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Choice of Foods and Ingredients for Moderately Malnourished Children 6 Months to 5 Years of Age

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Choice of Foods and Ingredients for Moderately Malnourished Children 6 Months to 5 Years of Age Choice of foods and ingredients for moderately malnourished children 6 months to 5 years of age Kim F. Michaelsen, Camilla Hoppe, Nanna Roos, Pernille Kaestel, Maria Stougaard, Lotte Lauritzen, Christian Mølgaard, Tsinuel Girma, and Henrik Friis Abstract quality, especially PUFA content and ratios, in children with moderate malnutrition. There is consensus on how to treat severe malnutrition, but there is no agreement on the most cost-effective way to treat infants and young children with moderate mal- Introduction nutrition who consume cereal-dominated diets. The aim of this review is to give an overview of the nutritional Child malnutrition is a major global health problem, qualities of relevant foods and ingredients in relation leading to morbidity and mortality, impaired intellec- to the nutritional needs of children with moderate mal- tual development and working capacity, and increased nutrition and to identify research needs. The following risk of adult disease. This review will deal with the general aspects are covered: energy density, macronutri- needs of children between the ages of 6 months and ent content and quality, minerals and vitamins, bioactive 5 years with moderate malnutrition. Infants below 6 substances, antinutritional factors, and food processing. months of age should (ideally) be exclusively breastfed, The nutritional values of the main food groups—cereals, and if malnourished, will have special needs, which will legumes, pulses, roots, vegetables, fruits, and animal not be covered here. Moderate malnutrition includes all foods—are discussed. The special beneficial qualities children with moderate wasting, defined as a weight- of animal-source foods, which contain high levels of for-height between –3 and –2 z-scores of the median minerals important for growth, high-quality protein, of the new World Health Organization (WHO) child and no antinutrients or fibers, are emphasized. In cereal- growth standards and all those with moderate stunt- dominated diets, the plant foods should be processed to ing, defined as a height-for-age between –3 and –2 reduce the contents of antinutrients and fibers. Provision z-scores. There are no specific recommendations on of a high fat content to increase energy density is empha- the optimal treatment of children with severe stunt- sized; however, the content of micronutrients should also ing, but it is assumed that children with severe stunt- be increased to maintain nutrient density. The source ing would benefit from a diet adapted for moderately of fat should be selected to supply optimal amounts of stunted children, as pointed out in the proceedings of polyunsaturated fatty acids (PUFAs), especially n-3 this meeting on the treatment of moderate malnutri- fatty acids. Among multiple research needs, the follow- tion [1]. Throughout this review, we have therefore not ing are highlighted: to identify the minimum quantity of distinguished between children with moderate stunting animal foods needed to support acceptable child growth and those with severe stunting. and development, to examine the nutritional gains of A recent (2005) analysis by the Maternal and Child reducing contents of antinutrients and fibers in cereal- Malnutrition Study Group (MCUSG) of data from 388 and legume-based diets, and to examine the role of fat national surveys from 139 countries [2] has provided new estimates of the global prevalence of under- weight, stunting, and wasting among children below 5 years of age, based on the new WHO Child Growth Kim F. Michaelsen, Camilla Hoppe, Nanna Roos, Pernille Kaestel, Maria Stougaard, Lotte Lauritzen, Christian Møl- Standards. Of the 556 million children under 5 years gaard, and Henrik Friis are affiliated with the University of of age in low-income countries, 20% (112 million) Copenhagen, Copenhagen, Denmark. Tsinuel Girma is affili- were underweight, 32% (178 million) were stunted, ated with Jimma University, Jimma, Ethiopia. and 10% (55 million) were wasted, including 3.5% (19 Please address inquiries to the corresponding author: Kim F. Michaelsen, Department of Human Nutrition, University million) who were severely wasted. Thus, about 36 of Copenhagen, Rolighedsvej 30, DK-1958 Frederiksberg C, million children are suffering from moderate wasting. Denmark; e-mail: [email protected]. Underweight, stunting, and wasting each contributes to Food and Nutrition Bulletin, vol. 30, no. 3 © 2009 (supplement), The United Nations University. S343 S344 K. F. Michaelsen et al. child mortality and disease burden. Of the almost 10 to be a “window of opportunity.” Thus, the require- million deaths annually among children below 5 years ments of stunted children may be different for different of age, it was estimated that the attributable fractions age groups. The main difference between the require- of underweight, stunting, and wasting were 19%, 15%, ments of wasted and stunted children will be that and 15%, respectively, whereas intrauterine growth wasted children have a higher energy requirement and restriction and low birthweight accounted for only therefore will also benefit from a higher energy density 3.3%. Altogether, these anthropometric indicators of and a higher fat content of the diet, provided the need malnutrition, using –2 z-scores as cutoffs, accounted for other nutrients is covered. If stunted children, with for 21.4% of child mortality and 21.1% of child disease no wasting, are given a diet with high energy density burden [2]. Of the 14.6% of deaths attributable to wast- and high fat content over longer periods, there is a risk ing, only 4.4% were due to severe wasting, and hence that they will develop obesity. However, in populations 10.2% of the deaths, or about 1 million, were due to with a high rate of malnutrition, it is likely that those moderate wasting. in the age group from 6 to 24 months would benefit The typical diet in populations with a high preva- from a relatively high energy density, even if they have lence of malnutrition consists predominantly of a not yet developed moderate wasting or are “only” starch-rich staple, such as a cereal (maize, rice) or tuber moderately stunted. Thus, a diet with a high energy (cassava), with limited amounts of fruits, vegetables, density could have an important role in preventing legumes, and pulses, and little or no animal-source moderate malnutrition in such populations. When food. Such a diet is bulky, has a low density of energy the need for other nutrients is expressed in relation to and nutrients and a low bioavailability of minerals, energy content, it is likely that the requirements will not and will result in impaired growth, development, and differ much between children with moderate wasting host defense to infections. In addition, introduction of and stunting [4, 5]. Other factors might also influence such a diet too early or contamination of the diet will the requirements of a moderately malnourished child. lead to frequent infections, which will further impair The needs are likely to be different if the child is mal- nutritional status and, hence, increase the risk of infec- nourished because of gastrointestinal problems, with tious diseases. Young children are also likely to be more impaired absorption of nutrients, or is malnourished sensitive to the effect of antinutrients, e.g., high levels mainly due to recurrent infectious diseases, as com- of phytate, which impairs the absorption of several pared with a child with malnutrition due mainly to an growth-limiting minerals, such as zinc. Infants and insufficient diet. young children are especially vulnerable to malnutri- The aim of this review is to identify foods and ingre- tion because they have a high growth velocity and also dients appropriate to treat moderately malnourished high energy and nutrient needs. Growth velocity up to children. These foods should be used to create a diet the age of about 2 years is especially high, and it is also that can fulfill the requirements of moderately mal- during this period that the brain reaches almost 90% of nourished children. Some foods and ingredients of adult size. Global figures on nutritional status have also limited availability may only be appropriate as part of shown that malnutrition among children below 5 years home-based diets in specific settings, whereas others of age develops mainly during the period from 6 to 18 could be used in food supplements distributed by inter- months [3]. This period, which is the complementary national organizations, nongovernmental organizations feeding period, is therefore of special importance and (NGOs), and governments. In table 1, the desirable will be given special attention in this review. Breast- characteristics of such a diet are outlined, and these milk is not included among the foods discussed in this characteristics will be discussed in detail in this review. review, as the importance of breastfeeding, especially Individual foods and ingredients may fulfill only some for malnourished infants and young children, has been of these characteristics. For instance, green leafy veg- emphasized in many other reviews. In the treatment of etables may provide a high content of micronutrients moderate malnutrition, it is very important that breast- and be a valuable food, although they have low fat and feeding be continued whenever possible and that the low energy contents. dietary treatment given does not replace breastmilk. As pointed out in the review by Golden on the nutritional requirements of moderately malnourished Nutritional qualities of foods and children [4], the nutritional needs of a wasted and a ingredients stunted child differ. In particular, the time needed to reverse the condition will differ considerably between Energy density wasting and stunting. It will often be possible to reverse moderate wasting within 2 to 4 weeks, whereas revers- The energy density is one of the most important quali- ing moderate stunting may take months or years, if it ties of foods for wasted children. If the energy density is possible at all. Reversing stunting is easier the earlier is too low, the food becomes too bulky, and the child treatment is started, and the first 2 years especially seem will not be able to eat adequate amounts.
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