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Feeding and nutrition of infants and young children
Guidelines for the WHO European Region, with emphasis on the former Soviet countries
WHO Library Cataloguing in Publication Data
Feeding and nutrition of infants and young children : Guidelines for the WHO European Region, with emphasis on the former Soviet countries / Kim Fleischer Michaelsen...[et al.]
(WHO regional publications. European series ; No. 87)
1.Nutrition 2.Policy-making 3.Guidelines 4.Europe I.Fleischer Michaelsen, Kim II.Series
ISBN 92 890 1354 0 (NLM Classification: QU 145) ISSN 0378-2255
Text editing: Frank Theakston Cover design: Sven Lund
Feeding and nutrition of infants and
young children
Guidelines for the WHO European Region,
with emphasis on the former Soviet countries
Kim Fleischer Michaelsen, Lawrence Weaver, Francesco Branca and Aileen Robertson
WHO Regional Publications, European Series, No. 87
World Health Organization Regional Office for Europe
Copenhagen
ISBN 92 890 1354 0 ISSN 0378-2255
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vintroductioncontents
Foreword ......................................................................................... ix
Acknowledgements ......................................................................... xi
Recommendations ......................................................................... xiii
Introduction ................................................................................... 1 Why is this publication needed and for whom is it intended? ......... 1 Some determinants of health in Europe ........................................ 3 The contents of this book ............................................................ 4 Terminology ............................................................................... 5 Adaptation and implementation of these guidelines ...................... 5 References ................................................................................... 7
1. Health and nutritional status and feeding practices ................... 9 Nutrition-related health problems in young children .................... 9 Feeding practices and recommendations ....................................... 26 References ................................................................................... 35
2. Recommended nutrient intakes ................................................ 39 Introduction ............................................................................... 39 Recommendations are derived from requirements ........................ 40 Nomenclature of recommended nutrient intakes .......................... 42 References ................................................................................... 43
3. Energy and macronutrients ....................................................... 45 Energy ........................................................................................ 45 Energy density ............................................................................ 51 Protein ....................................................................................... 54 Fat .............................................................................................. 59 Carbohydrates ............................................................................ 62 References ................................................................................... 66
4. Vitamins .................................................................................... 69 Vitamin A .................................................................................. 69 B vitamins .................................................................................. 73 Vitamin C .................................................................................. 74 Vitamin D .................................................................................. 76 References ................................................................................... 79 Appendix .................................................................................... 81
vi
5. Minerals other than iron ........................................................... 85 Iodine ......................................................................................... 85 Zinc ........................................................................................... 91 Calcium ..................................................................................... 93 Sodium ...................................................................................... 94 References ................................................................................... 96 Appendix .................................................................................... 98
6. Control of iron deficiency ........................................................ 101 Introduction ............................................................................. 101 Physiology and pathophysiology of iron .................................... 105 Symptoms and consequences of iron deficiency .......................... 112 Complementary foods and control of iron deficiency ................. 114 Other interventions to control iron deficiency ............................ 118 References ................................................................................. 122
7. Breastfeeding and alternatives ................................................ 127 The importance of breastfeeding ................................................ 127 Nutritional benefits of breastfeeding .......................................... 127 Non-nutritional benefits of breastfeeding ................................... 133 Importance of maternal nutrition .............................................. 139 Practical aspects of breastfeeding ................................................ 141 How to increase the duration and incidence of breastfeeding ....... 146 Contraindications to breastfeeding ............................................. 152 Alternatives to breastfeeding ...................................................... 156 References ................................................................................. 161
8. Complementary feeding .......................................................... 169 What is complementary feeding? ............................................... 169 Physiological development and maturation ................................ 170 Why are complementary foods needed? ...................................... 174 When should complementary foods be introduced? .................... 174 Composition of complementary foods ...................................... 177 Practical recommendations for the introduction of
complementary foods ........................................................... 181 What are the best foods to prepare for infants? ............................ 184 Some practical recommendations for food preparation ............... 195 References ................................................................................. 196
9. Caring practices ....................................................................... 199 Introduction ............................................................................. 199 The UNICEF Care Initiative and nutrition ................................ 199
vii
Factors affecting the ability of caregivers to carry out optimum feeding practices ................................................... 202
Care for girls and women and the consequences ......................... 203 Feeding young children ............................................................ 204 Psychosocial care ...................................................................... 208 Resources for care ..................................................................... 209 References ................................................................................ 214
10. Growth assessment ................................................................ 217 Introduction ............................................................................ 217 How to measure growth and use growth charts .......................... 218 Reference populations .............................................................. 219 Interpretation of measurements of attained growth .................... 222 Catch-up growth ..................................................................... 224 References ................................................................................ 224
11. Dental health .......................................................................... 227 Prevalence of dental caries ......................................................... 227 How caries are formed .............................................................. 229 Relationship between diet and dental caries ................................ 229 Prevention of dental caries ........................................................ 230 References ................................................................................ 232
12. Food safety ............................................................................. 235 Introduction ............................................................................ 235 Microbiological contamination ................................................ 235 Chemical contamination .......................................................... 240 References ................................................................................ 244
Annex 1. The International Code of Marketing of Breast-milk Substitutes and subsequent relevant resolutions of the World Health Assembly .................................................. 247
Annex 2. Prevention of mother-to-child transmission of HIV......... 279
Annex 3. Infant feeding in Integrated Management of Childhood Illness ........................................................... 283
introduction
Foreword
A child’s first 2 or 3 years of life are the most crucial for normal physical and mental development. Nevertheless, current feeding practices in some countries may be doing more harm than good to the development of young children. Children under 3 years of age are vulnerable to poor nutrition; the growth rate during this period is greater than at any other time, and there thus exists an increased risk of growth retardation. Also, the immunological system is not fully mature at this age, resulting in a risk of frequent and severe infections. Both cognitive and emotional potentials start to develop early, and so the foundations of intellectual, social and emotional competencies are also estab- lished during this period. In summary, poor nutrition during the early years leads to profound defects including delayed motor and cognitive development, behavioural problems, deficient social skills, a reduced attention span, learning deficiencies and lower educational achievement.
Infants, especially those who have a low birth weight or are otherwise vulner- able, are at high risk of morbidity and mortality during the first 2 years of life, especially after 6 months of age. In the period after birth most infants, even the most vulnerable, grow and develop normally if they are exclusively breastfed. If foods or drinks are introduced too early or are not given safely in the correct quantity at the optimum time, growth rates falter dramatically and can lead to growth retardation. By the time these children are 2 years old, many will be stunted. This is irreversible, and as adults they will remain small and be likely to have reduced mental and physical capacities. To reduce the high prevalence of stunting – common among vulnerable groups in the European Region – national feeding guidelines based on those given in this book should be imple- mented by health ministries. This will promote normal growth and develop- ment in the first 3 years of life, especially for the most vulnerable.
Nutrition-related health problems during the first 3 years of life lead to short- and long-term consequences, such as cardiovascular disease, that limit human potential within society. Improving infant and young child nutrition should thus be a priority, and be seen as an integral part of social and economic development. During times of economic crisis countries face difficult choices, so it is imperative to advocate social sector investments, notably nutrition policies for young children. Failing to ensure that young children receive optimum nutrition is counterproductive. Faced with limited resources, countries may decide to reduce general expenditure by limiting resources devoted to the
x
development of young children. In the long run, however, failing to invest in the young will be more costly to the state and to society. Future mental and physical capacity will be compromised and, in addition, treating the resulting preventable diseases will be extremely costly. By placing emphasis on the first three years of life and developing comprehensive nutrition policies, countries can avert many preventable deaths, avoid irreversible mental damage, and preserve a child’s priceless endowment of emotional, intellectual and moral qualities.
The 1997 edition of UNICEF’s State of the world’s children states: “Approxi- mately half the economic growth achieved by the United Kingdom and a number of Western Countries between 1790 and 1980 … has been attributed to better nutrition and improved health and sanitation conditions, social investments made as much as a century earlier”. The social and economic costs of poor nutrition are huge. For this reason, international investment banks agree that investing in nutrition makes sense: it reduces health care costs and the burden of chronic preventable diseases in adulthood, it improves social and economic development and it promotes learning and intellectual capacity. No economic analysis, however, can fully do justice to all the benefits of sustained mental, emotional and physical development in childhood.
In general, the central role that nutrition and feeding practices play with regard to the health and development of young children is not sufficiently well understood by enough health professionals. Health professionals should be a source of correct and consistent information on nutrition. These guidelines have been produced to facilitate this and strengthen the role of the health sector. A large proportion of the health service budget is used to treat preventable nutri- tion-related disorders, costs that could be substantially reduced if these disor- ders were prevented. Implementing these guidelines will enable countries to develop their own national nutrition policies for infants and young children. In doing this, the health sector can carry out its role effectively within this crucially important area of public health. Children represent the future of a nation, and these guidelines have been produced with the intention that young children, especially the disadvantaged, will have a better future.
Marc Danzon John Donohue Regional Director Regional Director WHO Regional Office CEE/CIS and the Baltics
for Europe UNICEF Office for Europe Copenhagen, Denmark Geneva, Switzerland
introduction
Acknowledgements
This publication was prepared by WHO’s Nutrition Policy, Infant Feed- ing and Food Security programme at the Regional Office in collaboration with the United Nations Children’s Fund (UNICEF). The authors would like especially to thank Rachel Elsom and Ellenor Mittendorfer, who carried out most of the background research and helped draft the manu- script.
The financial support provided by the Governments of the Netherlands and the United Kingdom is gratefully acknowledged. In this context we would especially like to thank Elly Leemhuis-de Regt and Jacob Waslander of the Netherlands for their interest and support. Many individuals contributed to this book, and in particular Dr Bruno de Benois (WHO), Professor François Delange (Belgium), Professor Patrice L. Engle (United States), Dr Marco Jermini (WHO), Dr Lida Lhotska (UNICEF), Dr Yasmine Motarjemi (WHO), Dr Elizabeth M. Poskitt (United Kingdom), Professor Andrew Rugg- Gunn (United Kingdom) and Dr Jovile Vingraité (Lithuania).
Special thanks are also due to the participants attending the UNICEF/ WHO Regional Consultation on Prevention and Control of Iron Defi- ciency Anaemia in Women and Children, held in Geneva in February 1999, and to the following who contributed to individual sections or reviewed the draft text: Dr Carlo Agostoni (Italy), Ms Helen Armstrong (United States), Professor Zulfiqar Bhutta (Pakistan), Professor Ken Brown (United States), Dr Nancy Butte (United States), Dr Michel Chauliac (France), Professor Forrester Cockburn (United Kingdom), Professor Kathryn Dewey (United States), Dr Conor Doherty (United Kingdom), Dr Henrik Friis (Denmark), Dr Serge Hercberg (France), Professor Olle Hernell (Sweden), Professor Peter Howie (United Kingdom), Ms Sandra Huffman (United States), Ms Hind Khatib (UNICEF, Geneva), Dr Fe- licity Savage King (WHO headquarters, Geneva), Professor Berthold Koletzko (Germany), Ms Sandra Lang (United Kingdom), Dr Christian Mølgaard (Denmark), Dr Olga Netrebenko (Russian Federation), Ms Nancy Jo Peck (Switzerland), Dr John Reilly (United Kingdom), Ms Patti Rundall (United Kingdom), Dr Werner Schultink (UNICEF, New York), Dr Roger Shrimpton (UNICEF, New York), Dr Inga Thorsdóttir (Ice-
xii
Kim Fleischer Michaelsen Research Department of Human Nutrition The Royal Veterinary and Agricultural University Frederiksberg Denmark
Lawrence Weaver Department of Child Health Royal Hospital for Sick Children University of Glasgow United Kingdom
Francesco Branca National Research Institute for Food and Nutrition Rome Italy
Aileen Robertson Nutrition and Food Security WHO Regional Office for Europe Copenhagen Denmark
land), Dr Abdelmajid Tibouti (UNICEF, Geneva), Professor Brian Wharton (United Kingdom), Professor Susan Reynolds Whyte (Den- mark), Dr Anthony Williams (United Kingdom) and Dr Charlotte Wright (United Kingdom).
Recommendations
INTRODUCTION
It is recommended that each country review, update, develop and imple- ment national nutrition and feeding guidelines for infants and young chil- dren, based on the recommendations in this publication.
HEALTH AND NUTRITIONAL STATUS AND FEEDING PRACTICES
It is recommended that each country establish nutrition surveillance of infants and young children as an integral part of its health information system.
Breastfeeding practices, feeding patterns and the nutritional status of in- fants and young children should be monitored regularly to enable problems to be identified and strategies developed to prevent ill health and poor growth.
RECOMMENDED NUTRIENT INTAKES
Each country should use recommended nutrient intakes for infants and young children, based on international scientific evidence, as the founda- tion of its nutrition and feeding guidelines.
ENERGY AND MACRONUTRIENTS
Provision of adequate dietary energy is vital during the period of rapid growth in infancy and early childhood. Attention must be paid to feeding practices that maximize the intake of energy-dense foods without compro- mising micronutrient density.
An adequate protein intake with a balanced amino acid pattern is important for the growth and development of the infant and young child. If the child receives a varied diet, however, protein quantity and quality are seldom a problem. It is prudent to avoid a high-protein diet because this can have adverse effects.
During complementary feeding and at least until 2 years of age, a child’s diet should not be too low (because this may diminish energy intake) or too
xiv
high in fat (because this may reduce micronutrient density). A fat intake providing around 30–40% of total energy is thought to be prudent.
Consumption of added sugars should be limited to about 10% of total energy, because a high intake may compromise micronutrient status.
VITAMINS
In countries where there is a high prevalence of childhood infectious disease, it is important to determine whether vitamin A deficiency is a public health problem.
In countries where rickets is a public health problem, all infants should receive a vitamin D supplement as well as adequate exposure to sunlight.
MINERALS OTHER THAN IRON
In countries where iodine deficiency is a public health problem, legislation on universal salt iodization should be adopted and enforced.
CONTROL OF IRON DEFICIENCY
Iron deficiency in infants and young children is widespread and has serious consequences for child health. Prevention of iron deficiency should there- fore be given high priority.
When complementary foods are introduced at about 6 months of age, it is important that iron-rich foods such as liver, meat, fish and pulses or iron- fortified complementary foods are included.
The too-early introduction of unmodified cow’s milk and milk products is an important nutritional risk factor for the development of iron deficiency anaemia. Unmodified cow’s milk should not therefore be introduced as a drink until the age of 9 months and thereafter can be increased gradually.
Because of their inhibitory effect on iron absorption, all types of tea (black, green and herbal) and coffee should be avoided until 24 months of age. After this age, tea should be avoided at mealtimes.
Optimal iron stores at birth are important for the prevention of iron deficiency in the infant and young child. To help ensure good infant iron stores, the mother should eat an iron-rich diet during pregnancy.
xv
At birth the umbilical cord should not be clamped and ligated until it stops pulsating.
BREASTFEEDING AND ALTERNATIVES
All infants should be exclusively breastfed from birth to about 6 months of age, and at least for the first 4 months of life.
Breastfeeding should preferably continue beyond the first year of life, and in populations with high rates of infection continued breastfeeding through- out the second year and longer is likely to benefit the infant.
Each country should support, protect and promote breastfeeding by achiev- ing the four targets outlined in the Innocenti Declaration: appointment of an appropriate national breastfeeding coordinator; universal practice of the Baby Friendly Hospital Initiative; implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant resolutions of the World Health Assembly; and legislation to protect the breastfeeding rights of working women.
COMPLEMENTARY FEEDING
Timely introduction of appropriate complementary foods promotes good health, nutritional status and growth of infants and young children during a period of rapid growth, and should be a high priority for public health.
Throughout the period of complementary feeding, breast-milk should continue to be the main type of milk consumed by the infant.
Complementary foods should be introduced at about 6 months of age. Some infants may need complementary foods earlier, but not before 4 months of age.
Unmodified cow’s milk should not be used as a drink before the age of 9 months, but can be used in small quantities in the preparation of comple- mentary foods from 6–9 months of age. From 9–12 months, cow’s milk can be gradually introduced into the infant’s diet as a drink.
Complementary foods with a low energy density can limit energy intake, and the average energy density should not usually be less than 4.2 kJ (1 kcal)/g. This energy density depends on meal frequency and can be lower if meals are offered often. Low-fat milks should not be given before the age of about 2 years.
xvi
Complementary feeding should be a process of introducing foods with an increasing variety of texture, flavour, aroma and appearance, while main- taining breastfeeding.
Highly salted foods should not be given during the complementary feeding period, nor should salt be added to food during this period.
CARING PRACTICES
Policy-makers and health professionals should recognize the need to sup- port caregivers, and the fact that caring practices and resources for care are fundamental determinants of good nutrition and feeding and thereby of child health and development.
GROWTH ASSESSMENT
Regular growth monitoring is an important tool for assessing the nutri- tional status of infants and young children and should be an integral part of the child health care system.
DENTAL HEALTH
It is recommended that the frequent intake of foods high in sugar, sugary drinks, sweets and refined sugar should be limited to improve dental health.
Teeth should be cleaned gently twice a day as soon as they appear.
An optimal fluoride intake should be secured through water fluoridation, fluoride supplements or the use of fluoride toothpaste.
FOOD SAFETY
Safe food, clean water and good hygiene are essential to prevent diarrhoea and food- and water-borne diseases, which are a major cause of poor nutri- tion, stunting and recurrent illness.
Breastfeeding should be encouraged even where contamination of breast- milk is a concern, and mothers should be reassured that the risk from contamination is very small compared with the overall benefits of breastfeeding.
introduction
Introduction
It is recommended that each country review, update, develop and implement national nutrition and feeding guidelines for infants and young children, based on the recommendations in this publication.
WHY IS THIS PUBLICATION NEEDED AND FOR WHOM IS IT INTENDED?
Optimum nutrition and good feeding of infants and young children are among the most important determinants of their health, growth and development. Good feeding practices will prevent malnutrition and early growth retardation, which is common in some parts of the WHO European Region. Poorly fed children have greater rates and severity of enteric and other infections, and they are at risk of dying prematurely. There is evidence to suggest that infant nutrition has long-term health consequences and plays a role in preventing the development of some chronic noncommunicable diseases in adults. Furthermore, micronu- trient deficiencies, especially of iron and iodine, are associated with delayed psychomotor development and impaired cognitive function. Thus improvements in nutrition are desirable not only for the physical health and growth of young children but also for reducing the risk of infection, maximizing psychomotor development and school perform- ance and, in the long term, improving opportunities for participating in social development.
The transition from an exclusively milk diet to one in which an increas- ing variety of foods is required to satisfy nutritional needs is a particu- larly vulnerable time. Poor nutrition and less-than-optimum feeding practices during this critical period may increase the risk of faltering growth and nutritional deficiencies. Despite the importance of infant and young child nutrition and feeding practices, limited attention has been paid to the need for guidelines based on scientific evidence. Rec- ommendations on infant nutrition and feeding practices in the eastern part of the European Region are based on former Soviet recommenda- tions, which are outdated and require revision. Moreover, a number of traditional dietary practices in the Region appear to have adverse effects on nutritional status; this is particularly true in the case of iron.
2
This publication has been produced to address this situation. It con- tains the scientific rationale for the development of national nutrition and feeding recommendations from birth to the age of 3 years, and is designed to provide information that will help national experts to develop or update their current national feeding recommendations.
This publication builds on WHO/UNICEF recommendations (1) and several national publications (2–6). In addition, a review of the literature has been carried out to develop appropriate scientifically based recommen- dations for Europe. In some key areas scientific evidence is limited, how- ever, and it has therefore been necessary to base recommendations on prag- matic information, erring on the side of caution. Nevertheless, new data are continually becoming available, and it will be important to review the guidelines frequently and regularly.
The guidelines are designed for the WHO European Region, with empha- sis on the countries that resulted from the dissolution of the former Soviet Union. Nutrition and feeding practices vary throughout the Region and these recommendations should be applied flexibly and be adapted to local and national needs and circumstances. Despite the wide range of socioeco- nomic conditions found between and within the Member States of the Region, it is believed that many recommendations can be applied univer- sally. They are especially applicable to the most vulnerable groups of infants and young children living in deprived conditions. These are mainly found in the eastern part of the Region, but are also common in ethnic minorities and children of low-income families in western Europe.
This publication is primarily intended for ministries of health, paediatri- cians, dietitians, nutrition scientists and public health and other health professionals interested in nutrition who are concerned with the health of young children. It will allow policy-makers and national experts to develop or update their current national nutrition and feeding recommendations. It can also be used as a text for postgraduate education in child health. It is therefore hoped that the information provided will be effectively dissemi- nated to these health professionals and to others working in relevant areas of the civil service and the private sector. There is now evidence to support claims that optimum infant and young child feeding will re- duce the risk of some of the most prevalent adult diseases, such as cardiovascular disease, in the European Region. These guidelines, if implemented, will therefore not only have a positive impact on the health, growth and development of young children, but also strengthen their chances of growing up to be healthy adults.
3
SOME DETERMINANTS OF HEALTH IN EUROPE
Historically, life expectancy in the European Region has been high and is increasing. Since the dissolution of the Soviet Union, however, there has been a dramatic decrease in life expectancy at birth in those countries that were formerly part of it. Thus, in 1994, the average life expectancy in these countries was 66 years, which approaches that of developing countries (62 years). This decline in life expectancy is due in part to a rise in mortality among infants and young children.
Reducing premature mortality and so improving life expectancy can be achieved by improving the nutritional status of young children and their mothers. Although the nutrition of mothers is not dealt with in depth in this book, it is recognized that an optimum maternal diet will help to ensure the birth of healthy infants and improve their life expectancy. There is a sizeable body of evidence to suggest that good maternal nutrition supports optimal fetal development, which has long-term health conse- quences and plays a role in preventing the development of noncommunicable diseases, notably coronary heart disease, hypertension, stroke, chronic bron- chitis, obesity and diabetes (7–9). The mother’s diet immediately prior to conception and during pregnancy influences the growth and development of the embryo and fetus. Where poor maternal nutrition is common (often linked to poverty) it is associated with low birth weight (< 2500 g), prema- ture birth and high perinatal mortality, as well as the development of noncommunicable diseases in adulthood. The influence of early nutrition on cognitive development and adult health is another area of growing interest, particularly with respect to pre-term and low-birth-weight infants (10–13). Investment in child nutrition will also contribute to a country’s economic development (11).
Poor child care is often associated with bad environmental conditions and poverty. While the impact of poverty is greatest in the eastern part of the Region, there is evidence of growing inequalities in western Europe (14). The gap between rich and poor is widening in some countries. It is esti- mated that almost one third of children in the United Kingdom are living in poverty – three times the number in 1979 – and one in five lives in a household where nobody works – twice the rate of 1979 (15). At the 1998 World Health Assembly it was pointed out that 32% of the population of the WHO European Region is living in poverty (the same percentage as found in developing countries). These statistics are derived from the global reports of the United Nations Development Programme (UNDP) (16) and UNICEF (17) and they illustrate the extent to which underlying pov- erty could predispose to malnutrition through a poor-quality diet.
4
Despite the high prevalence of poverty, there is little evidence of widespread protein-energy malnutrition (PEM) throughout the Region. Only in some of the central Asian republics are there signs of wasting and PEM.In Tajikistan and Uzbekistan, around 10% of children have been classified as suffering from PEM. However, in all of the central Asian republics and Azerbaijan, levels of growth retardation and stunting are high. In addition, levels of anaemia are high: 60% and 70% in Kazakhstan and Azerbaijan, respectively (see Chapter 1).
THE CONTENTS OF THIS BOOK
Chapter 1 reviews what is known about the current situation of child nutrition, together with limited information about current infant and young child feeding practices from selected countries in the Region.
Chapters 2–6 deal with nutrient recommendations, energy and the macronutrients (protein, fat and carbohydrates) and the most important vitamins and minerals. International recommendations on nutrient intake currently used by the European Union, the United Kingdom, the United States and WHO are compared. These recommendations provide a stand- ard against which the adequacy of the diet of a population of infants and young children can be assessed. The difference between nutrient “require- ments” and “recommendations” is explained, and how the latter concept has evolved and is designed to cover the wide range of individual variation in nutritional needs found within a population. The nutrient recommenda- tions provide guidance on how much of each nutrient is required for the optimum health of young children, whether prevention of deficiency is enough, and whether overconsumption of a nutrient can be harmful. Other factors that affect the definition of nutrient recommendations, such as nutrient bioavailability, are also discussed. Iron deficiency anaemia is one of the major health problems throughout the Region and one that this publi- cation aims to prevent, and therefore an entire chapter (Chapter 6) is de- voted to this subject.
In Chapters 7–9, the importance of breastfeeding and the appropriate age for the introduction of complementary foods and fluids are reviewed. International experts agree that exclusive breastfeeding during early infancy is the most beneficial. The precise age at which appropriate, adapted family foods should be introduced will differ from infant to infant. Too early an introduction of complementary foods and fluids increases the risk of infec- tion and reduces the benefit of exclusive breastfeeding. Too late an intro- duction can result in interruption of growth, undernutrition and an
5
increased risk of illness. Chapter 9 is dedicated to the important role of the caregiver, and emphasizes that how infants and children are cared for can have a dramatic impact on their growth and development.
Chapter 10 deals with normal growth and development. Dental health, a major problem in children, especially in eastern Europe, is addressed in Chapter 11. Finally, Chapter 12 stresses the critical importance of preparing food for infants and children in a clean and hygienic way in the home. Poor food hygiene results in an increased incidence of diarrhoea, one of the main causes of growth retardation and stunting in the Region.
TERMINOLOGY
The term exclusive breastfeeding is frequently used in this book and means that all fluid, energy and nutrient requirements are provided by breast-milk alone, even in hot climates. The only possible exception is the addition of small amounts of medicinal supplements.
When foods are specifically prepared to meet the particular nutritional or physiological needs of the infant, they are described as complementary foods and could either be transitional foods or adapted family foods. These terms are used in the way that the term “weaning foods” is or was used. The term “weaning” is no longer recommended because, although it is derived from the old English wenian, meaning “to accustom”, it has come to imply the cessation of breastfeeding. In this publication the term “weaning” is purposely avoided and it is stressed that the introduction of complemen- tary foods should neither displace breast-milk nor initiate the withdrawal of breastfeeding.
The introduction of complementary foods in relation to the age of the child is shown in Fig. 1. Part A illustrates the contribution of breast-milk and other foods to total energy intakes at different ages; part B presents the same information as a percentage of total energy intake.
ADAPTATION AND IMPLEMENTATION OF THESE GUIDELINES
The foods that constitute the customary diet of infants in the WHO European Region are extremely varied because of the diversity of what is available and of cultural habits. To address these issues effectively it will be necessary for health ministries to produce national guidelines suited to the local situation. Before such guidelines can be developed, however, local
6
conditions should be assessed. Gathering quantitative food intake data on the customary diet of young children is a challenge, but it is important to collect such information in addition to anthropometric data on weight and length. It is strongly recommended that health ministries, ideally jointly with ministries responsible for food and agriculture, undertake regular monitoring of the health and growth of infants and young children and that
Fig. 1. Contribution of different food sources to young children’s energy intake in relation to age
To ta
l e ne
rg y i
nt ak
e (k
ca l/d
ay )
Transitional foods Family foods
Breast-milk
Complementary feeding
Family foods Transitional foods
Breast-milk
Complementary feeding
Pe rc
en ta
ge o
f t ot
al e
ne rg
y i nt
ak e
Exclusive breastfeeding
Exclusive breastfeeding
Source: World Health Organization (1).
Age
Age
7
the process becomes an integral part of the national health and nutrition information system.
The recommendations presented in this publication will help health pro- fessionals involved in the care of infants and young children, and will assist policy-makers to develop national nutrition and feeding guidelines to pre- vent disease and achieve better health and development of young children. The health benefits are likely to persist into adulthood, and provide the foundation of a healthy start in life. These guidelines present a scientific consensus for health promotion and information to develop national rec- ommendations. They provide a clear direction for the sustainable develop- ment of health and socioeconomic policy, and can help policy-makers identify resources needed to improve the health of young children and thus that of the population in future generations.
REFERENCES
1. Complementary feeding of young children in developing countries: a re- view of current scientific knowledge. Geneva, World Health Organiza- tion, 1998 (document WHO/NUT/98.1).
2. DEPARTMENT OF HEALTH, UNITED KINGDOM. Weaning and the weaning diet. Report of the Working Group on the Weaning Diet of the Committee on Medical Aspects of Food Policy. London, H.M. Stationery Office, 1994 (Report on Health and Social Subjects, No. 45).
3. CANADIAN PEDIATRIC SOCIETY, DIETITIANS OF CANADA & HEALTH
CANADA. Nutrition for healthy term infants. Ottawa, Minister of Public Works and Government Services, 1998.
4. Recommendations for the nutrition of infants: recommendations for health personnel. Copenhagen, National Board of Health, 1998.
5. FOMON, S.J. Protein. In: Fomon, S.J. Nutrition of normal infants. St Louis, MO, Mosby, 1993, pp. 121–139.
6. GARROW, J.S. ET AL., ED. Human nutrition and dietetics, 10th ed. Lon- don, Churchill Livingstone, 1999.
7. BARKER, D.J.P., ED. Fetal and infant origins of adult disease. London, British Medical Journal, 1992.
8. OZANNE, S.E. & HALES, C.N. The long-term consequences of intra- uterine protein malnutrition for glucose metabolism. Proceedings of the Nutrition Society, 58: 615–619 (1999).
9. HERNANDEZ-DIAZ, S. ET AL. Association of maternal short stature with stunting in Mexican children: common genes vs common environment. European journal of clinical nutrition, 53: 938–945 (1999).
8
10.MARTORELL, R. The nature of child malnutrition and its long term implications. Food and nutrition bulletin, 20: 288–292 (1999).
11.HEAVER, R. & HUNT, J.M. Improving early childhood development – an integrated program for the Philippines. Washington, DC, World Bank, 1995.
12. GUNNEL, D. ET AL. Separating in utero and postnatal influences on later disease. Lancet, 254: 1506–1507 (1999).
13. LUCAS, A. ET AL. Fetal origins of adult disease – the hypothesis revisited. British medical journal, 319: 245–249 (1999).
14. DALY, A. ET AL. Diet and disadvantage: observations on infant feeding from an inner city. Journal of human nutrition and dietetics, 11: 381– 389 (1998).
15. DEPARTMENT OF SOCIAL SECURITY, UNITED KINGDOM. Opportunity for all: tackling poverty and social exclusion. London, Stationery Office, 1999.
16. UNITED NATIONS DEVELOPMENT PROGRAMME. Human development re- port 1997. New York, Oxford University Press, 1997.
17. UNITED NATIONS CHILDREN’S FUND. The state of the world’s children 1998. Oxford, Oxford University Press, 1998.
introductionchapter 1
Health and nutritional status and feeding practices
It is recommended that each country establish nutrition surveillance of infants and young children as an integral part of its health information system.
Breastfeeding practices, feeding patterns and the nutritional status of infants and young children should be monitored regularly to enable problems to be identified and strategies developed to prevent ill health and poor growth.
NUTRITION-RELATED HEALTH PROBLEMS IN YOUNG CHILDREN
In order to develop national feeding guidelines and nutritional recommen- dations, sound data should be available on growth, nutrition-related dis- eases and feeding practices. The greatest concern is child survival, so mortal- ity is one of the most important indicators of child health. The infant mortality rate is calculated as the number of deaths among children under 1 year of age divided by the total number of live births occurring in the same period. The under-5 mortality rate is calculated as the number of deaths among children under 5 years of age divided by the total number of live births occurring in the same period. Mortality data are usually reported routinely, but they may not be accurate in many countries because of poor or incomplete death certification.
Post-neonatal mortality (deaths among infants aged between 1 month and 12 months) is used as an indicator of poor living conditions and thereby poor nutrition, because many deaths during the first month of life are caused by congenital malformations and neonatal complications unrelated to nutrition. High mortality rates may not always be related to poor nutri- tion, and it is not always possible to establish a direct causal link between malnutrition and mortality. Nevertheless, a correlation has been demon- strated in several studies, and according to Pelletier (1) the relationship is continuous. Thus even mild and moderate malnutrition carries an increased risk of mortality.
Indicators of poor nutritional status can provide an early indication that a child is at risk (see Chapter 10). The most widely used are anthropometric.
10 chapter 1
For example, in children below the age of 5 years, measured weight and height can be compared with the weights and heights of children of the same age in a healthy reference population. The reference population rec- ommended by WHO is that drawn up by WHO and the Centers for Disease Control and Prevention in Atlanta (CDC) (2). Indices are usually expressed as standard deviations from the mean (Z score), centiles or per- centage of the median.
The weight-for-height index is a measure of fatness or thinness and is sensitive to sudden changes in energy balance. A weight-for-height index more than two standard deviations below the mean is called “wasting” and indicates severe weight loss, which is often due to acute starvation and/or severe disease. Provided there is no serious food shortage, the population prevalence of wasting is usually below 5% even in poor countries. Children with a weight-for-height index more than two standard deviations above the mean are defined as overweight or obese.
Height-for-age is an index of the growth and development of the skeleton. A low value may be an expression of long-term exposure to nutritional inadequacy and indicate chronic malnutrition in children lacking essential nutrients, but it is also related to poor sanitary conditions, repeated infec- tions, diarrhoea and inadequate care. Stunting is defined as a height-for-age index more than two standard deviations below the mean of the WHO/ CDC reference population. Stunting, unlike wasting, is relatively common throughout the European Region, especially in low-income groups.
The distribution of weights in the reference population used in the former Soviet Union is shifted to the right compared with that of the WHO/CDC population, so that the 5th centile of the Soviet reference corresponds approximately to the 10th centile of the WHO/CDC reference. This leads to a 5% overestimation of the prevalence of malnutrition and a 5% under- estimation of the prevalence of obesity in countries that base their data on the former Soviet reference population.
Biochemical indicators are sometimes useful for assessing nutritional sta- tus, and some may provide an early indication of a specific nutrient defi- ciency, but because of their cost and invasiveness they cannot be measured routinely. Haemoglobin is one exception, because simple and relatively inexpensive field measurement methods have been developed. However, different haemoblobin cut-off points have been used to define mild and mod- erate anaemia (3), and comparisons between countries are not always possible unless the same cut-off points have been used or the raw data are available.
11health and nutritional status and feeding practices
It is often not possible to assess nutrient intake because food intake surveys are lacking. Moreover, data on breastfeeding rates from different countries cannot be compared easily because the definitions used are often different. Most surveys do not include data on exclusive breastfeeding. There is a need to stress the importance of exclusive breastfeeding for optimum child health (see Chapter 7) and create awareness of the need to measure its prevalence in every country. It is recommended that a standardized questionnaire for collecting data on breastfeeding and infant and young child feeding practices be developed for the WHO European Region to strengthen the current surveillance systems, which are not well established in most countries.
This chapter provides an overview of the situation in the European Region using the limited data available. For the purpose of comparison, the Mem- ber States of the WHO European Region have been divided into eight geographical regions, as shown in Table 1. Where possible, data from the central Asian republics (CAR) and the other members of the Common- wealth of Independent States (CIS) have been compared with those from western or southern Europe or from the Nordic countries. It is hoped that this comparison will highlight the disparity in health and nutritional status across the Region, and help to identify the nutritional problems of greatest concern. Based on the limited data available, some of the differences in infant and young child feeding practices are highlighted.
Mortality Fig. 2 shows the wide disparity in infant and under-5 mortality rates in the European Region, ranging from the highest in CAR, particularly Tajikistan and Turkmenistan (over 55 and 75 per thousand live births for infant and under-5 mortality, respectively) to the lowest in the Nordic countries such as Finland and Sweden (5 per 1000 live births for both). The mortality rates in central and eastern Europe and in the Balkans fall between these two extremes at around 10–20 per 1000 live births. The difference between infant and under-5 mortality is relatively large in countries with high mor- tality rates. In contrast it is almost zero in Finland and Sweden, indicating that very few deaths occur after the first year.
Since the 1970s, infant mortality rates have been steadily decreasing across the Region (Fig. 3). However, while the averages for the European Union and the Nordic countries have dropped from 22 and 13 deaths per 1000 live births, respectively, in 1970 to just 5 in 1995, the figures for CIS and especially CAR remain significantly higher than in the rest of the Region.
12 chapter 1
Ta bl
e 1.
T he
M em
be r S
ta te
s of
th e
W H
O E
ur op
ea n
Re gi
on
Ba lk
an Ba
lt ic
Ce nt
ra l
Ce nt
ra l
Co m
m on
w ea
lt h
N or
di c
So ut
he rn
W es
te rn
co un
tr ie
s co
un tr
ie s
A si
an an
d of
In de
pe nd
en t
co un
tr ie
s Eu
ro pe
Eu ro
pe re
pu bl
ic s
ea st
er n
St at
es (C
AR )
Eu ro
pe (e
xc lu
di ng
CA R)
Al ba
ni a
Es to
ni a
Ka za
kh st
an Bu
lg ar
ia Ar
m en
ia De
nm ar
k An
do rra
Au st
ria Bo
sn ia
a nd
La tv
ia Ky
rg yz
st an
Cz ec
h Re
pu bl
ic Az
er ba
ija n
Fi nl
an d
G re
ec e
Be lg
iu m
He rz
eg ov
in a
Li th
ua ni
a Ta
jik is
ta n
Hu ng
ar y
Be la
ru s
Ic el
an d
Is ra
el Fr
an ce
Cr oa
tia Tu
rk m
en is
ta n
Po la
nd G
eo rg
ia N
or w
ay Ita
ly G
er m
an y
Sl ov
en ia
U zb
ek is
ta n
Ro m
an ia
Re pu
bl ic
o f
Sw ed
en M
al ta
Ire la
nd Th
e fo
rm er
Sl ov
ak ia
M ol
do va
M on
ac o
Lu xe
m bo
ur g
Yu go
sl av
Ru ss
ia n
Po rtu
ga l
N et
he rla
nd s
Re pu
bl ic
o f
Fe de
ra tio
n Sa
n M
ar in
o Sw
itz er
la nd
M ac
ed on
ia Uk
ra in
e Sp
ai n
Un ite
d Yu
go sla
vi a
Tu rk
ey Ki
ng do
m
13health and nutritional status and feeding practices
Deaths per 1000 live births
Fi g.
2 . I
nf an
t m or
ta lit
y ra
te s
an d
un de
r-5 m
or ta
lit y
ra te
s in
E ur
op ea
n co
un tr
ie s,
a ro
un d
19 96
Unite d Kingdom
Neth erl
an ds
Fra nce
Norw ay Fin
lan d Sw
ed en
Tur key
Malta Ital
y Spa in Tur
km eni
sta n Taj
ikis tan Uzbe
kis tan
Kaza khs
tan
Kyrg yzs
tan
Azer bai
jan
Rep ublic
of M oldova Arm
eni a
Russ ian
Fe der
ati on Ukra ine
Roman ia Bulg
ari a Polan d Slo
vak ia
Fed era
l Repu blic
of Yu
go sla
via
So ur
ce : H
ea lth
f or
a ll
da ta
ba se
, W HO
R eg
io na
l O ffi
ce f
or E
ur op
e.
Bosnia a nd Herz
egovin a Croa
tia
Lat via Lith
uan ia Est
on ia
0
1020304050607080
In fa
nt m
or ta
lit y
ra te
U nd
er -5
m or
ta lit
y ra
te
14 chapter 1
So ur
ce : H
ea lth
f or
a ll
da ta
ba se
, W HO
R eg
io na
l O ffi
ce f
or E
ur op
e.
Fi g.
3 . I
nf an
t m or
ta lit
y ra
te s
in th
e Eu
ro pe
an R
eg io
n, 1
97 0–
19 97
Deaths per 1000 live births 45 40 35 30 25 20 15 10 5 0
20 00
19 90
19 95
19 85
19 80
19 75
19 70
Eu ro
pe an
U ni
on Ce
nt ra
l a nd
e as
te rn
E ur
op e
Co m
m on
w ea
lth o
f In
de pe
nd en
t St
at es
N or
di c
co un
tri es
Ce nt
ra l A
sia n
re pu
bl ic
s
15health and nutritional status and feeding practices
Whereas in western European countries the primary causes of infant mor- tality are congenital malformations, injuries and “cot deaths” (sudden in- fant death syndrome), such deaths in countries with high mortality rates are mainly caused by infectious diseases. Poor nutritional status compromises the immune function of young children and makes them more susceptible to infections, particularly those affecting the respiratory and gastrointestinal tracts. In Azerbaijan, for example, the under-5 mortality rate from respira- tory diseases is 24.5 per 1000 live births, while in Slovakia it is only 1.5 per 1000 live births.1 In CAR, infants suffer from acute respiratory infections, diarrhoeal diseases and vaccine-preventable diseases such as tuberculosis; seven out of ten deaths are due to these illnesses, often in combination. Among children under 5, acute respiratory infections (notably pneumonia) are responsible for between 30% and 50% of all infant deaths. In Bulgaria and the Federal Republic of Yugoslavia, respiratory diseases are also the main cause of death in children (4).
Fetal, infant and child growth
Low birth weight Low birth weight is defined as a birth weight of less than 2500 g. It is the result of either preterm delivery or intrauterine growth retardation, which can be related to poor nutritional status of the mother. Fig. 4 illustrates the prevalence of low birth weight across the European Region. Rather surpris- ingly, only Romania and the former Yugoslav Republic of Macedonia show a significantly higher prevalence (11%) compared with the countries of western Europe. Bulgaria and Poland, for example, both have a lower prevalence (6% and 5%, respectively) than the United Kingdom (7%).1
Within the European Union, the proportion of low-birth-weight chil- dren has remained relatively constant over the past 20 years. Only the Nordic countries have seen a fall in the percentage of low-birth-weight infants.
In contrast, there appears to have been an increase in prevalence in CIS. In Armenia, for example, preterm delivery was recorded in 5.6% of live births in 1991 and this increased to 6.6% in 1996 (5). Births do not always take place in hospital, however, and so the information is not always complete. Furthermore, figures from eastern Europe may be biased by differences in reporting and in the definition of low birth weight. In some countries infants with a birth weight of less than 1000 g are not included because their risk of dying is so high. As a result, it is difficult to determine to what extent
1Data from the health for all database, WHO Regional Office for Europe.
16 chapter 1
Fi g.
4 . P
re va
le nc
e of
lo w
b ir
th w
ei gh
t ( <
25 00
g ) i
n Eu
ro pe
, 1 99
0– 19
97
The fo rm
er Y ugosla
v
Repu blic
of M ace
do nia
Croa tia
Lat via Lith
uan ia Est
on ia
So ur
ce : H
ea lth
f or
a ll
da ta
ba se
, W HO
R eg
io na
l O ffi
ce f
or E
ur op
e.
Percentage
02468
1 0
1 2
Unite d Kingdom
Fra nce
Norw ay
Fin lan
d
Sw ed
en
Tur key
Ital y Spa in
Tur km
eni sta
n
Taj ikis
tan
Uzbe kis
tan
Kaza khs
tan
Azer bai
jan
Russ ian
Fe der
ati on
Roman ia
Bulg ari
a
Polan d
Slo ven
ia
Belg ium
Gree ce
Geo rgia Arm eni
a
17health and nutritional status and feeding practices
the present data reflect the real situation. There is clearly a need to standard- ize the definition and collection of data to improve comparisons between countries.
Wasting, overweight and stunting
European data from the Global Database on Child Growth and Malnutri- tion and from population surveys are shown in Table 2.
A prevalence of wasting greater than 5% has been documented only in Tajikistan and Uzbekistan, where it is 10–12%. Otherwise there is gener- ally a low prevalence of wasting throughout the Region, ranging from zero and 0.8% in France and Italy in the 1970s to around 2–3% in other countries in the 1990s. Even in vulnerable groups such as refugees in Arme- nia and Azerbaijan, and populations under siege in Bosnia and Herzegovina (10), the data indicate that protein–energy malnutrition was not a wide- spread public health problem.
Overweight in older children has been observed in several countries of the Region, particularly in the west. In a recent study of British schoolchildren aged 7–8 years, for example, the prevalence of overweight and obesity significantly exceeded the expected frequency (13). In contrast, only a slight excess prevalence has been observed in countries in the east of the Region, such as Armenia and the Federal Republic of Yugoslavia. The Russian Fed- eration is the exception, where 20% of young children are overweight – the highest prevalence in the Region (11). Comparing obesity data for the 0–5- year-old age group is not very useful, however: while a high weight-for-age index in infancy may not be a cause for concern, since it is unlikely to continue into adulthood, obesity in the 4–5-year-old age group and older may well do so (14,15).
The main nutrition-related problem in the Region is growth retardation, indicated by a low height-for-age index. The prevalence of stunting is especially high in CAR, where it affects between 7% and 43% of children under 5 years of age (Table 2). Stunting is usually most pronounced in rural areas and this is an indication of its link with environmental conditions. Such high rates of stunting are similar to those observed in African countries and should be considered a major public health problem. Intermediate values of stunting (10–22% of young children) have been observed in other CIS countries (Table 2). In contrast, the other regions all have low levels or no stunting in young children when compared with the WHO/CDC reference population.
18 chapter 1
Balkan countries Bosnia and
Herzegovina 1993 0–5 1.3 – – Croatia 1995–1996 1–6 0.8 5.9 0.8 The former
Yugoslav Republic of Macedonia 1999 0–5 5.3 5.6 5.2
Federal Republic of 1996 0–5 (rural) 2.2 4.8 6.8 Yugoslavia 0–5 (urban 3.5 8.0 1.7
Central Asian republics (CAR) Kazakhstan 1995 0–3 (rural) 3.0 3.8 21.8
0–3 (urban) 3.7 4.9 7.5 Kyrgyzstan 1997 0–3 (rural) 3.2 – 27.7
0–3 (urban) 4.3 – 14.8 Tajikistan 1996 0.5–5 10.9 – 42.6 Uzbekistan 1996 0–3 (rural) 12.2 – 30.7
0–3 (urban) 10.2 – 32.6
Central and eastern Europe Czech
Republic 1991 0–5 2.1 4.1 1.9 Hungary 1980–1988 0–5 1.6 2.0 2.9 Romania 1991 0–5 2.5 2.3 7.8
Commonwealth of Independent States (excluding CAR) Armenia 1998 0–5 3.8 5.8 12.2 Azerbaijan 1996 0–5 2.9 3.7 22.2 Republic of
Moldova 1996 0–5 3.2 11.7 9.6 Russian
Federation 1993 0–5 3.5 20.9 17.0
Southern Europe Italy 1975–1977 0–6 0.8 4.4 2.7 Turkey 1993 0–5 (rural) 3.0 2.7 27.1
0–5 (urban) 2.9 2.9 16.1
Western Europe France 1975 0–3 0.0 3.6 5.8 United
Kingdom 1973–1979 0–5 1.0 2.9 2.4
Table 2. Prevalence of wasting, overweight and stunting in children aged 0–5 years in selected countries of the WHO European Region
Country Year of Age Wasting Overweight Stunting survey (years) (%) (%) (%)
Sources: Branca et al. (6,7); Macro International (8,9); Robertson et al. (10); World Health Organization (11); WHO/UNICEF (12).
19health and nutritional status and feeding practices
Anthropometric data for the 0–3 or 0–5-year-old range should be inter- preted with caution, since they are affected by the distribution of ages within the sample. Stunting is rare during infancy and the rates of stunting are therefore usually higher if a survey includes children aged up to 5 years instead of up to 3 years. Again, there is a need to standardize the method of data collection throughout the Region in order to make useful comparisons.
Micronutrient status The prevalence of the deficiency of four micronutrients is described here: iodine, iron and vitamins A and D. These are discussed in more detail in Chapters 4–6.
Iodine The definition of mild, moderate and severe iodine deficiency (Table 3) is based on the combined evaluation of four different indicators: goitre in school-age children, thyroid volume greater than the 97th centile, median urinary iodine in school-age children and adults, and the prevalence of levels
Table 3. Indicators of the prevalence of iodine deficiency disorders and criteria for a significant public health problem
Indicator Normal Mild Moderate Severe deficiency deficiency deficiency
Prevalence of goitre in school-age children < 5% 5–19.9% 20–29.9% > 30%
Frequency of thyroid volume in school-age children > 97th centile by ultrasound < 5% 5–19.9% 20–29.9% > 30%
Median urinary iodine in school-age children and adults 100–200 µg/l 50–99 µg/l 20–49 µg/l < 20 µg/l
Prevalence of neonatal thyroid stimulating hormone above 5 µU/ml whole blood < 3% 3–19.9% 20–39.9% > 40%
Source: WHO Regional Office for Europe (16).
20 chapter 1
of thyroid stimulating hormone in neonates above 5 µU/ml whole blood (16). Iodine deficiency disorders remain common in the European Region, as shown in Table 4.
There are clear differences in the success of public health interventions to eliminate the problem. In western European countries, iodine deficiency disorders have virtually been eliminated through universal salt iodization. In contrast, moderate levels are still found in the central Asian republics, other former Soviet countries, central and eastern Europe and Turkey. Indeed, severe or critical levels are reported in both Albania and Tajikistan. Surveys of the prevalence of goitre in schoolchildren aged 6–11 years, conducted in a range of European countries (Fig. 5), show that the highest goitre rates occur in Turkey, Belarus, Azerbaijan, the central Asian republics and even Italy. Such high goitre rates should be considered a public health priority and measures should be taken to deal with the problem.
Universal salt iodization (see Chapter 5) used to be practised in the former Soviet Union. Since the dissolution of that country, however, iodization plants are no longer in production. Although salt iodization is on the public health agenda of most of the former Soviet countries, it is not always implemented. Urinary excretion of iodine can be used to evaluate the effi- ciency of iodization policies; in the former Yugoslav Republic of Macedo- nia, for example, urinary iodine excretion has increased to normal levels as a result of salt iodization. An extensive review of the situation was carried out in the WHO European Region in 1998–1999 (17).
Iron
In Europe, information on the prevalence of iron deficiency in children is limited. Most studies have investigated only the prevalence of anaemia, usually by measuring haemoblobin levels, and not its etiology, even though iron deficiency is likely to be the most common cause.
Comparison is further hindered by the use of different age groups. While some studies are carried out only in children under 3 years of age (Fig. 6), other studies go up to 5 years of age (Fig. 7). The highest prevalence of anaemia has been reported from the central Asian republics, where more than half of the children under 3 years had haemoglobin < 12 g/dl blood (Fig. 6). It should be pointed out, however, that only a small proportion of cases were of severe anaemia (haemoglobin < 7 g/dl). In western Europe anaemia is less frequent in children of this age; in the United Kingdom, for example, a 12% prevalence has been observed in children aged 1–2 years and a 6% prevalence in children aged 2–4 years. The United Kingdom
21health and nutritional status and feeding practices
Region Virtually Marginal Generally Severe or eliminated and mild moderate critical
Balkan countries The former Croatia Albania Yugoslav Republic of Macedonia
Baltic countries Estonia Latvia Lithuania
Central Asian Kazakhstan Tajikistan republics (CAR) Kyrgyzstan
Turkmenistan Uzbekistan
Central and Slovakia Czech Bulgaria eastern Europe Republic Poland
Hungary Romania
Commonwealth Republic of Armenia of Independent Moldova Azerbaijan States Belarus (excluding CAR) Georgia
Russian Federation
Ukraine
Nordic countries Finland Iceland Norway Sweden
Southern Europe Turkey
Western Europe Netherlands Switzerland United
Kingdom
Source: WHO Regional Office for Europe (16).
Table 4. Iodine deficiency disorders in selected European countries, according to WHO classification
22 chapter 1
Fi g.
5 . P
re va
le nc
e of
g oi
tr e
in c
hi ld
re n
ag ed
6 –1
1 ye
ar s
in E
ur op
ea n
co un
tr ie
s, 1
98 5–
19 94
So ur
ce : W
HO R
eg io
na l O
ffi ce
f or
E ur
op e
(1 6)
.
Percentage
05
1 0
1 5
2 0
2 5
3 0
3 5
4 0
Germ an
y
Neth erl
an ds
Belg ium
Portu gal
Tur key
Gree ce
Ital y
Spa in
Tur km
eni sta
n
Taj ikis
tan
Uzbe kis
tan
Kaza khs
tan Kyrg yzs
tan
Azer bai
jan
Arm eni
a
Ukra ine
Roman ia
Bela rus
Polan d
23health and nutritional status and feeding practices Fi
g. 6
. P re
va le
nc e
of a
na em
ia a i
n ch
ild re
n un
de r 3
y ea
rs o
f a ge
in fi
ve c
ou nt
ri es
So ur
ce s:
M ac
ro In
te rn
at io
na l (
8, 9)
; W HO
/U N
IC EF
(1 2)
; L aw
so n
et a
l. (1
8) ; S
ha rm
an ov
(1 9)
.
a D ef
in ed
a s
< 12
g /d
l h ae
m og
lo bi
n. b C
hi ld
re n
ag ed
1 –2
y ea
rs .
01020304050607080
Se ve
re M
od er
at e
M ild
To ta
l
Percentage
U zb
ek is
ta n
Ka za
kh st
an Ky
rg yz
st an
Az er
ba ija
n Un
ite d
Ki ng
do m
b
24 chapter 1
So ur
ce s:
B ra
nc a
et a
l. (6
,7 );
Ro be
rts on
e t a
l. (1
0) ; L
aw so
n et
a l.
(1 8)
.
Fi g.
7 . P
re va
le nc
e of
a na
em ia
a i n
ch ild
re n
un de
r 5 y
ea rs
o f a
ge in
fo ur
c ou
nt ri
es
a D ef
in ed
a s
< 12
g /d
l h ae
m og
lo bi
n. b C
hi ld
re n
ag ed
2 –4
y ea
rs .
Un ite
d Ki
ng do
m b
Bo sn
ia an
d He
rz eg
ov in
a
Th e
fo rm
er Yu
go sla
v Re
pu bl
ic o
f M
ac ed
on ia
Ar m
en ia
Se ve
re M
od er
at e
M ild
To ta
l
30 25 Percentage
1520 10 5 0
25health and nutritional status and feeding practices
survey used a cut-off point of 11 g/dl blood; according to this, anaemia occurs in 10–30% of pre-school children living in inner cities in the United Kingdom (20). Prevalence among a nationally representative sample of Asian children living in the United Kingdom was significantly higher than this (between 20% and 45%) (18).
Factors other than iron deficiency cause anaemia. In Uzbekistan, a study of 243 children under 5 years of age showed that 72% were anaemic, but only 2% of these seemed to have non-nutritional anaemia (caused by infections and chronic diseases). In 40% of cases anaemia was associated with both low iron and low vitamin A status; 10% of cases were associated with iron deficiency alone and 20% with vitamin A deficiency alone (21).
Food intake data from the Russian Federation suggest that both women and children are at high risk of iron deficiency. Grain products rich in phytates are the major food source of iron in the Russian Federation (22). Moreover, the reported high intake of tea and low consumption of vitamin C from vegetables and fruit also compromise the bioavailability of iron present in the diet. A survey of 4077children under 2 years of age showed a preva- lence of anaemia, assessed by clinical signs, that varied from 2% (Moscow region) to 16% (Urals region). The prevalence of haemoglobin levels under 11 g/dl blood was much higher and varied from 22% (Moscow city) to 47% (Urals region). The mean haemoglobin level was significantly higher in young children in cities than in those in small towns and rural regions, at 12.2 and 11.6 g/dl, respectively (O. Netrebrenko, personal communication, 1997).
There is a shortage of studies on the cause of the high prevalence of mild to moderate anaemia in parts of eastern Europe, such as the too-early intro- duction of cow’s milk and milk products and tea. A small study in Uzbekistan, which included measurement of ferritin and haemoglobin levels, suggested that deficiency of both iron and vitamin A was responsible. A survey carried out in Kazakhstan associated anaemia in children with stunting, morbidity and geophagia (the habit of eating soil). Geophagia was also reported from Uzbekistan (21) and is considered a symptom of iron deficiency anaemia. Clearly, further studies are needed to investigate the cause of the high prevalence of anaemia found in some parts of the European Region.
Vitamin A
Serum retinol levels under 0.35 µmol (100 µg) per litre indicate severe vitamin A deficiency; levels under 0.70 µmol (200 µg) per litre indicate low vitamin A status. A 10% prevalence of low serum retinol points to an
26 chapter 1
important public health problem requiring at least public information strategies (23).
There is a lack of data describing the vitamin A status of populations in the Region. Evidence suggests, however, that vitamin A deficiency is likely to be a problem in the central Asian republics. A study in the Aral Sea area of Uzbekistan showed that 40–60% of children under 5 years of age had serum retinol levels < 100 µg/l (21). Another study carried out in Armenia indicated that only 0.8 % of children under 5 years of age had low levels of retinol (< 200 µg/l) (24). A recent survey in the former Yugoslav Republic of Macedonia, however, showed higher levels of mild deficiency in children under 5 years: 30% had serum retinol values under 200 µg/l, but only 1% had severely low levels (< 100 µg/l) (7). More information is clearly re- quired before any policy recommendations can be made about vitamin A status in the Region.
Vitamin D deficiency and rickets
Radiographic identification of rickets has been reported in the Region, but for most countries only routine clinical data are available. One of the main causes of rickets is likely to be the traditional practice of swaddling infants, often continued until the age of 2 years, which is common in some parts of the Region. Near total covering of the skin limits its exposure to ultraviolet light and is therefore a key factor in the development of rickets. In the former Yugoslav Republic of Macedonia, 16% of children were reported to show clinical signs of rickets (7). A study of 1135 Armenian children under 5 years of age (6) reported that 7% had an epiphyseal enlargement of the wrist, 2% had craniotabes, 25% had frontal and parietal bossing and 11% had beading of the ribs. When serum alkaline phosphatase (an indicator of vitamin D deficiency) was measured, however, only 4–6% of the children under 2 years of age had high values, indicating that rickets was no longer active in the majority. Some young children may be naturally bow-legged, thereby confounding the diagnosis of rickets; it is also unclear to what degree lack of exposure to sunlight or dietary vitamin D deficiency are responsible (see Chapter 4).
FEEDING PRACTICES AND RECOMMENDATIONS
Many countries in the WHO European Region do not have national guide- lines for feeding infants and young children. Nevertheless, they do exist in several countries including Denmark, Ireland, the Netherlands, Sweden and the United Kingdom. In the former Soviet Union the need for such guidelines, which were last updated in 1982 (25), was long recognized. The
27health and nutritional status and feeding practices
scientific basis underpinning optimum infant and young child feeding is still a relatively new area of research, and advances are occurring all the time. There is thus a need to ensure guidelines keep abreast of the science on which they are based.
Infant feeding recommendations appear to vary considerably between west- ern and eastern Europe. In many countries of eastern Europe, feeding guide- lines have been influenced by the recommendations of the former Soviet Union (25). A review identified a number of recommendations from the former Soviet era that differ from international standards (26). Poor com- plementary feeding practices help to explain the poor iron status and possi- bly the high levels of stunting among infants and young children in the European Region, and particularly in the countries of the former Soviet Union.
In relation to breastfeeding, the former Soviet literature recommended:
• late initiation of breastfeeding (up to 6–12 hours after birth), particu- larly in sick women and including those with anaemia;
• prelacteal feeds of 5% glucose until lactation was established; • exclusive breastfeeding for the first month only (although not widely
practised); • breast-milk as the main feed for the first 4–4½ months; • complete cessation of breastfeeding by 10–11 months of age; and • breastfeeding to follow a strict timetable.
The importance of a night break between feeds was often emphasized. According to the six feeds per day regimen, a 6½-hour break during the night was advised; this break increased to 8 hours on the five feeds per day schedule. A review of the Soviet literature (J. Vingraité, personal commu- nication, 1998) revealed that some authorities allowed feeds to deviate from this schedule by all of 10–15 minutes.
Non-adapted formulas in the Soviet Union included diluted fresh or fermented cow’s milk with added sugar, vitamins and minerals. The introduction of cow’s milk diluted with cereal water was recommended at 2–3 months (for example, 50 ml pure cow’s milk or kefir, 45 ml cereal water and 5 ml 100% sugar syrup).
Former Soviet recommendations on the introduction of weaning foods included: additional fluids, primarily tea and water with sugar, for breastfed infants; the introduction of vegetable and “fruit” juices (jam with water) at
28 chapter 1
1 month of age; the introduction of unmodified cow’s milk at 4 months and pure kefir at 3 months of age; the introduction of fruit at 2 months, hard boiled egg yolk at 3 months and curd at 4 months of age; the addition of sugar and salt solutions to infant foods; and the introduction of cereal porridges with added sugar, syrup, salt and butter at 4 months of age.
Of particular concern is that in cases of diagnosed anaemia (and rickets), porridge and other solids were recommended to be introduced earlier than 4 months of age.
Breastfeeding: initiation, duration and practice of exclusive breastfeeding Owing to a lack of comprehensive and comparable data and of standardized international definitions, it is difficult to make a general statement about the prevalence of breastfeeding in the WHO European Region. The data on the percentages of breastfed infants given in Fig. 8 have been taken from different sources (27). These data should be interpreted with caution: the survey methodology varied and in some cases the way in which the surveys were carried out was not described.
With these caveats, it can be seen that the practice of breastfeeding varies dramatically between European countries. In the United Kingdom, some 25% of infants are breastfed at 3 months, compared with over 90% in Uzbekistan. Nevertheless, the prevalence of breastfeeding within a country can change dramatically over a few years. In Norway, for instance, the prevalence of breastfeeding at 3 months rose from only 25–30% in 1969 to around 80% in 1985 (28).
Unfortunately the data presented in Fig. 8 do not show the rates of “exclu- sive” breastfeeding. Few studies have provided a definition of “exclusive” breastfeeding, but data from those that have are presented in Fig. 9, which shows the relatively high rates of exclusive breastfeeding in Sweden both at 3 and 6 months. In contrast, the rates of exclusive breastfeeding in the central Asian republics are much lower (around 10% or less) at 3 months, except in Georgia and Kyrgyzstan where the levels are around 30%. Poland is making excellent progress: the prevalence of exclusive breastfeeding in- creased dramatically from almost zero in 1988 to some 40% in 1997.
In the Russian Federation in 1996 breastfeeding was initiated in about 95% of babies born in maternity hospitals (O. Netrebrenko, personal commu- nication, 1997). The mean duration ranged from 3 to 4 months depending on when breastfeeding was initiated and on the mother’s educational level.
29health and nutritional status and feeding practices Fi
g. 8
. P re
va le
nc e
of b
re as
tf ee
di ng
in d
iff er
en t c
ou nt
ri es
o f t
he E
ur op
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Re gi
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So ur
ce : W
HO R
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ffi ce
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E ur
op e
(2 7)
.
Russi an
Fe dera
tio n 1996
Percentage
Unite d Kingdom 1995
Neth erl
an ds
1996
Norw ay
1991
Sw ede
n 1 993
Taj ikis
tan 1996
Uzbe kis
tan 1997
Kaza khs
tan 1995
Kyrg yzs
tan 1997
Azer ba
ijan 1996
Republic of M
oldova 1996
Arm enia 1
993
Ukra ine 1
996
Bulg ari
a 1 989–1996 Po lan
d 1 997
Slo vak
ia 1 990
Fed era
l Repu blic
of Yu go
sla via
1996
Bosnia a nd Herz
egovin a 1
993
Croa tia
1995
Luxem bourg 1994
Lith uan
ia 1 993
Est onia
1996
Czec h R
epu blic
1991 Geo rgia 1
998
Germ an
y 1 996
Denm ark
1992 Sw
itze rla
nd 1994 Bela
rus 1993
Ire lan
d 1 992
Lat via
1996
010203040506070809010 0
3 m
on th
s
6 m
on th
s
30 chapter 1
0
10
20
30
40
50
60
70
80
3 months
6 months
Fig. 9. Prevalence of exclusive breastfeeding in selected countries of the European Region, 1989–1998
Pe rc
en ta
ge Sw
ed en
Po lan
d Ky
rgy zst
an Geo
rgi a
Lu xe
mbo ur
g Ka
za kh
sta n
Uzb ek
ist an
Fe de
ral Re
pu bli
c o f Y
ug os
lav ia
Bo sn
ia an
d H erz
eg ov
ina Az
erb aij
an
Source: WHO Regional Office for Europe (27).
The most educated women breastfed their infants significantly longer than women with lower levels of education. The prevalence of partial breastfeeding was about 50% at 3 months and about 30% at 6 months. The majority of breastfed infants also received cow’s milk. The prevalence of exclusive breastfeeding in infants aged 4 months varied between 22% and 28% in most regions. In St Petersburg, however, the prevalence of exclusive breastfeeding was very high (42%), probably as a result of higher education levels and of the commitment of the local authorities to implementing the international breastfeeding recommendations (see Chapter 7).
Studies in the central Asian republics indicate that, despite the high preva- lence of breastfeeding, a low percentage of infants are exclusively breastfed (Fig. 9); in over 50% breastfeeding has not begun after the first 24 hours. The lack of exclusive breastfeeding, together with deteriorating socio- economic conditions, water contamination and low immunization rates,
31health and nutritional status and feeding practices
pose a threat to infant health. In Kazakhstan, despite a high level of breastfeeding with a mean duration of around 12 months, the period of exclusive breastfeeding is very short (8). In the former Yugoslav Republic of Macedonia only 8% of children are exclusively breastfed at 4 months of age. Conversely, in the Nordic countries, where great efforts have been made to increase rates of exclusive breastfeeding, the percentage is very high (Fig. 8 and 9).
The rates of breastfeeding seem to be increasing throughout the Region, and the Nordic countries especially have very high rates compared with 20 years ago. Efforts should be made to maintain these high rates and greater efforts should be made in all other countries to increase rates of exclusive breastfeeding during the first few months of life (see Chapter 7). This is especially important for vulner- able groups such as ethnic minorities and low-income families living in high- risk areas with poor hygiene, sanitation and water supply.
Use of infant formulas, cow’s milk and other liquids Bottle feeding is common throughout the European Region. In Uzbekistan, 35% of children under 3 months of age examined in the 1996 Demo- graphic and Health Survey were being fed using a bottle with a nipple, 12% to take infant formula and 23% to take evaporated milk (9). In rural areas, the use of cow’s milk was more common.
The early introduction of cow’s milk is associated with gastrointestinal blood loss. Because the content and bioavailability of iron in cow’s milk is also low, early introduction of cow’s milk can lead to iron deficiency (see Chapter 6). In the Russian Federation, 12-month-old infants who received cow’s milk during the first 3 months of life had significantly lower haemo- globin levels than those who received cow’s milk after 7 months of age (O. Netrebrenko, personal communication, 1997). Similarly, in the United Kingdom, Asian infants are more likely than white infants to receive cow’s milk and are also more likely to have iron deficiency anaemia (29). Further- more, Asian infants tend to have a higher intake of cow’s milk than white children (30). A study in Italy showed that, between 1983 and 1992, a reduction in the proportion of infants fed cow’s milk together with an increase in breastfeeding has been paralleled by a reduction in both anaemia and iron deficiency in infants and young children (31).
Table 5 shows the early introduction of cow’s milk and other fluids to the infant’s diet in some countries. In Lithuania, cow’s milk is diluted with water or mixed with cereal water from rice, oat or buckwheat (J. Vingraité, personal communication, 1998). In Azerbaijan, wheat flour is used in combination with diluted cow’s milk and egg.
32 chapter 1
In the Russian Federation, the types of non-breast-milk fluid given to infants differ between the large cities and the smaller towns or rural areas. In Moscow, some 50% of infants start to receive infant formula at 2 months as a supplement to breast-milk. In addition to formulas, about 10% of infants in the cities received unadapted milks (cow’s milk, kefir, goat’s milk) as supplements during the first 4 months. Some 22% of infants in small towns and rural areas received cow’s milk or kefir at least 3 times a day during the first 4 months as a breast-milk substitute. The time of introduc- tion of unadapted milks depended on the mother’s education and the family income: infants of low-income families receive cow’s milk signifi- cantly earlier than those from wealthier families (O. Netrebrenko, personal communication, 1997).
Other fluids commonly given to infants in the first or second month of life include plain or sweetened water and tea. In Uzbekistan, 40% of children received tea within the first month after birth and by 3 months of age the
< 4 weeks < 3 months < 5 months
Baltic countries Lithuania Cow’s milk, goat’s
milk, kefir
Central Asian republics (CAR) Kazakhstan Water, tea with sugar Cow’s milk, tea Kyrgyzstan Water, tea with sugar Cows milk, tea Uzbekistan Water, fruit juice Cow’s milk, tea
Commonwealth of Independent States (excluding CAR) Armenia Water, tea Fruit juice, cow’s
milk Azerbaijan Water, tea Cow’s milk Russian Federation Fruit juice
Western Europe United Kingdom Herbal drink Cow’s milk
Water
Table 5. Age of introduction of non-breast-milk fluids into the infant’s diet
Average age of introduction
Sources: Branca et al. (6); Macro International (8,9); WHO/UNICEF (12); Mills & Tyler (30).
Country
33health and nutritional status and feeding practices
proportion had increased to 72% (21). Other central Asian republics show similar patterns. For example, 21%, 34% and 49% of infants in Kazakhstan, Kyrgyzstan and Uzbekistan, respectively, received tea during the first few months of life (19). In Armenia, water and herbal tea are introduced during the first 2 months and tea in the third month. In most instances water is boiled and given without the addition of sugar, but sugar is added to herbal tea (67%) and to ordinary tea (95%). The introduction of tea and sugar occurs even earlier in rural areas (6).
The practice of giving teas (both ordinary and herbal) to infants also appears to persist in western Europe, especially among ethnic minorities, and in central Europe. This practice is not recommended, not only because it interferes with breastfeeding but also because the polyphenols present in tea impair iron absorption.
Introduction of semi-solid and solid foods Table 6 shows the time of introduction of complementary foods in some countries. In the Russian Federation, the proportion of infants receiving foods before 4 months of age ranges from 17% in St Petersburg to 32% in the Urals region (O. Netrebrenko, personal communication, 1997). Simi- larly, in Armenia, children are fed semi-solid foods (crushed fruit and veg- etables, porridge and potatoes) and biscuits at 4–5 months, and at 6 months they are given eggs. Bread and pasta, minced meat, fruit and vegetables are introduced at around 8–9 months of age. Other meat preparations and fish are the last to be introduced, at around 1 year of age. Compared with the Russian Federation, there appear to be fewer differences between urban and rural areas in Armenia or between residents and refugees in the age at which various foods are introduced (6).
In the United Kingdom in 1996, white mothers tended to start giving their infants solid food earlier than Asian mothers. At 8 weeks, 2% of Bangla- deshi, 3% of Pakistani and 5% of Indian infants had received some solid food, compared with 18% of white infants. In all groups the majority of mothers introduced food between 8 weeks and 3 months. By the age of 3 months, between 70% and 73% of Asian mothers and 83% of white mothers had given their infants some solid food (29).
In the central Asian republics, infants’ diets are often monotonous, mainly consisting of a porridge poor in nutrients. The results of the 1996 Demographic and Health Survey in Uzbekistan (9) found that 19% of 4–7-month-old infants had received meat, poultry, fish or eggs in the 24 hours preceding the interview, while 35% had received fruit or vegetables.
34 chapter 1
< 3 months 3–4 months 5–6 months > 6 months
Baltic countries Lithuania Fruit, berries, Curd, egg yolk, Meat, broth
vegetable juice oil, butter, cereals
Central Asian republics (CAR) Uzbekistan Vegetables, Broth Poultry, fish, Family food
fruit eggs, meat, flour, potatoes
Commonwealth of Independent States (excluding CAR) Armenia Fruit, porridge,
vegetables, potatoes, biscuits
Azerbaijan Potatoes, cereals, soup, milk, porridge, biscuits
Russian Federation Fruit Vegetable Meat purée, cereals
Southern Europe Italy Rice porridge, Meat, pasta, Eggs, fish, rice,
fruit, parmesan vegetables pulses
Spain Cereals, fruit Bread, vegetables, yoghurt, meat, fish, eggs, pulses
Table 6. Time of introduction of complementary foods into the infant’s diet
Average age of introduction
Sources: Branca et al. (6); Macro International (9); WHO/UNICEF (12); Ferrante et al. (32); Savino et al. (33); Van den Boom et al. (34).
Country
35health and nutritional status and feeding practices
In the Balkan region, Albanian infants receive diets based heavily on cereals (35) and in the former Yugoslav Republic of Macedonia diets include large amounts of grain, beans and vegetables. The socioeconomic situation af- fects nutritional status by decreasing the ability to buy meat and milk products due to their high price (36). Thus the introduction of fruit and vegetables, and of meat and liver may be delayed or reduced by economic and/or seasonal factors. In contrast, meat is introduced at 5–6 months in Italy and after 6 months in Spain.
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4. Central and eastern Europe in transition: public policy and social condi- tions. Poverty, children and policy: responses for a brighter future. Flor- ence, UNICEF International Child Development Centre, 1995 (Econo- mies in Transition Studies, Regional Monitoring Report, No. 3).
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women in Armenia. Rome, National Institute of Nutrition, 1998. 7. BRANCA, F. ET AL. Mulitiple indicator cluster survey in Fyrom with micro-
nutrient component. Rome, National Institute of Nutrition, 1999. 8. Kazakstan Demographic and Health Survey, 1995. Calverton, MD,
Macro International Inc., 1996. 9. Uzbekistan Demographic and Health Survey, 1996. Calverton, MD,
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11. WHO global database on child growth and malnutrition. Geneva, World Health Organization, 1997 (document WHO/NUT/97.4).
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14. ROLLAND-CACHERA, M.F. ET AL. Increasing prevalence of obesity among 18-year-old males in Sweden: evidence for early determinants. Acta paediatrica, 88: 365–367 (1999).
15. ROLLAND-CACHERA, M.F. ET AL. Influence of adiposity development: a follow-up study of nutrition and growth from 10 months to 8 years of age. International journal of obesity and related metabolic disorders, 19: 573–578 (1995).
16. DELANGE, F. ET AL., ED. Elimination of iodine deficiency disorders (IDD) in central and eastern Europe, the Commonwealth of Independent States and the Baltic states. Proceedings of a conference held in Munich, Ger- many, 3–6 September 1997. Copenhagen, WHO Regional Office for Europe, 1998 (document WHO/EURO/NUT/98.1).
17. Comparative analysis of progress on the elimination of iodine deficiency disorders. Copenhagen, WHO Regional Office for Europe, 2000 (docu- ment EUR/ICP/LVNG 01 01 01).
18. LAWSON, M.S. ET AL. Iron status of Asian children aged 2 years living in England. Archives of disease in childhood, 78: 420–426 (1998).
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20. GREGORY, J.R. ET AL. National diet and nutrition survey children aged 1.5–4.5 years. Vol 1. Report of the diet and nutrition survey. London, H.M. Stationery Office, 1995.
21. MORSE, C. The prevalence and causes of anemia in Muynak District, Karakalpakistan, the Republic of Uzbekistan. Brandon, MS, Crosslink International, 1994.
22. KOHLMEIER, L. Deficient dietary iron intakes among women and chil- dren in Russia: evidence from the Russian Longitudinal Monitoring Survey. American journal of public health, 88: 576–580 (1998).
23. Indicators for assessing vitamin A deficiency and their application in moni- toring and evaluating intervention programmes. Geneva, World Health Organization, 1996 (document WHO/NUT/96.10).
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25. Infant feeding. Methodical recommendations. Moscow, Ministry of Health of the USSR, 1982.
26. Complementary feeding and the control of iron deficiency anaemia in the Newly Independent States: presentation by WHO at a WHO/UNICEF consultation, Geneva, Switzerland, 4 February 1999. Copenhagen, WHO Regional Office for Europe, 2000.
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promotion and support of breastfeeding. Copenhagen, WHO Regional Of- fice for Europe, 1999 (document EUR/ICP/LVNG 01 01 02).
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introductionchapter 2
Recommended nutrient intakes
Each country should use recommended nutrient intakes for infants and young children, based on international scientific evidence, as the foundation of its nutrition and feeding guidelines.
INTRODUCTION
This and the next four chapters include discussion and comparison of the recommended nutrient intakes (RNIs) from the European Union, the United Kingdom, the United States and WHO. These values provide a standard against which the adequacy of the diets of young children, as measured by food intake surveys, can be assessed (1).
The purpose of RNIs is to provide guidance for policy-makers on how much of each nutrient is needed to ensure that a population is healthy (Box 1). The aim is to prevent deficiency (for example, iodine to prevent goitre); to optimize health (for example, recommendations for anti- oxidants in vegetables and fruit); and to provide safe limits above which a nutrient (for example, excess protein or energy) could be harmful.
1. RNIs provide a benchmark for the development of dietary guidelines and the planning of public health nutrition strategies.
2. RNIs can be useful for food labelling (for example, a food might be described as containing x% of the recommended intake of vitamin C for a given age group).
3. RNIs can be used to assess and interpret dietary surveys and food intake information relating to normal healthy populations.
4. RNIs can be used to assess the adequacy of the dietary intake of vulnerable groups.
Source: adapted from Weaver (2).
Box 1. Applications and limitations of recommended nutrient intakes
40 chapter 2
Additional factors such as bioavailability (of iron, for example) must be taken into consideration when setting national RNIs.
RECOMMENDATIONS ARE DERIVED FROM REQUIREMENTS
A requirement is defined as the lowest continuing level of intake of a nutrient that will maintain a defined level of nutrition in an individual (3). The actual nutrient requirement will vary from individual to individual, whereas a nutrient recommendation must cover the requirements of al- most all those in a given population. RNIs are useful for assessing the diet of groups within a population, not of individual children, and r