Nutrition during the first 1000 days
This is our fourth in a series of articles that deal with nutrition before, during, and after pregnancy, and how this influences risk factors related to paediatric cancer. The last article covered nutrition during pregnancy.
The first 1000 days, a period encompassing pregnancy and the first 2 years, is considered to be the most important with regards to growth and development. During this period the baby’s organs are actively growing to functional capacity, and are very vulnerable to any form of injury and malformation. This period—also known as the critical window of opportunity, requires that the child be fed in a perfect manner by providing it with adequate amounts of nutrients, not too much and not too little, so that all the organs grow optimally. Any inadequacies or excess of nutrients during this this time period exposes the child to a wide range of diseases which could develop immediately, or later in life1UNICEF. (2019, May 24). UNICEF. Retrieved from UNICEF Website: https://www.unicef.org/turkey/en/press-releases/early-moments-matter-childrens-brain-development-unicef. Childhood malnutrition is the single biggest contributor to under-five mortality due to greater susceptibility to infections, and slow recovery from illness2motherchildnutrition.org. (2017, December 16). Mother and Child Nutrition. Retrieved from motherchildnutrition.org: http://motherchildnutrition.org/malnutrition/about-malnutrition/impact-of-malnutrition.html. This is the reason why women attending antenatal visits are told to exclusively breastfeed for the first six months and introduce complementary foods (weaning) at six months3World Health Organisation. (2006). Infant and Young Child Feeding Counselling: An Integrated Course. Geneva: WHO.. Staying well-nourished during the first 1,000 days can pave the way for a strong, healthy, productive future. Evidence shows that optimal nutrition during this time can have a lasting impact on a child’s growth, learning, and future productivity4Judith, B. E., Janet, I. S., Beate, K. U., Ellen, L., Maureen, M., Carolyn, S., … Nancy, W. (2011). Nutrition Through the Life Cycle. Belmont: Cengage..
As a mother, one of the best things that only you can do for your baby is to breastfeed. Breastfeeding is more than a lifestyle choice—it is an important health choice. Any amount of time that you can do it will help both you and your baby. While breastfeeding isn’t the only option for feeding babies, every mother has the potential to succeed and make it a wonderful experience.
During the first 2 years of life, which are characterized by rapid physical and social development, many changes occur that have an effect on feeding and nutrient intake. The adequacy of infants’ nutrient intakes affects their interaction with their environment. Healthy, well-nourished infants have the energy to respond to, and learn from, the stimuli in their environment and to interact with their parents and caregivers in a manner that encourages bonding and attachment5Mahan, K., & Raymond , J. L. (2017). Food & The Nutrition Care Process, 14th edition. St. Louis, Missouri: Elsevier Inc..
Infant feeding involves two very important stages: exclusive breastfeeding and complementary feeding (weaning). Both of these stages have very important principles which we need to follow in order to bring up a healthy child6Judith, B. E., Janet, I. S., Beate, K. U., Ellen, L., Maureen, M., Carolyn, S., … Nancy, W. (2011). Nutrition Through the Life Cycle. Belmont: Cengage..
Immediately after birth, the baby needs to be initiated on breastmilk, this is because the thick yellowish milk known as colostrum is very healthy and helps protect the baby from illness. Early initiation of breastfeeding prevents the baby from becoming hypoglycemic, hypothermic7United Nations Children’s Fund (2011). Infant and Young Child Feeding. New York: UNICEF., and helps the mother to expel the placenta from pregnancy and reduce bleeding. Many women experience psychological benefits, including increased self-confidence, facilitated bonding with their infants8Kuzela, A. L., Stifter, C. A., & Worobey, J. (1990). Breastfeeding and mother-infant interactions. J Reprod Infant Psychol, 8:185–94., and faster return to pre-pregnancy weight. In addition to these short-term benefits, women who nurse at a younger age and for longer durations have lower risk of developing breast and ovarian cancer9Narod, S. A. (2006). Modifiers of risk of heredity of breast cancer. Oncogene, 25:5832–6. and rheumatoid arthritis10Karlson, E. W. (2004). Do breast-feeding and other reproductive factors influence future risk of rheumatoid arthritis? Results from the Nurses’ Health Study. Arthritis Rheum, 50(11):3458–67..
The key to successful breastfeeding management is for the mother–infant breastfeeding dyad to receive support, informed, consistent, and individualized care from healthcare professionals both in the hospital and after discharge. Daily milk production is not related to the total milk storage capacity within the breast11Daly, S. E., Owens, R. A., & Hartmann, P. E. (1993). The short-term synthesis and Infant-regulated removal of milk in lactating women. Exp Physiol, 78(2):209–20.. The vast majority of women do not experience significant problems with breastfeeding, and many of the more common problems that do arise can be prevented through prenatal breastfeeding education and a positive, supportive, breastfeeding initiation period12Judith, B. E., Janet, I. S., Beate, K. U., Ellen, L., Maureen, M., Carolyn, S., … Nancy, W. (2011). Nutrition Through the Life Cycle. Belmont: Cengage..
Breastfeeding must be initiated within the first hour after birth, it should be breastmilk only but in case the child cannot access breastmilk, the responsible person needs to consult a nutritionist to recommend an appropriate feeding plan for the child13Ministry of Health (Uganda). (2016). Guidelines For Integrated Management of Acute Malnutrition. Kampala.. The American Academy of Pediatrics recommends that whole cow’s milk, skim milk, and reduced-fat milks not be used in infancy14Ziegler, E. (1999). Cow’s milk and intesintestinal blood loss in late infancy. J Pediatrics, 135:720–26. because of the link with developing iron-deficiency anemia15Kleinman, R. E. (2009). Pediatric nutrition handbook, 6th ed. Chicago, IL: American Academy of Pediatrics..
It is recommended that the child must be fed on breastmilk only during the first six months because the baby’s digestive system is just developing and cannot handle the vigorous digestion of complex foods. Some mothers may feel that their children are not getting satiated with the breastmilk and they may start giving them porridges and soft foods. These foods are soft to the touch, but their metabolism is too straining on the young body. This early introduction of complementary foods exposes the baby to a wide variety of diseases including allergies, ear infections, and obesity, which is a risk factor for various cancers16Mahan, K., & Raymond , J. L. (2017). Food & The Nutrition Care Process, 14th edition. St. Louis, Missouri: Elsevier Inc.. Breastfeeding should be upheld for six months exclusively, and then when weaning is started at 6 months, breastfeeding should be continued for upto 2 years if the mother can manage it.
The value of human milk is widely recognized for its dynamic composition and the appropriate balance of nutrients which protect children against chronic childhood diseases17Jensen, R. G. (1995). Handbook of Milk Composition. New York: Academic Press.. Other benefits include:
- The relatively low protein-content of breast milk compared to cow’s milk meets the infant’s needs without overloading the immature kidneys with nitrogen.
- The balance of nutrients in breast milk matches human infant requirements for growth and development.
- Breast milk is iso-osmotic (of similar ion concentration; in this case to human blood plasma), and therefore meets the requirements for infants without other forms of food or water.
- Human milk provides generous amounts of lipids in the form of essential fatty acids.
- Long-chain polyunsaturated fatty acids, especially docosahexaenoic acid (DHA) promotes optimal development of the central nervous system.
- Minerals in breast milk are largely protein-bound and balanced to enhance their availability and meet infant needs with minimal demand on maternal reserves.
Breastfeeding may reduce the risk of developing celiac disease18Ivarsson, A., Persson, L. A., Nystron, L., Ascher, H., Cavell, B., Danielsson, L., … Hernell, O. (2000). Epidemic of coeliac disease in Swedish children. Acta Paediatr, 89(2):165–7., inflammatory bowel disease19Koletzko, S. (1989). Role of infant feeding practices in development of Crohn’s disease in childhood. BMJ, 298(6688):1617–18., and neuroblastoma in children20Daniels, J. L., Olshan, A. F., Pollock, B. H., Shah, N. R., & Stram, D. O. (2002). Breastfeeding and neuroblastoma, USA and Canada. Cancer Causes Control, 13(5):401–5..
Mother’s milk provides the infant with temporary immunity to many infectious diseases. It is economical, nutritionally perfect, sanitary, saves time spent in shopping for or preparing formula, easy to digest, and does not cause gastrointestinal disturbances or allergic reactions. Breastfed infants have fewer infections, especially ear infections, during the first few months compared to formula-fed babies. Because breast milk contains less protein and minerals than infant formula, it reduces the load on the infant’s kidneys. Breastfeeding also promotes oral-motor development in infants, and decreases the infant’s risk of obesity and diabetes21Roth, R. A. (2010). Nutrition and Diet Therapy, 10th edition . New York: Cengage..
A breastfeeding mother can reduce the chances of exposing her child to environmental chemicals by following the recommendations below. Additional suggestions for avoiding chemical exposures in and around the home are given in the report from the Environmental Working Group22Environmental Chemical Working Group. (2015). 2015 Annual Report. Washington D.C: EWG..
- Avoiding smoking cigarettes and drinking alcohol. Studies have found higher levels of contaminants in smokers and alcoholics.
- Beware when purchasing houses or apartments, that those built before 1978 especially, might have lead-based paints.
- In general, eat a variety of foods. Eat organically-grown food, if available.
- Increase consumption of grains, fruits, and vegetables.
- Thoroughly wash and peel fruits and vegetables to help eliminate the hazard of pesticide residues on the skin. When available, eat food grown without fertilizer or pesticide-application.
- Avoid fish that may have high mercury levels, such as swordfish, tilefish, and locally caught fish from areas with fish advisories.
- Limit exposure to chemicals such as solvents found in paints, non-water-based glues, furniture strippers, nailpolish, and gasoline fumes.
- If you work with solvents (in the workplace or at home), postpone breastfeeding for several hours after exposure.
- Run tap water through a home filter before drinking. Filters can reduce levels of common tap-water pollutants.
- Attempt to avoid occupational exposure to chemical contaminants in the workplace, and seek improved chemical safety standards for all employees, especially pregnant and lactating women.
- Workers should be diligent in following their workplaces’ safety recommendations.
- Alert other family members to be sensitive to contaminant residue they may inadvertently bring into the home. Shower and change clothing before leaving work, and keep and launder work clothes separate from other clothing.23Judith, B. E., Janet, I. S., Beate, K. U., Ellen, L., Maureen, M., Carolyn, S., … Nancy, W. (2011). Nutrition Through the Life Cycle. Belmont: Cengage.
Complementary feeding (weaning) refers to the gradual introduction of the baby to food other than breast milk. It starts at a time when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. Typically, it covers the period from 6 to 24 months of age, and is a critical period.
The introduction of solid foods before the age of 6 months is not recommended because the child’s gastrointestinal tract and kidneys are not sufficiently developed to handle solid food. Furthermore, it is thought that the early introduction of solid foods may increase the likelihood of overfeeding and the possibility of the child developing food-allergies, particularly those whose parents suffer from allergies24Roth, R. A. (2010). Nutrition and Diet Therapy, 10th edition . New York: Cengage.. In Uganda, despite the government interventions to enhance optimal complementary feeding, the practice is substantial and has led to the high prevalence of infant stunting at 29%, underweight at 14% and wasting at 5% among children under-five (5) years25Uganda Bureau of Statistics. (2017). Uganda Demographic and Health Survey. Kampala: UBOS..
Appropriate complementary feeding has four dimensions, which are:
- Timely – foods are introduced when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding.
- Adequate – foods provide sufficient energy, protein, and micronutrients to meet a growing child’s nutritional needs.
- Safe – foods are hygienically stored and prepared, and fed with clean hands, using clean utensils, and not bottles with teats.
- Properly fed – foods are given consistent with a child’s signals of appetite and satiety, actively encouraging the child to consume sufficient food using fingers, spoon or self-feeding as suitable for age.
The frequency of complementary feeding differs between children. This is important to know, to avoid underfeeding and overfeeding. The frequency increases with age due to increased physical activity and rapid growth.
Recommendations for feeding frequency are:
- 2–3 times a day for 6–8 months
- 3–4 times a day for 9–11 months
- 3–4 times a day with 1–2 snacks for 2–24 months
Food consistency and variety is important in meeting the micro- and macro-nutrient needs of the child. Feed mashed and semi-solid foods, softened with breastmilk, beginning at 6 months of age. It’s important to feed energy-dense combinations of soft foods to 6–11 month olds, then introduce “finger foods” beginning around 8 months of age.
Make the transition to the family diet at about 12 months of age.
Dietary diversity is recognized as a key element of high quality diets and increasing the variety of foods consumed ensures adequate intake of essential nutrients, and promotes good health and nutrition.
Feed vitamin A-rich fruits and vegetables daily. Feed meat, poultry, or fish daily, or as often as possible. Use fortified foods, such as iodized salt, vitamin A-enriched potatoes, iron-enriched flour, or other staples.
Give vitamin-mineral supplements when animal products and/or fortified foods are not available. Avoid giving drinks with low nutrient-value, such as tea, coffee, or sugary beverages. Feed infants directly and assist older children when they feed themselves.
Offer favorite foods and encourage children to eat when they lose interest or have depressed appetites. If children refuse many foods, experiment with different food combinations, tastes, textures, and methods for encouragement. Feed slowly and patiently, and minimize distractions during meals.
Do not force children to eat.
Hygiene and Food handling
Maintaining proper hygiene is an important aspect of nutrition because it reduces the risk of a person getting food-poisoning or other food-borne illnesses which would in turn affect one’s nutrient intake, leading to malnutrition.
Be sure to:
- Wash caregiver’s and children’s hands before food preparation and eating.
- Store foods safely, and serve foods immediately after preparation.
- Use clean utensils to prepare and serve food.
- Serve children using clean cups and bowls, and never use feeding bottles.
Food and its presentation are extremely important during the baby’s first year. Physical and mental developments are dependent on the food itself and psycho-social development is affected by the time and manner in which the food is offered. Although babies have been fed according to prescribed time schedules in the past, it is preferable to feed infants on demand. Feeding on demand prevents the frustrations that hunger can bring and helps the child develop trust in people.
The first 1000 days of a child’s life are very important in determining its health later on in life. Maintaining proper feeding practices during this time has health benefits which go beyond measure.
The next article in this series concerns nutrition requirements for children with cancer.
Photos by Andrae Ricketts via Unsplash.
|↲1||UNICEF. (2019, May 24). UNICEF. Retrieved from UNICEF Website: https://www.unicef.org/turkey/en/press-releases/early-moments-matter-childrens-brain-development-unicef|
|↲2||motherchildnutrition.org. (2017, December 16). Mother and Child Nutrition. Retrieved from motherchildnutrition.org: http://motherchildnutrition.org/malnutrition/about-malnutrition/impact-of-malnutrition.html|
|↲3||World Health Organisation. (2006). Infant and Young Child Feeding Counselling: An Integrated Course. Geneva: WHO.|
|↲4, ↲6, ↲12, ↲23||Judith, B. E., Janet, I. S., Beate, K. U., Ellen, L., Maureen, M., Carolyn, S., … Nancy, W. (2011). Nutrition Through the Life Cycle. Belmont: Cengage.|
|↲5, ↲16||Mahan, K., & Raymond , J. L. (2017). Food & The Nutrition Care Process, 14th edition. St. Louis, Missouri: Elsevier Inc.|
|↲7||United Nations Children’s Fund (2011). Infant and Young Child Feeding. New York: UNICEF.|
|↲8||Kuzela, A. L., Stifter, C. A., & Worobey, J. (1990). Breastfeeding and mother-infant interactions. J Reprod Infant Psychol, 8:185–94.|
|↲9||Narod, S. A. (2006). Modifiers of risk of heredity of breast cancer. Oncogene, 25:5832–6.|
|↲10||Karlson, E. W. (2004). Do breast-feeding and other reproductive factors influence future risk of rheumatoid arthritis? Results from the Nurses’ Health Study. Arthritis Rheum, 50(11):3458–67.|
|↲11||Daly, S. E., Owens, R. A., & Hartmann, P. E. (1993). The short-term synthesis and Infant-regulated removal of milk in lactating women. Exp Physiol, 78(2):209–20.|
|↲13||Ministry of Health (Uganda). (2016). Guidelines For Integrated Management of Acute Malnutrition. Kampala.|
|↲14||Ziegler, E. (1999). Cow’s milk and intesintestinal blood loss in late infancy. J Pediatrics, 135:720–26.|
|↲15||Kleinman, R. E. (2009). Pediatric nutrition handbook, 6th ed. Chicago, IL: American Academy of Pediatrics.|
|↲17||Jensen, R. G. (1995). Handbook of Milk Composition. New York: Academic Press.|
|↲18||Ivarsson, A., Persson, L. A., Nystron, L., Ascher, H., Cavell, B., Danielsson, L., … Hernell, O. (2000). Epidemic of coeliac disease in Swedish children. Acta Paediatr, 89(2):165–7.|
|↲19||Koletzko, S. (1989). Role of infant feeding practices in development of Crohn’s disease in childhood. BMJ, 298(6688):1617–18.|
|↲20||Daniels, J. L., Olshan, A. F., Pollock, B. H., Shah, N. R., & Stram, D. O. (2002). Breastfeeding and neuroblastoma, USA and Canada. Cancer Causes Control, 13(5):401–5.|
|↲21, ↲24||Roth, R. A. (2010). Nutrition and Diet Therapy, 10th edition . New York: Cengage.|
|↲22||Environmental Chemical Working Group. (2015). 2015 Annual Report. Washington D.C: EWG.|
|↲25||Uganda Bureau of Statistics. (2017). Uganda Demographic and Health Survey. Kampala: UBOS.|