m s o f v i t a m i n D into.dcation (Belkina 1971). Vuamin E. T h e r e q u i r e d daily a l l o w a n c e for infants one y e a r o f age is 5 I . U . with a

ratio o f 0.6 nag a-tocopherot per g r a m p o l y - u n s a t u r a t e d fatty- acids (E/PUFA) being desired ( N A S - - N R C !968). The amportance o f v i t a m i n E a n d its evaluation in the infant's diet up to one y e a r o f age has been r e v i e w e d by Davis (1972). The v i t a m i n E c o n t e n t o f milk, milk products and s i m u l a t e d milk for infants is found to be a d e q u a t e f o r infants ( H e r r i n g a n d Drurv 1969) either in terms of the total a m o u n t o f v i t a m i n 17. present or the low v i t a m i n ( E / P U F A ) ratio. Linoleic acid is o f t e n used as a critical fatty acid in d e t e r m i n i n g the r e q u i r e m e n t o f v i t a m i n E. I t has been

VOL. 43. N t~ suggested that 0.f3 m g o f 0 c , t o c o p h e r ~ required t o b a l a n c e 1 O. o f l i n o l e i e r ~ ( N A S - N R C 1969). T h e a d m i n i s t r a t l o l l v i t a m i n E in larger infants resulted&! significant rise in blood cel!slplasma ratio, but in p r e m a t u r e int.'rots, this did occur (Samuel a n d G u i l f o r d 1970). reason for this lipid shift is obscure requires fltrther study. I t has been r e c o m m e n n a that all the newbor~i should be given 0 . ~ 1.0 m g of v i t a m i n K per d a y p a r e n t e r ~ as a prophylaxis a g a i n s t h a e m o r r h a disease o f the n e w b o r n ( C o m m l t t e e ' ~ Nutrition lq61). Breast feeding has b ~ implicated by S u t h e r t a n d a n d his a s s o c i t (1967) as a n i m p o r t a n t fa,c t o r i n aet~ology of h a e m o r r h a g i c disorders in newborn. Oow's milk c o n t a i n i n g h i ~ v i t a m i n K than breast milk is k n o w n t o more effective in correcting vitamin deficiency in the n e o n a t e ( G o l d m a n a i r A m a d i o 1969, S u t h e r ! a n d et al. i 9 6 ~ Vitamirt K s u p p l e m e n t a t i o n for i n f a ~ receiving milk substitute i n f a n t - f o r m u l a e ~ been discussed by the C o m m i t t e e on N u t l ~ tion (1971). 50 /zg;litre of v i t a m i n E ~.~ infant milk f o r m u l a e s e e m e d to be a ~ adequate amount. All m i l k substittttll formulae containing tess t h a n 25/~g/litre.~lm v i t a m i n K should be s u p p l e m e n t e d t o ~ level of 100 t~g/litre o f v i t a m i n K. Vitamin K.

B Vitamins. H u m a n milk n o r m a l l y coroll

t a i n s a b o u t h a ! f a s m u c h t h i a m i n e as t ~ present in cow's milk, but t h a t o f thiamlni~ deficient mothers :contains m u c h low"~ (Guthrie 1967). h f f a n t i l e beri-beri ocetu~ most frequently at the age o f 2-5 montlt!l especially a m o n g infants _nursed s o l e l y ~ breast milk tBrozek 1957, Salcedo t 9 6 2 ~

'.~ARAIN A N D D U B A S H - - N U T R I T I O N A l . , KEQUIRI~MI~N'I',~ O1, INFANTS

The infant's diet should be s u p p l e m e n t e d by 2-5 m o n t h s of age, giving m u c h m o r e attention to the infants o f d e v e l o p i n g countries w h o d e r i v e c o n s i d e r a b l y less a m o u n t o f t h i a m i n e from breast milk (NASN R C 1958, G o p a l a n 1956, G o p a l a n a n d Narsing R a o lq71). T h e I n d i a n Council of M e d i c a l R e s e a r c h (1968) has recommt.nded the s u p p l e m e n t a t i o n o f the diet of lactating m o t h e r s to p r o v i d e adeq~mte amounts o f B v i t a m i n s to the infants. Infants w i t h low i n t a k e of pyridoxine showed signs o f hyperirritability a n d convulsions (Coursin 1969, Scriver a n d H u t c h i s o n 1963). T h e p y r i d o x i n e n e e d is related to the p r o t e i n i n t a k e a n d is 20 ~g per G. of dietary p r o t e i n (Coursin !969). During processing o f m i l k food products, 45-70 % of p y r i d o x i n e present m a y be lost a n d this leads to a deficiency (Davies et al. 1959). T h e biotin c o n t e n t o f breast m i l k ( n o r m a l l y 1110 to 1115 of that o f cow's milk) diminishes even m o r e d u r i n g infection or malnutrition

( N e u w e i l e r et al.

1949, Sve-

Jcar a n d H o m o l k a 1950). I n f a n t s with seborrheic d e r m a t i t i s u n d e r 6 m o n t h s of age were r e p o r t e d to recover w h e n biotin containing foods such as liver a n d egg yolk were a d d e d to the n o r m a l d i e t (Sve-Jcar and H o m o l k a 1950, N i s e m o n 1969). Q u i t e a n exhaustive study has been m a d e on the p a r t i c i p a t i o n of the B vitamins in physical a n d physiological processes of the b o d y a n d their deficiency syndromes. All the m e m b e r s of the v i t a m i n B c o m p l e x possess in c o m m o n a c e r t a i n similarity of action b u t at the s a m e time, each one o f t h e m iX~ssesses a n u m b e r of i n d i v i d u a l traits. T h e ~liet o f infants should be m o n i t o r e d a d e q u a t e l y to m e e t the n e e d e d a m o u n t o f all B vitamins.

243

Breast fed infants receive 15-20 m g per day o f ascorbic acid while cow's milk provide.g only a very little a m o u n t a n d m a i n t a i n s m u c h lower b l o o d levels (Abt e t a l . 1963). Ascorbic acid s u p p l e m e n t a t i o n should be started on the day the child is born. N A S - N R C (1968) has r e c o m m e n d e d 35 m g o f ascorbic acid per d a y as a d i e t a r y allowance. ICIVIR (1968) has not m a d e any r e c o m m e n d a t i o n for I n d i a n infants up to one y e a r hut supplem e n t a t i o n of the m a t e r n a l diet with ascorbic acid to an extent of 30 m g m o r e t h a n the n e e d e d a m o u n t has been suggested to p r o v i d e d a d e q u a t e a m o u n t o f this v i t a m i n to breast fed infants. D a r i n g infancy, characteristic bone changes in scurvy caused by v i t a m i n C deficiency have been r e p o r t e d by m a n y workers (Lorenz 1954, G r e w a r 1965, Ossofsky 1965). An a d e q u a t e s u p p l y o f v i t a m i n C has b e e n c l a i m e d to increase Vitamin C.

resistance to infection, physical g r o w t h u p to one year o f age a n d increased absorption o f iron being a v a i l a b l e in the f~n'ous state (Whitacre e t a l . 1959, A p t e a n d V e n k a t a c h a l a m 1965, M c C u r d y a n d D e r n 1968). Ascorbic acid has a n essential role in the functioning o f c e r t a i n e n z y m e s ( K i n g 1970). T o m e e t the a d e q u a t e r e q u i r e m e n t ot v i t a m i n C, breast m i l k should be fortified with this v i t a m i n by prescribing a diet high in v i t a m i n C for the m o t h e r a n d from the second a n d third m o n t h s , breast-fed babies should be given v e g e t a b l e a n d fruit juices. Babies w h o are raised on m i x e d diet or on the bottl+ alone n e e d v i t a m i n C fortified juices to m e e t the r e q u i r e m e n t of this important vitamin. Need for Supplementation of Milk T h e best substitute for breast milk,

"244

X~,,XANJOURNAL OF PED|ATRICll

certainly the most c o m m o n l y used are cow's milk, modified lmffalo's milk and c o m m e r cially p r e p a r e d infant milk formulae. Different types o f infant foods based on cow's milk are available in the market. A l t h o u g h milk contributes a significant portion of the infant's r e q u i r e m e n t of calories, protein, calcium and vitamins d u r i n g i n f a n c y it is grossly deficient in iron a n d some vitamins. It is therefore not a perfect food for infants and it should be fortified with the necessary vitamins a n d minerals. T h e s u p p l e m e n t a t i o n o f the milk formula with iron a n d vitamins has been emphasiscd hy m a n y authors (Filer a n d 'Martinez 1963, 1964, Filer 1971). Modilac, a f o r m u l a m a n u f a c t u r e d by the Gerber Products C o m p a n y , was designed to m e e t the nutritional d e m a n d s o f growing infants. Available as double strength (20 cal per ft. oz 30 ml) a n d single strength in ready-tofeed disposable feeding bottles, the tbrmula has b u t t e r fat r e p l a c e d by coma oil which has a higher linoleie acid c o n t e n t a n d is fortified with iron a n d ~,itamins (Gerber Co. Report 1969). Limit

on Milk

Intake

O ' C o n n e r (1967) has issued a rem i n d e r that excessi,se milk intake caused iron d e f i c i e n c y a n a e m i a in toddlers and preschool children and therefore r e c o m m e n d ed a restriction in m i l k iv,take at a level of 32 ft. oz. (960 m l ) p e r d a y regardless of the age. I f one agrees to the concept o f limiting m i l k intake to n o t m o r e than 32fl. oz. (960 m l ) p e r . d a y and c o m p a r e s -the daily -caloric r e q m r e m e n t s of the growing infants a p p r o x i m a t e d by N a i m a r k (1957) growth s p e c t r u m ( T a b l e 5) d u r i n g the first y e a r of life on the basis o f 32 (960 ml) and 24 ft. oz. (720 m l ) o f whole milk intake per d a y , it

Vol. 43, N~' can readily be seen from Tabl large babies (10-1l lbs. (4.5-5 s weight) do not get their caloric ments from eitiwr 32 (960 ml) or (720 ml) of milk from as early as t h e ~ m o n t h of life. Average babies n e e d tional calorie than those suppli.ed by oz. (960 ml) of milk intake from t h e ~ o f 3 to 4 months a n d the smaller b.alm require calorie s u p p l e m e n t a t i o n f r o m ~ age of 6-9 months as seen f r o m T a b l e 5. Fortification

of Milk

or Milk

Formltln

Vitamins T h e a m o u n t of v i t a m i n A r e q u i r e m n is not met with by the feeding of a milk d l alone to the infant from the third m o n t l i life (Died and Litwin 1966). I n f a n t r e q u l ments and the a d e q u a c y of a milk e l i in infant nutrition have already b t ~ discussed. T h e intake of vitamin fortified e~,aporated milk has been reportI to cause respiratory infections (Sturrolm

1952) a n d feeding of overfortifie'd vitamizl~ milk showed hypervitaminosis symptonJ in infants ( C o m m i t t e e on Nutrition 196~t1 H e a t labile vitamins like t h i a m i n e aetll ascorbic acid are substantially lost bv heal sterilization of the formulae. A variety s u p p l e m e n t a r y foods have been r e c o m m ~ ' ) ed to meet the infants' v i t a m i n requiremei~. ( C o m m i t t e e on Nutrition 1958, 1969; Dieli and L i t ~ i n 1966). Iron

Iron deficiency disease is the mo~ c o m m o n disease all over the world :m rapidly growing babies a n d children. It'll specially ~revalent in infants b e t w e e n age of 6-24 months. I f tt-e inf=nts' diet:~ not a d e q u a t e in iron content, iron deficieni'~ m a y exist in infants as a subclinical;till

gCAR,XIN AND DUBA.~ll ~ N U T R I T I O N A L

T a b l e 5.

245

I~F,Q UII~.F_,MEN'I'~ OF INFAN'I']~

I)a~ly~alor~e requirements during the first year o.["infam's life related to calories supplied by formulae or ~hole milk. D a i l y caloric intake at a g e ot "a

I month

4 momhs

LB

AB

SI',

I,i;

725

520 360

925

AB

G months

SB

690 480

LB

l0 months

AB

SI"

1025 785

550

I.B

AB

SB

1195 1000 725

Ca!gries from milk oJ Jormulae above

a.

24 ft. oz. (720 ml) milk p e r day-----480 calories 32 ft. oz. (960 ml) milk p e r d a y = 6 5 0 calories approximated from Naimark growth s p e c t r u m (! 957)

m a r g i n a l d e f i c i e n c y state ( L a h e y 1957) to a c o n s i d e r a b l e e x t e n t ( S t u r g e o n 1954) even w i t h e x c e l l e n t diets a n d in spite o f a d e q u a t e h a e m o g l o b i n c o n c e n t r a t i o n ( S c h u l m a n 1961). M a r s h et al. (!e~59) h a v e r e p r o t e d significantIv higher h a e m o g l o b i n , h a e m a t o c r i t a n d s e r u m iron in 3-9 m o n t h - o l d infants fed iron fortified m i l k f o r m u l a e t h a n those fed on f o r m u l a e w i t h o u t iron. I r o n fortification o f milk f o r m u l a e seems to be a n effective w a y to m e e t the iron req~,ir~ment o f infants o f 3-8 m o n t h s o f age, but a s y n d r o m e o f chronic b l o o d loss d u e to gastrointestinal i n t o l e r a n c e to w h o l e c o ~ ' s milk is n o w b e l i e v e d to b e a c o m m o n cause o f iron deficiency a n a e m i a a n d iron e n r i c h m e n t o f w h o l e m i l k m a y not be a d v i s a b l e since chronic b l o o d loss ~ill c o n t i n u e a n d p r o b a t?ly o v e r r i d e the d i e t a r y i n t a k e o f iron (Filer 1970). A n o t h e r p r o b l e m in the fortification o f Whole m i l k w i t h iron is the o b s e r v e d inverse

LB: L a r g e b a b i e s AB: A v e r a g e b a b i e s SB: S m a l l b a b i e s

r e l a t i o n s h i p o f d i e t a r y p r o t e i n to a v a i l a b l e iron. Iror, c o n t a i n i n g i n f a n t m i l k f o r m u l a e that h a v e b e e n s h o w n to be effective in p r e v e n t i n g n u t r i t i o n a l i r o n deficiency p r o v i d e b e t , a e e n 1.5 a n d 1.8 G. lzrotein p e r 100 mi. Iron at a level o f 8.0 m g p e r 32 ounces (960 m!) o f w h o l e milk a d d e d in the form o f ferrous s u l p h a t e is r e p o r t e d to be inefficiently u t i l i z e d for h a e m o g l o b i n synthesis f i o m a f o r m u l a c o n t a i n i n g 2.2 G. p r o t e i n per 100 ml than f i o m fi~rmulae c o n t a i n i n g 1.5 G. o f p r o t e i n per 100 ml. T h u s p r o t e i n conc e n t r a t i o n o f the milk f o r m u l a e s e e m s to play an i m p o r t a n t role for iaon a b s o r p t i o n a n d therefore, milk c a n n o t be fortified w i t h a d e q u a t e iron (Filer 1970). T h e use o f easily a w l i l a b l e iron fortified cereals or h.,poallergenic drinks c o n t a i n i n g a low protein at a level o f 2 G. p e r 100 ml will p r o b a b l y b e m o r e useful in m e e t i n g t h e infants' n e e d for iron d u r i n g tile first t w o v e a l s o f life.

246

INDIAN JOURNAl, OF I'F,DIATRIG~ Growth

Pattern Indian

of American

VOL. 43~ NO

Infants

T h e g r o w t h pa~tern o f A m e r i c a n a n d I n d i a n i n f a n t s differ c o n s i d e r a b l y after 5-6 m o n t h s o f life. Possibly this is d u e to the r e a s o n that A m e r i c a n infants start getting s u p p l e m e n t a r y fi)ods after 2-3 mtmths o f life w h i l e I n d i a n infants d e r i v e most o f the n u t r i e n t s f i o m rrtothcr's mi!k "Jr c o w ' s milk, b o t h o f w h i c h , as has a l r e a d y b e e n discussed are i n a d e q u a t e in quantity as well as in q u a l i t y a f t e r 5-6 m o n t h s . T h e g a i n in w e i g h t a n d height o f A m o r i c a n infants h a v e b e e n c o m p a r e d w i t h I n d i a n infants a n d a r e s h o w n in figures 1 a n d 2. I t will b e s e e n t h a t w e i g h t a n d height g a i n in I n d i a n i n f a n t s slow d o w n a f t e r 5 to 6 m o n t h s o f the i n f a n t ' s life. T h i s is dtae to i n a d e q u a t e n u l r i t i o n w h e n the breast milk b e c o m e s less in q u a n t i t y a n d p r o p e r s u p p l e m e n t a t i o n o f t h e infant's d i e t is lacking ( G h o s h et al. 1971). M o s t I n d i a n infants c o n f o r m to this p a t t e r n . a--.A

A M E R I C A N INF&NIS (MALES).

.....

AMERICAN INFANTS (FEMALES)

o

INDIAN

o

Physiologic

vs.

INFANIS

A c c o r d i n g to the p h y s i o l o g i c a l d e r a t i o n s , infants a r e a b l e to digest, a~stNm late a n d utilize m a n y solid t o o d s a v a i l a b l e in a finely d i v i d e d s t a t e b u t does not necessarily p r o v e their r e ~ d h l ~ for solid t b o d u m i l a l a t e r age ( C o m m i J on N u t r i t i o n 195};). As the c h i l d m a t u l ~ the s e c r e t i o n o f p r o t e o l y t i c enzyme~ in " ~ intestinal j u i c e increases the c a p a c i t y o f ~ / infant to digest n o n - m i l k p r o t e i n s a n d tim g e n e r a l l y h a p p e n s a f t e r 4 to 6 m o n t h s o f a m T h e tub~des o f t h e k i d n e y also b e c o m e ~lm cient by 6 m o m h ~ o f the infants a g e mak~lm them c a p a b l e o f h a n d l i n g a high p r o t e i n high s o d i u m d i e t ( C o m m i t t e e on N u t r i t i ~ 1958, G u t h r i e 1967). S u c k i n g a n d s w a l l o l ing reflexes a r e f u n c t i o n s w h i c h a r e v i t a l n e w b o r n infants a n d a r e b o t h e s t a b l i s l ~ parenterally (Gryboski 1965, 196gl B a c k w i n (1953) has p o i n t e d o u t that b y or 4 m o n t h s o f age, the i n f a n t is c a p a b l e ~t transferring solid f o o d p l a c e d in the fro~ o f his m o u t h to the b a c k o f the tongui o---o

AMERICAN INFANTS (MALES)

x- -.~

AMERICAN INFANTS (FEMALESi

s 11000 Ln ' 10000 :c < 9000 iY to 80 O0 z

t--r

considerationu

=

INDIAN

INFANTS

i

80 75

~E

7000 6000 SO00

{...)

70

Z

65

S

60

4000

55

300 0 LU 117

2000 1000 o

0

3rn

t

6m

,

e

50

!

l

9rn

12m

Fig. 1. Gain in welgdt in first year in normal infants.

0

3m

,

J

6m

o

9m

I

12m

Fig. 2. Gain in height in first )'ear in normal infant.*

Taken from Ghosts et al. (1971).

~AIgAIN AND

DUBASl! -

NU! RI'I'I(INAI, REOUIREMEN'iS

followed by swallowing. O n the basis of these considerations, the earliest age at which an infant is r e a d y to accept solid food is 3-4 months.

Advantages of mixed dlets T h e use o f supplementary food in addition to a milk diet is essential for an infant by 3-6 months o f age to prevent a drop in haemoglobin to a level o f less than the n o r m a l blood level of 12 G. per 100 ml (Committee on N u t r i t i o n 1969). L a h e y and Schubert (1957) have favoured the introduction of a mixed diet to prevent anaemia observed with a milk diet alone. Infants solely fed on whole milk preparations showed iron deficiency a n a e m i a (Committee on Nutrition 1969, C h a n d r a 1965). B r e n n e m a n n (1949) was also in favour o f e a r l y introduction of solid foods at a r o u n d 6 months o f age and claimed their a d v a n t a g e because o f easily available iron and vitamins and prevention of difficulties o f learning to chew. Beal a al. ( 1 9 6 2 ) h a v e stated that most infants fed on m o d e r n infant foods based on on|v milk are in j e o p a r d y o f a d e q u a t e iron supply a n d s u p p l e m e n t a t i o n with a variety of diets has been r e c o m m e n d e d . A n d e l m a n and Sered (1966) have stressed the need for exogenous iron, definitely after 6 months of age. ~qutritional c o n s i d e r a t i o n

of mixed diet

T h e r e is no substantial p r o o f o f superior nutritional status of infants consuming IgSupplementary solid foods before 2-3 months ~fage; after this period s u p p l e m e n t a r y foods ~aust be included in the infant's diet. ~knderson a n d F o m o n (1971),ehave stated ~that the c o n s u m p t i o n o f 100 G. cereal ~iluent m i x t u r e (15 G. d r y infant cereal: ~$G. milk) p~-~rd a y by the 6-12 m o n t h - o l d

OI

INVANTS

2.t7

infant provides 93% of the r e c o m m e n d e d d i e t a r y allowance of'iron and a sttbstantial contribution o f protein, calorie a n d vitamin requirements. L e v e r t o n et al. (1952) have observed that the a d d i t i o n of strained m e a t to the formula of bottle-fed infants promotes the fi~rmation of h a e m o g l o b i n a n d e r y t h r o cytes. T h e strained m e a t is an excellent source of available iron for p r e m a t u r e infants a n d contains all the essential a m i n o acids in higher c o n c e n t r a t i o n to produce adeqttate growth if protein r e q u i r e m e n t is m e t with (Sisson et al. 1951, Jacobs et ol. 1952). It is reasonable to believe that the infants are m o r e likely to get a d e q u a t e nutrition on a m i x e d diet suitably supplem e n t e d at the proper time. Cereals are generally a c c e p t e d between 289 a n d 3~months, vegetables b e t w e e n 4 a n d 4~ months a n d m e a t vegetable soup b e t w e e n 589 and 6 months o f age. Fruit a n d fruit juices should be given earlier than the cereal p r e p a r a t i o n but sometimes together ( C o m m i t t e e on Nutrition 1958). T h e recent report o f the C o m m i t t e e on Nutrition (1969) has suggested that the most effective w a y to prevKnt iron deficiency a n a e m i a is by providing an iron fortified d i e t a r y staple by 6 weeks to 18 m o n t h s o f age but no nutritional superiority or psychological benefit seems to result from the introduction of solid foods into the infant's diet prior to this age. T h e F A O / W H O (1970) Expert Group has stressed the need o f s u p p l e m e n t a r y food, since breast milk alone is not a d e q u a t e for infants aged 4 months or more. However, the C o m m i t t e e has d e p r e c a t e d the trend towards early w e a n i n g o f infants especially in developing countries where good supplem e n t a r y foods are not available or the economics of these foods are b e y o n d the reach o f the parents. Every effort should

24~

INDIAN

j.. ..U. R . .N. . . . . . . .

~,,

VOL. ,-1.O "" 9 N o . ~ m l

I ' I { D I A T I t l t ;,c;

ttmrefore be m a d e t,, dov,;Iop infant foods as a substitute, to cow's milk, a n d infant w e a n i n g foods from indigenous re.~ourc~..s like groundnuts, legumes a n d cereals in d e v e l o p i n g countries should prov~ useful supplements. Although the nutritional value o f solid |hods c o n s u m e d in the first few months o f the infant's life is usually o f m i n i m u m significance, the major a d v a n t a g e in favour o f their ttse is that the child b e c o m e s accust o m e d to a w i d e variety o f flavours and textures o f these foods a n d continues to a c c e p t n o r m a l family meals as he matures. F o r o l d e r infants, the introduction o f iron rich cereal p r e p a r a t i o n s , m e a t v e g e t a b l e preparations a n d fruit juices along with a milk d i e t in a p p r o p r i a t e a m o u n t s supplies a d e q u a t e nutrition for their proper physical a n d physiologica.l d e v e l o p m e n t . H o w e v e r , breast feeding should be encour a g e d at all levels at least throughout the first y e a r o f life. Conclusions

I t is e v i d e n t from the i n f o r m a t i o n c o l l e c t e d here that though considerable advances h a v e b e e n m a d e in our k n o w l e d g e o f nutritional r e q u i r e m e n t o f infants, these are confined to only a few. Efforts should therefore be m a d e to e d u c a t e the rural and u r b a n mothers through G o v e r n m e n t agencies a b o u t the i m p o r t a n c e o f i m p r o v e d nutrition d u r i n g infancy. T h e Protein F o o d Association o f I n d i a though m a k i n g constant efforts to i m p r o v e the nutritional status o f I n d i a n infants, e x p e c t a n t a n d nursing mothers, requires m u c h m o r e aid to achieve concrete results. E n o u g h scientific k n o w l e d g e is still a w a i t e d especially in d e v e l o p i n g countries to bring a b o u t c o n s i d e r a b l e i m p r o v e m e n t in the nutritional health o f infancy a n d to

eliminate faulty w e a n i n g practices preval& ew-n in the m i d d l e a n d u p p e r h a c t ~ grnups. An e x p l o r a t o r y survey o f the ftm c o n s u m e d by infants from families o f dit~lm rent e c o n o m i c groups should be m a d e tim assess the actual c o n d i t i o n prevailing a l ~ thereby to set up a n a t i o n - w i d e programmm to feed this v u l n e r a b l e group which is tll~ e m b l e m a n d hope o f t o m o r r o w ' s society. Despite milk being a significant soure~ o f basic food constituents, it is not a per(ee~ food for infants as some o f the nutrients lik~ vitamin C and iron are not present in it lit a d e q u a t e amounts. M i l k therefore shoul~ not be used exclusively in the infanrm diet a n d w h e n used, should be fortified witl~ iron a n d essential vitamins which a r m lacking in it; in the p r o p e r way. T h e provision o f s u p p l e m e n t a r y foocTtto the milk diet o f infants is very necessat~ To improve the d i e t a r y status o f infants, Iron fortified cereals a n d strained bab,r foods should be i n c o r p o r a t e d irt the infant's d i e t along with milk to assure proper nutrition. S u p p l e m e n t a t i o n o f 400 units of v i t a m i n D and 30 m g v i t a m i n (3 should be p r o v i d e d definitely after 3 months o f life. I n f a n t foods based on oil-seed meals especially groundnuts, cereals and pulses wil! definitely prove helpful to supplement the shortage o f milk supply. An infant food based on g r o u n d n u t has a l r e a d y b e e n d e v e l o p e d at C F T R I , Nix'sore but more. efforts are required to e x p l o r e its practical use and feasibility. ReE~Te~CeS .

3-;~

Abt, A.F., Vonschuchmg, S, and Enns, T. (106)~ Vitamin C requirements of man reexamined. Amer.~4

Clin..A'utr. 12, 21. Albanese, A.A., Higgons, R.A., Hyde, G . M . ax~ Otto, L. (1955). Biochemical and nutritional effects ~ lysine--reinforoed diets, lbid, 3, 121.

,~ARAIN AND DUBA~CH--NUTRI'I'IONAL RE~,~UIREMgNT~OF INFANTS Idem. (l~)~fl) l.y~ine and tryptophan content of protein~ and their utilization for human growth. Ibid. 4, 161.

Anddman, M.D. and E]wood, P.C. (I9fifi). Symptoms of iron deficiency anemia, community ~urvey. Brlt, ~. Prey. Soc. Med. 20, 117. Andelman, M D. and Sered, B.R. (l~fi6). Utili~tion of dietary iron by t,:rm infants. Amer. ]. Dit.

Child. ZIl, 4~. Andermn, T.A. and Forr,'~n, S.J. (1971). Commerdally prer~ared infant cmreal~: Nutritional consideration*. 07. Pedlar. 7B, 788. Anonymous. (1.m of the neonate. Pediatrics, 35, 445.

Fomon, S,J., Filer, L J Jr., Thom~_% L.N., Rogers, R.R. and Proksch, A.M. (igq'.)). Relaziomhip bet',~:een formula concentrati6n and rate of growth of normal infants. 3. ~Vutr. !gB, 241.

Gueguen, L. (1071). Mhneral composition of milk and its adaptation to the mineral need~ of the young. Ann..Vutr Aliment. 25, 335.

Gerber Go. Report (1969~. Cunent Practices in Infant feeding. A text of professional communication Department, Gerber Products Company, Michigan, U.S.A. Ghosh, S., Bhargava, S.K. and Bhargava, V., 9(1971). Growth pattern of babies in Delhi area in the first year of life. In Proceed. o~'the Nutr. Soe of India. ~Vutrition, Growth and Development No. 10, p. 82..Vational Institute of Nutrition, Hyderabad. Goldman, J.I. and Amadio, P. (lc6.q). Vitamin K deficiency after the newborn period. ?ediatHcs, 44, 74.5. Gopalan, C. (1956). Protein inw.ke ol breast fed poor Indian infants. 07. T, op. Pediat. 2, $9. Gopalan, C. and Belavady, B. (1960). Nutrition and lactation. Fed. Prof. 20, 177.

Gryboski, J.D. (196!~). Sucking and swallowing in the permature infants..Pediatrics, 45, 96.

Guthrie, H.A. (1967). Introductory Nutrition. Mosby, St. Louis. p. 182,212, 311, 332. Gyllenberg, H H., Rossander, M. and Roine, P. (1953). Strains of Lactobadllus bO~dus which requires strepogeain, ft. Gen. Mic~obiol. 9, 190. Gyorgy, P., Mello, M.I., Tores, F.E. and Barnes,s, L.A. (1953). Growth promotion in rats by crude concentrates of the LactobadUus bifidus (growth factor). Proc. Soc. ExptL Biol. Meal. 84, 464. Gyorgy, P., Dhanmitra, S. and Streers, E. (1962). Protective effects of human milk in experimental StaMLvlococcus infection. Science, 137, 388. Hagberg, B., Axtrup, S. and Berfenstam, R. {1953}. Heavy metals in the blood of the foetus and infant. Etud-neo-natal 2, 81.

252

INDIAN

JOtmUaL o r vntnAT~ttr

VOL. 43, N o ,

|tallberg, L.(I971). Iron requirement in children. In Proc. of Nutr. Soci. of ltJdia tm NutT. Growth and Development No. 111,]',..38. Natlot,ai ir~titute ot Nutrition, Hyderabad. llansen, A.E., Withe, 11.1"., !'oelsciz, A.N., Haggard, M,E., Adam, D.J.D. and Davis, Ii. (19631. 12.ole oflinolcic acid in infant nu|rilior,. ,..a:..,.:.., ~l 171. Hcgsted, D.M., Mackibbin, J . M . and Drinker, O.K. (1945). The Biological, Hygienic and Medical Properties of Zinc and Zinc Corr, pounds. Pub. Ileahh Rep. (Supplements) No. 179. Henry, K.M. (1957). The nutritive milk. Dairy Sci. Abstr. 19, 60a, 692.

value of

Herting, D.C. and Drury, E.E. (1.9~9). Vitamin E content of milk, milk products and simulated milk products in relevance to infant nutrition. Amer. o7. Glin. Nutr. ~9, 147. Holt, L,E. Jr. (1959). The protein requirement of infants. 3 . Pediat. 54,49,6. Holt, L.E. J r , and Snyderman, S.E. (1965). Protein and amino acid i~equiremenr of infants and children, aVtar. Abst~. and lgev. 35, I. Hopkins, L.L. Jr., Rtmsome -- Kuti and Majaj, A.S. (196g). Improvement of impaired carbohydrate metabolism hy chromium II in malnourished infants. Amer. ft. CAin. aVutr. 21, 203. Houtsmuller, U.M.T. (1971). Evaluation of modern foods as source of lipids. Lipid-malnutrition and Developing Brain Symposium, (Pub. 1972). Assoc. Sel. Publ., Amsterdam. p. 213. Huettig, G. (1969). Problems in the nutrition of premature infants. Ernaehr Umsch. 16, 387. I.C.M.R. (1968). Recommended Dietary Allowances for Indians. LC. M.R., New Delhi.

failure due to maternal deprivation, under n*atr~t and congenital heart disease. Pediatrics, 44, 647. 1.ahey, M.E., (1957). Iron deficiency arlei,~ Pediat. Ciin. A orth A,ner. Saunders, Philadelpll p. 481.

],almy, M.E. and Schubert, W.K., (1957). i'~ deficiency syndrome occurring in infancy. (AbstrnA~ Amer. .7. Dis. Chdd. 93, 31. Leverton, R.M., Clark, G., Bancrofq P.M. a Copeman, C. (1952). Further studies of the ~ e , meat in the diet of infants and young children. Pediat. 40, 761. Loreez, A.J. (19541. The conquest of seurvr .~. Am. Dieter. Assoc. 30, 664. M'ackeith, R C. (1963). Proc. .N'utr. Soc. 22, 128.

Is a big baby healthy

Macy, I;G., Kelly, H . J . and Sloan, P.F. ( 1 9 ~ The Composition of Milks. National Academy Science. Washington D.C. Publication 254, p. 54. Majaj, A.S. and Hopkins, L.L. Jr. (1966). rrium and kwashiorkor. Lancet, 2, 59"2. Ma='sch, A., Long, H. and Steerwalt, E. (1959) Comparative haematoiogic response ta iron fortificati~of a milk formula for infants. Pediatrics, 24, 404. McCance, R.A. and Widdowson, E.M. (t964) Protein metabolism and requirement.~ in the newborrt In Mammalian Protein Metabolism. Munro, H . N and Allison, J'B. (eds.} Academic Press, New Yorl~ X'ol. 11, p. 225. McCurdy, P.R. and Dern, R . J . (1968). Thera~ peutic implication of ferrous sutphate--ascorbic acid mixtures. Amer. ~. Clin. _Afutr. 21,284.

Jacobs, H . H . and George, G.S. (1952). Evaluation of meat in the infants" diet. P, diatrics, 10, 463.

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~ 949).

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l~rcast

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Iron

requirements

in

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Comments.

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VOL.

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Nutritional requirements of infants and need for supplementing milk diet with infant weaning foods.

lndtam .7. Pedlat. 4~: 232, 197G NUTRITIONAL REQUIREMENTS OF INFANTS AND NEED EOR SUPPLi~MI~N/ MILK DIET WITH INFANT WEANING FOODS* BRI.JF,SH NARAIN...
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