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Consultative group on maternal and young child nutrition
The Consultative Group on Maternal and Young Child Nutrition met for the first time on 22-23 February 1979 in Geneva. It was established as a task force by the Advisory Group on Nutrition (AGN) as part of its assistance to the UN-ACC Sub-committee on Nutrition (SON) described in the first issue of the Bulletin. Members of the Group are: Professor Ihsan Dogramaci (Turkey), Dr. Demissie Habte (Ethiopia), Dr. J.K. Harfouche (Lebanon), Dr. Yngve Hofvander (Sweden), Dr. F. Mönckeberg (Chile), Dr. Sheila Pereira (South India), and Dr. Barbara Underwood (United States); and its Chiarperson is Dr. Priyani Soysa of Sri Lanka.
The following agenda was submitted:
1. Briefing of consultative group on activities related to maternal and child nutrition within the United Nations systems and others concerned.
2. Discussion issues:
a) Content of background paper for October meeting sponsored by WHO/UNICEF on Infant and Young Child Feeding.
b) Actions recommended to advise mothers with restricted resources who cannot breast-feed.
c) Characteristics of appropriate complementary foods; when and how they should be introduced.
d) Disposition of the Manual on Feeding Infants and Young Children.
3. Future work and modus operandi of the consultative group.
The meeting was opened by Madam Chairperson, Dr. E.P. Soysa. There followed an extensive information session and discussion as to the role of the Consultative Group on Maternal and Young Child Nutrition. Its role emerged as:
1. responding to specific questions raised by the agencies on technical, programme, and Policy matters;
2. identifying issues in the area of maternal and young child nutrition that should be addressed by the United Nations system and others concerned, advising on how the problem might be tackled and indicating actions that can be taken at national, regional and international levels.
The Group then addressed the issues on the agenda. The following is a report to the AGN and SON of the Group's early reflections on some of these issues. The report does not represent a definitive statement of recommended actions on all agenda items. Time was too short to provide for in-depth consideration of all these issues. Recommendations are made on certain issues and others will be forthcoming from future meetings.
Background Paper for WHO/UNICEF-Sponsored Meeting on Infant and Young Child Feeding (October 1979)
One prominent gap in the outline for the paper was consideration of the pyscho-social aspects of breast-feeding. Breast-feeding failures are more often for psycho-social than physiological reasons. Dr. Harfouche agreed to prepare a report on this area to submit to Dr. Bèhar for incorporation into the background paper. Another area thought to be inadequately covered was legal considerations. Dr. Soysa agreed to prepare information on the legal aspects based on experience in Sri Lanka. Other areas the group considered must be a part of the background paper included: economic aspects of breast feeding; the lactation/fertility/child-spacing aspects, the reality of competing options for time and resource usage among low-income mothers of transitional societies and their scepticism of the motives of advice coming from the elite, and a consideration of strategies for programme implementation. Members of the Consultative Group were invited to send comments and contributions on these topics before the end of March 1979.
Feeding Infants for the First Year
The first year, particularly the first six months, is the most critical period in a child's extero-gestate life. Not only is incremental physical growth occurring at a most rapid rate, but psycho-motor development and acculturation are also taking place rapidly. Breast milk should be the primary food source during this time. Usually food complementary to breast milk is needed in the second trimester to maintain incremental growth at a consistent rate. There is much individual variation in when such a food adjunct is needed; in general this is between four and six months. There is no reason for introducing complementary foods before this period as long as growth remains adequate. The reasons for introducing complementary food in the four-to-six-month period are both physiological and psycho-social. Additional work is needed to establish the relationship between the time more solid foods are introduced and later acceptance of a mixed-solids diet. The Group felt that problems of later acceptance were most common when exclusive milk feeding extended to nearly one Year.
The term "weaning" should be used to denote the process in which a child changes from breast milk to a mixed diet, other foods being given regularly over time in increasing amounts until replacement is virtually complete. The term also denotes the transitional period in which the infant is gradually introduced to new interactive experiences within his environment, a period of emerging independence. It is therefore a very important period in the normal development of the child, depicted graphically as shown in the figure.
Breast milk should be the exclusive food for the first few months of life (period 11. The first complementary foods introduced (period 2) are primarily for providing energy, which frequently can be supplied by a small amount of the staple from the adult diet, and for beginning the educational or acculturation process. Soon, however, there is need for a protein adjunct as well as calories to assure that the combined contribution of breast milk and other diet fully meets the energy and protein needs (period 3). These requirements can usually be met from locally available traditional food sources if appropriately combined and fed. The excessive bulk of cereal diets can be a problem from the time the child is weaned (period 4) to about three years unless care is taken to increase caloric density.* Addition of oil at each feeding is the easiest means of adding concentrated calories, and can be achieved by mixing the oil with dry cereal before cooking cereal gruels. Where oil is unavailable, caloric density can be increased by a variety of means such as toasting of wheat or the fermenting of cereals to decrease swelling during subsequent cooking. There is need to explore additional local means for increasing caloric density of indigenous foods usable for child feeding.
During the weaning process the variation in foods introduced should concentrate on those that will provide vitamins and minerals not supplied in adequate amounts from the cereal or legume staples. This usually means vegetables, leaves, or fruits, and their introduction is more urgent where animal milk rather than breast-feeding is being used.
More information is needed across cultures to assess the potential for better utilization of local foods for complementary feeding of young children. Traditional factors that limit the use of certain foods for child feeding should be identified and a determination be made as to which are amenable to change.
There is some information that maximum utilization of food to support child growth involves factors in addition to those inherent in the food per se. Studies show that psychomotor stimulation and affection improve nitrogen retention and lead to a more rapid recovery rate among undernourished infants. Studies in animals suggest the mechanism is that stress increases activity of enzymes of the urea cycle, lessening the retention of nitrogen to support protein synthesis. This fact emphasizes the need to encourage the intimate interaction between infant and mother facilitated by the process of breast-feeding during the important early months of rapid growth. The intimate bonding established during this period should be encouraged continually during the weaning process together with progressive environmental stimulation.
Feeding the Infant Whose Mother Cannot Breast-Feed
Infants from families with restricted resources whose mothers die, or, in exceptional cases, cannot breast-feed, present especially difficult feeding problems for at least the first three months, and usually the first six months of life. The problem is not only the nutritional quality of what is available and affordable but also its hygienic quality when fed. The Group agreed that it is very difficult to feed such infants and have them survive the first three months in the absence of milk or milk-based products. Some local mixtures based on cereal protein sources may sustain survival, but generally produce marasmic infants. In some cases, for example in Ethiopia, mixtures based on legume protein apparently are used. There is need for careful exploration and evaluation of other potential local food sources of this kind used in various cultures.
Milk-based mixtures can be used successfully but are expensive. Processed acidified whole cows' milk is used successfully in Chile, and early evidence, to be confirmed, suggests less diarrhoea than that associated with the use of unacidified cows' milk. Yoghurt is a natural, less expensive, local milk product used successfully in many cultures. There is little evidence to counter-indicate the use of acidified milk for infants less than three months; the barriers, if any, apparently are cultural factors as well as cost and limited availability.
The Group recommends that, in the small percentage of cases where lactation fails during early infancy, the sequence should be to:
1. make all efforts to re-establish lactation;
2. provide breast-feeding by a relative or wet nurse;
3. feed another milk or milk product available at the lowest price, including yoghurt;
4. feed a cereal augmented by any available milk, however limited;
5. feed a cereal augmented by other locally available protein sources.
Care must be taken to assure adequate caloric density and protein at the minimum level of 2 g/kg body weight. Additionally the infant should be fed frequently on his own demand schedule.
Beyond three months, infants can be reared on cereal and/or legume-sugar-oil mixtures, in addition to milk. In the absence of milk during the second trimester, growth may be sustained with other foods, although not satisfactorily.
Feeding should be done from the most easily cleaned locally available implement; often this is a cup and spoon or traditional surrogate. Difficult-to-clean bottles, particularly plastic bottles, should be avoided. The risk of contamination from use of unsanitary bottles is so great and potentially fatal to these fragile infants, especially those under three months, that measures should be considered to regulate the minimum standard specifications for bottles manufactured and available for infant feeding purposes.
Manual on Feeding Infants and Young Children
The Consultative Group discussed the Manual on Feeding Infants and Young Children by Cameron and Hofvander. This Manual, previously published under the sponsorship of the Protein Advisory Group, has received broad acceptance and currently is in high demand in its second revision. The Group agreed that there was a need to consider a third revision updating the material and introducing changes to make it serve as a guideline from which country-specific adaptations could be made. The Group consensus was that this could serve a useful purpose, and each member agreed to review the manual and send suggestions to the authors. They would consider these and develop a draft of how the manual might be revised for the Group to react to at the next meeting.
Some Additional Reflections
1. Breast-feeding should be viewed as an integral part of child-rearing and must be considered within the total ecologic context of the family and community.
2. Development of educational materials on breast-feeding needs careful consideration to avoid past errors that failed to appropriately incorporate to maximum advantage many traditional, cultural, and religious considerations and to consider realistically the competing demands on a woman's time available for food preparation.
3. Maternal and young child nutrition should be addressed as integral parts of development programmes, both within the health sector (particularly that focused on primary health care) and other relevant sectors. To accomplish this, the gaps between policy decisions, maternal and child health needs, and potential resources to meet these must be narrowed. The WHO programmer to disseminate information and stimulate action through the Collaborative Study on Breast-feeding followed by regional and national workshops, and the anticipated collaborative programme on the weaning period to identify appropriate local food resources and technology for preparation, preservation, and feeding are important steps in closing this gap. These are programmes worthy of additional enthusiastic support.
4. It is important to recognize that the means for meeting maternal and young child nutritional needs will vary in traditional and transitional populations. In some instances, particularly among populations that live on a cash economy, processed infant foods have a place. These must be properly considered within the economic resources of the family and the other locally available unprocessed foods appropriate to the complementary feeding period. Although ideally the production and availability of nutritious and sanitary weaning foods should be free from a profit-making incentive, in practice government subsidies generally have not been an economically sustainable means of making these products universally available. Therefore, consideration should be given at the country level to legislation that will prevent the introduction of undesirable infant-feeding practices. At the global level, there is a need to develop universally acceptable codes of ethics for the quality, marketing, and promotion of infant foods.
The Group considered its next meeting should logically be held after the October 1979 WHO/UNICEF meeting on Infant and Young Child Feeding in order to consider issues arising and submitted by concerned agencies. Additionally, the Group's agenda should include further in-depth consideration of how to feed the child whose mother cannot breast-feed and begin discussions of issues in maternal nutrition.
On the issue of feeding the non-breast-fed infant, the Group felt the principles outlined at the initial meeting could serve as the working paper to be refined and finalized as recommendations to the AGN at the next meeting. The subject of maternal nutrition is so important and extensive that the Group recommended that a consultant should be requested to prepare a state-of-the-art background paper in advance of the next meeting.
The Group suggested that its next meeting be held in Geneva, Rome, or Sri Lanka.
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