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Human and clinical nutrition

Appropriate weaning practices and foods to prevent protein-energy malnutrition: An Asian review

Kraisid Tontisirin and Uruwan Yamborisut


Despite considerable progress in recent decades, the world still falls short of the goal of adequate food and nutrition for all. No other people feel this more than children living in the developing countries of Asia. This paper reviews the problem of protein-energy malnutrition in selected countries in this region, its determinants including improper breast-feeding and weaning practices, and the need to develop guidelines and strategies for improved weaning practices and foods at three focal levels: family, community, and commercial.



Growth is the most sensitive and readily measured indicator of health and nutrition for the individual child. It is also a more general index of health in a community because it is dynamic and reflects positive change. However, because of the exclusive nature of a young infant's diet and the limited ability of the digestive tract to deal with excessive intakes of some nutrients, feedings for the young must closely match nutrient needs. In most developing countries with generally poor environmental conditions, average infant growth in weight and height is satisfactory until about three months of age, when it begins to fall off. Growth faltering at this age may occur as the child outgrows its mother's capacity to produce breast milk and to provide adequate supplementation. In introducing weaning foods, there may be diverse effects from timing, such as early or late weaning, and from the types of foods used. This process also has great geographic and cultural variations.


Child malnutrition in Asia

Despite general improvements in food availability and health and social services, hunger and malnutrition exist in some forms in nearly all countries. Between 1975 and 1990 the average prevalence of protein-energy malnutrition (PEM) in children in Africa, Asia, the Middle East, and the Americas combined, as estimated by FAD/WHO, was reduced from 47.5% to 40.8%. Nevertheless, there were 155 million underweight children in Asia in 1990, representing 44% of children under five years of age [1]. Table 1 shows the prevalence of low-birthweight infants and underweight children [2]. As of 1990, for instance, Japan and China had the lowest percentage of low birthweight and India had the highest. The prevalence of wasting and stunting among children in India and Pakistan was also higher than in other countries.

The poor are less likely to starve in urban centres than in the rural countryside. However, inadequate diets, harmful lifestyles, overcrowding, and unhygienic living conditions leave city dwellers prone to infection and various forms of malnutrition. In rural areas, undernutrition in various forms is a major peril, particularly among the landless. Periodic starvation is common during the time before harvesting or when food is in short supply and prices rise. Within this context, two factors playing major roles in the pathogenesis of PEM and low birthweight are inadequate dietary intake and the combined effect of stress and infections, which may interfere with the intake, absorption, and assimilation of nutrients.

Poor feeding practices

Societal changes (so-called development) are inducing changes in dietary practices. Increasing numbers of women in urban areas engaged in regular employment outside the home, the absence of facilities for breast-feeding at work sites, the breakup of families, maternal ill health, and the impact of high pressure commercial advertisements through the press and other media all contribute to early abandonment of breast-feeding and greater use of commercial baby foods. Studies that distinguish between exclusive and partial breast-feeding show that high percentages of infants in developing countries are breast-fed exclusively for very short periods [3, 4]. Moreover, complementary foods are introduced much earlier than the recommended age of four months [5], often even in the first month of life. Such foods are usually bulky and thus low in energy density. Consumption of a large volume satiates an infant, reducing the frequency of suckling and consequently reducing breast-milk output. Early introduction of cereals and particularly vegetables can interfere with the absorption of breast-milk iron [6], thus potentially resulting in iron deficiency. In addition, weaning foods prepared under unhygienic conditions are frequently contaminated with pathogens and thus are a major factor causing diarrhoea and associated malnutrition [7].

Misperceptions about and the inappropirate use of commercial baby foods, which are increasingly available but which to date are not able to meet optimum nutrient requirements, may cause young children's health to deteriorate. On the other hand, prolonged exclusive breast-feeding and delayed weaning can also contribute to a high prevalence of growth faltering [8].

TABLE 1. Low-birthweight infants and moderately and severely underweight children (percentages) in selected Asian countries, 1990


Low birth- weight

Under weight (0-4 yrs)

Wasting (12-23 mo)

Stunting (24-50 mo)




































Sri Lanka















Source: Ref. 2.

Weaning practices: Past experiences in some Asian countries

In rural areas, under-educated mothers, taboos, and customary food practices seem to be significant causative factors for malnutrition in young children.

In most areas in India it is believed that children should not be given solids until they "cut some teeth." Fruits and green leafy vegetables are rarely fed [9].

In Sri Lanka, about 25% of mothers in urban areas begin giving semi-solid food after the fourth month versus 6% in rural areas. Solids such as rusks and biscuits are offered in significant amounts only after the child is six months old, and approximately 80%I00% of mothers have introduced solid foods to their children by the age of 12 months. This is related to late supplementary feeding [10].

In most rural areas of Thailand, chewed rice paste, gruel, or banana is usually given to infants as early as a few days after birth [11, 12]. On the other hand, the introduction of nutritious foods such as fish, meat, and oils to growing infants is delayed. When rural children are ill, they may be given only rice and salt because of a belief that eggs, meat, and other foods increase body temperature. Children with diarrhoea are given no food until the diarrhoea ceases. These practices aggravate malnutrition.

To solve these problems, it is crucial that the underlying beliefs and practices should be gradually modified.


Guidelines and recommendations for improving child growth and health

Promoting maternal well-being and breast-feeding

It is crucial to mothers' physical and mental health that they have ready access to health services. Dietary guidelines for pregnancy and lactation should be widely disseminated. Action also must be taken to promote maternal education and literacy. At a basic level, policies and programmes should empower mothers to breast-feed their infants exclusively from birth through 3-6 months of age and to continue breast-feeding with the addition of supplementary foods for up to two years or longer.

In Thailand, the importance of breast-feeding has been recognized for a long time and was included explicitly in the National Food and Nutrition Plan in the fourth National Economic and Social Development Plan (NESDP) (1977-1981). Early activities included policy meetings, the adoption of a marketing code for infant food products, and public campaigns promoting breast-feeding. During the fifth NESDP (1982-1986) the Nutrition Division of the Ministry of Public Health, in collaboration with other agencies, launched a nationwide campaign on breast-feeding every March for five consecutive years. Breast-feeding received national attention again in 1991 when maternity leave for 60-90 days was granted for mothers working in government services. With the support of UNICEF and WHO, Thailand is now one of 12 countries launching the baby-friendly hospital initiative (BFHI) [13]. Media coverage of awards, practices in the first BFHI hospitals, and the breast-feeding experience of celebrities have led to broader public awareness.

Improving feeding and weaning practices

It is necessary to consider the appropriate timing and quality of weaning foods. Depending on the physiological maturation of each infant, a general rule is that solid foods may be given at three to four months of age. A staple food that is calorically dense and adequate in protein is important, and high content of vitamins A and D, iron, and zinc should be emphasized. To prevent diarrhoea caused by bacterial contamination, freshly cooked or freshly peeled foods should be used. Approaching two years of age, the child should be consuming a variety from the family diet, with items from each of the basic food groups.

The following are Thai guidelines for supplementary feeding based on the child's age:

3 months, begin feeding rice gruel/bananas;
4 months, add egg yolk, liver, or legumes;
5 months, add fish, green leafy vegetables, pumpkin;
6 months, begin one meal;
7 months, add ground meat, begin whole egg;
8-9 months, give two complete meals;
10-12 months, give three complete meals.

Proper feeding and weaning practices have three focal levels: family, community, and commercial. At the family level, since breast milk is fully adequate for the first three months of life, supplementary food should not be started until after that time. At the community level, nutrition programmes should become an active part of the primary health care and rural development systems. Communities must be given the tools and guidance to monitor children's growth and nutrition status and to produce and distribute appropriate supplementary foods to combat malnutrition and the means to secure resources (monetary and human) that can maintain innovative community nutrition activities.

In Thailand it has been demonstrated that a diet based on cereal and legumes such as rice, soya beans, and groundnuts or rice, mung beans, and sesame can provide adequate protein, fat, and energy intakes for young children [14]. Four supplementary food mixtures were developed, with protein contents ranging from 13.2 to 16.5 g/100 g and fat from 10.6 to 13.2 g/100 g, whose energy content meets or exceeds the recommended Thai standards (table 2), and the Institute of Nutrition and Ramathibodi Hospital, Mahidol University, carried out a project in two villages in Ubon province in north-eastern Thailand between 1978 and 1980 [15] in which these mixtures played an essential role. Villagers were encouraged to bring the raw ingredients for the rice and legume mixtures to a village centre for processing. Nutrition education was also introduced at the centre, and the centre served as a feeding station for moderately and severely malnourished preschoolers. The project was extremely successful, as indicated by a decrease in the prevalence of PEM from 55% to 21 % in 18 months.

Under a poverty-alleviation plan, rice, legume, and oil-seed mixtures have been extensively produced and distributed using community participation in more than 10,000 rural villages since 1983 under the supervision of the Nutrition Division, Ministry of Public Health. Hence, from 1982 to 1986 the overall prevalence of PEM in preschool children decreased from 51 % to 24%, with a remarkable reduction of mild PEM from 35.7% to 21.7%, of moderate PEM from 13% to 2.7%, and of severe PEM from 2.1% to less than 0.1%. The success in introducing village-based supplementary foods depended largely on community involvement, with health volunteers or women's groups participating in the production and dissemination of the mixtures. The programme was also integrated with growth monitoring and other primary health care activities. In many villages, income from sale of the food mixtures was used to set up village nutrition development funds.

TABLE 2. Protein, fat, and energy contents of supplementary food mixtures (per 100 g)


Protein (g)

Fat (g)

Energy (kcal)

Rice/soya beans/ groundnuts (14:3:3)




Rice/soya beans/ sesame (14:3:3)




Rice/mung beans/ groundnuts (4:1:4)




Rice/mung beans/ sesame (12:4:3)




Various organizations have issued guidelines for the composition of commercially produced supplementary foods, with different approaches and substances (e.g., expression of nutrients per unit of weight or per unit of energy) [16,17]. Many developing countries have adopted Codex Alimentarius guidelines with suitable modifications for local circumstances. For example, Thai standards for infant foods require not less than 2.5 g of protein per 100 kcal. an amino acid score not less than 70% of the FAD/WHO reference pattern, 2.6 g of fat per 101) kcal, and not less than 300 mg of linoleic acid per 100 kcal.

Regardless of the level of food development, home-prepared supplementary food is still encouraged. Various factors such as food resources, culture, socio-economic status, and the culinary practices of each local area can influence the acceptability of foods and the eating behaviour of young children. For infant foods, the mother's acceptance is probably as important as the infant's, especially since the mother determines whether the product is purchased. Therefore, a proper understanding of the nutrient needs of children must be reinforced for all mothers.

Improving the quality of weaning foods

Supplementary food mixtures should be improved because they arc limited in certain macronutrients and micronutrients such as calcium and phosphorus, and perhaps some vitamins and trace elements [18]. In addition, antinutritive factors in legumes, especially soya beans, may reduce the bioavailability and absorption of some nutrients; fortunately, most of these factors can be significantly reduced by heat treatment. Similarly, removing the hulls of legumes would lower their fibre content and thus increase digestibility [19].


Improvement of dietary bulk density with germinated cereal and legumes

Another problem is that most of the traditional first supplementary foods introduced in many countries are prepared from cereal or starchy roots, commonly mixed with water. When they are cooked, starch granules become gelatinized, making the food mixture viscous and very difficult to feed to small children. Hence, the children's food intake becomes inadequate to satisfy their nutritional requirements.

One possible solution is to reduce the dietary bulk of the weaning foods without significantly changing their nutritional value. A traditional processing method, malting, reduces viscosity and hence bulk. During the germination of grains, amylolytic enzymes, or amylases, are developed and activated. When these enzymes are present in a gruel, they rapidly break down the starch, resulting in a decrease in its water-holding capacity and thus causing the mixture to become more liquid.

Recent work in India showed that adding only a small amount of malted flour, or "amylase-rich food" (ARF), at a level of 3%-4% of total solids, to a cooked gruel resulted in thinning [20]. Higher intake of the ARF-treated gruel substantially improved child growth [21]. Similarly, ARF from wheat, maize, pearl millet, or sorghum could reduce the viscosity of thick gruel better than legumes.

The Institute of Nutrition developed ARF from local staple cereals as well as legumes [22]. By adding ARF made with rice germinated for four days to a 25% cereal-legume gruel at 0.5%-1% of total solids, an optimum thinning effect was obtained. The enzyme activity of the rice ARF was significantly higher than that of mung-bean ARF according to the enzyme inhibitor content in the latter.

Growth assessment and monitoring

Large-scale supplementary feeding programmes, either alone or integrated into other development plans such as the NESDP, are being implemented in many countries. However, it is necessary to evaluate their success in terms of a decline in the prevalence of PEM and improved growth status of target children. Growth monitoring is a tool for identifying problems and warning mothers about a child's health. The monitoring of breast-feeding, weaning practices, and their determinants is essential and should be undertaken. Other information sources, such as the national epidemiological information system and household socio-economic and demographic surveys, provide many pertinent data.



Undernutrition among young children has several aetiologies. A decline in breast-feeding abounds and calls for increased promotion of breast-feeding for at least 18 months, including support for maternal leave and the baby-friendly hospital initiative. During and after breast-feeding, appropriate supplementary feeding is crucial, but this rests on developing weaning-food guidelines and practices at family, community, and commercial levels. Strategies must also realistically address various constraints such as economics, social and cultural environments, and time. The production of low-cost supplementary foods from local ingredients using malting techniques in some Asian countries shows the advantage of decreasing the viscosity and hence the bulk of such foods. The success of supplementary feeding programmes relies oncarefully articulated education messages about maternal and child nutrition requirements and involves maximum community participation. Intra-household food distribution also affects the nutrition status of children, as do hygiene and eating behaviours. These call for in-depth analysis and the implementation of comprehensive programmes to modify food habits. Simple and meaningful growth-monitoring systems are also necessary for mothers and health care providers.



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