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Growth Children and Vegetarian Diet

P.M. Udani

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Introduction

The most important aspect of paediatrics or childhood is growth and development, as they are the parameters of health and disease.

Definition of Vegetarian Foods in Relation to Milk

It should be emphasized that the milk which is produced by human and other animals is also one of the most important items of vegetarian diet even though it is of animal origin. For example, human milk produced by the baby's mother is the best and most suitable food for the baby and from every angle, it is vegetarian even though it is of animal (human) origin. God has provided specific milk for human babies. Its function is not bnly to provide essential nutrients of specific composition, so that it is easily digested by babies and utilized for their rapid growth but also to provide strong and special defence against various infections, infestations and allergens. It also leads to emotional bonding between the mother and child.

When human milk is not available, we have to take recourse to animal milk like that of a cow, a buffalo or a goat.These animals' milk can be used for children, particularly infants, but in a modified manner, because of their relatively poor digestibility, lack of supply of defensive substances which a human new born or infant needs and absence of true emotional bonding between the mother and the child which occurs when the baby is breast-fed.

Basic Vegetarian Foods

Cereals and Sugar

These are mainly concerned with growth and tissue repair. They are particularly important in childhood when the body is growing rapidly.

Fats

It is essential to emphasize that the fat cells laid down in infancy and early childhood are very difficult to reduce even at a later age. Hence programmes of prevention of obesity and its various complications should be started in childhood by restricting too much fat in the diet as it is a rich source of calories.

Pulses

The combination of cereals and pulses makes very good food as it provides calories for energy, protein for growth in children and for repair of the tissues.

Vegetables

Vegetables are very important items of a child's diet. They are rich in minerals like iron and some vitamins particularly vitamin A and C and many other nutrients mentioned in the earlier chapters.

Fruits

They form an important constituent of vegetarian diet as they supply vitamins, minerals and easily digestible sugars. Ripe bananas, apples, sweet limes and oranges are commonly used in children.

Vitamins

Some of the vitamins and the adverse effects of their deficiency especially in children will be described here.

Vitamin A

With deficiency of vitamin A, children develop night blindness, dryness of conjunctiva and with severe deficiency the cornea or transparent part of the eyes becomes hazy and is ultimately destroyed. It may be mentioned that as many as 40,000 children become blind in India every year and 40,000 are at the risk of blindness. The small expenditure of rupees two per child per year on vitamin A given by mouth twice a year for the first 5 years can prevent blindness and its socio-economic miseries (Fig. 6). It is almost a tragedy that the society, community and various governmental and non governmental agencies cannot play their role adequately in tackling this problem. The poor child's Vitamin A requirements can be met with cheaply through green leafy vegetables like drumstick leaves.

Vitamin B1 or Thiamine

It is essential for the proper functioning of the various enzymes and proper functioning of the nerves. With deficiency of vitamin B1 or thiamine, the child develops swelling of the legs and face, fatiguability and at times marked weakness of the lower limbs. In severe cases they may be unable to walk because of paralysis of the lower limbs which initially involves the feet and later spreads to both the lower limbs. Fortunately this is rare in our country, because in most of our traditional cooking unpolished rice is consumed. It is also desirable to use minimum water to cook the rice. It is not good to throw away the supernatant water floating over the cooked rice as it contains the essential nutrient viz. vitamin B1 or thiamine.

Nicotinic Acid

This is one of the B2 vitamins which is necessary to maintain the health of the skin, intestine and mental functions. Deficiency of nicotinic acid produces dermatitis (skin changes), diarrhoea and has adverse effect on mental functions.

Riboflavin (vitamin B2)

It is essential for the normal condition and functioning of the mucocutaneous junctions like those of the army of the mouth, anal region and also the mucous membrane of the tongue, vulvovaginal junction and eyes. With involvement of the eyes, the child gets lacrimation (excessive watering), itching and burning sensation due to conjunctival irritation and vascularisation (growth of blood vessels) of the cornea.

Vitamin B6 or Pyridoxine

This is one of the important vitamins necessary for the proper functioning of the nervous system including brain and nerves. It is also necessary for the formation of blood. With deficiency of vitamin B6, the child may get anaemia, similar to the type caused by iron deficiency. With its deficiency the child may get involvement of the nerves with tingling, numbness, weakness of the muscles, particularly of lower limbs. It is also necessary, along with vitamin B12, for the formation of myelin or white matter of the nerves and the brain. Pyridoxine deficiency may, rarely, produce convulsions in new born babies and infants.

Folic Acid

Folic acid is the vitamin necessary for the formation of blood. With deficiency of folic acid the child develops megaloblastic anaemia.

Vitamin C or Ascorbic Acid

This is a very important vitamin for the proper maintenance of the functions of the lining of blood vessels, collagen tissue, proper formation of bones. It also helps in fighting against infection and to stand various stresses and strains as it helps the adrenal cortex (one of the endocrine glands) to function well. Without vitamin C the child will develop weakness, anaemia, poor appetite, frequent infections, and if the deficiency is severe, the child develops bleeding from the gums,bones and various tissues. However, the most important effect is on the bones in which because of bleeding under the periosteum (the outer covering of long bones) and damage to the ends of the bones (viz.metaphyses and epiphyses) the child gets severe pain and develops what is known as pseudoparalysis i.e. limbs, though appear paralysed, are not actually paralysed but appear so because of severe paun.

Vitamin D

This is one of the important vitamins which is essential for the growth, proper formation and strength of the bones and muscles. It also enhances immunity. Vitamin D is formed in the body by exposure of the skin to morning or evening sunlight and also from the food. The tradition of oil massage to the baby and exposing him / her to the ultraviolet rays of the sun mainly available in the early morning and evening, is common in our country and is useful. Lack of exposure to sun and overclothing can lead to signs of deficiency of vitamin D. With its deficiency, the child will develop softening. The softening of the bones leads to bending of the bones, deformities and in severe cases fracture of the bones. It may be emphasized that even though milk is an excellent food it is deficient in vitamin D and hence vitamin D supplements must be given to babies on mother's rnilk or top milk feeds. We see a high incidence of rickets in breast-fed babies who grow very rapidly, if deficiency of vitamin D is not corrected by adding vitamin D in the diet or exposing the child to ultraviolet rays of the sun. With vitamin D deficiency the infant may get low levels of calcium in the blood (hypocalcaemia) which is a common cause of convulsions and spasms in infancy and early childhood.

Minerals

It is desirable to mention a few of the important minerals here. The iron is derived from the vegetables particularly green leafy vegetables. If not taken in adequate amount it will lead to what is known as iron deficiency anaemia. It is an extremely common condition in children and as many as 70-80% of the children have mild, moderate or severe anaemia. Iron deficiency occurs in children of poor and middle socio-economic groups not only because of iron deficiency in the diet but also due to parasitic infestations like hookworms. Often the frequent infections in these children interfere in the utilisation of iron to form blood. It may be mentioned that in severe anaemia, particularly due to iron deficiency, when haemoglobin is less than 50 - 60% or 8 gms% or less (normal being 12 to 14 gms%), the child develops immune incompetence or lack of resistance to fight infections as the anaemia affects the T lymphocytes which are vital in the maintenance of T cell immunity.

Copper

Though this is essential in the normal diet, it is adequately met with when iron containing foods are taken, as they usually go together.

Calcium and Phosphorus

These are the main constituents of the bones and are also found in other tissues—for example muscles. They are important fo formation and giving strength to the bones. Calcium is also im portant in the maintenance of proper cardiac function. Deficiency of calcium can lead to poor formation of bones. However, inspite of adequate amounts of calcium, if vitamin D is not supplied, the child can get rickets. One of the most important functions of calcium is to maintain the normal functioning of the nervous system. This is particularly important in children but much more so in infancy which is a period of rapid growth, where associated vitamin D deficiency leads to severe calcium deficiency and the child may get convulsions or spasms of the limbs, a condition which is known as tetany. However, a diet which is adequate in amount and contains milk and milk products (butter, ghee,cream etc.), pulses and vegetables will supply adequate calcium. Symptoms of calcium deficiency are usually secondary to deficiency of Vitamin D.

Iodine

Iodine is one of the most important minerals in the vegetarian diets. Moreover, iodine can be supplied in iodised salt. Iodine deficiency is a major health problem in India. About 120 million people in India live in the known goitre endemic regions and 4.0 million people are afflicted with goitre. For example, Delhi has been identified to be an endemic goitre area. The development of new goitrogenic areas are related to iodine deficiency and presence of goitrogenic foods which could inhibit the synthesis of the thyroid hormone. Thiocyanates present in many foods like cabbage,turnip, various staple foods like maize and millets and in milk in which it is added as a preservative, are the most important goitrogenic agents. When there is adequate iodine in the diet, the effect of moderate levels of thiocyanates on inhibition of thyroid hormone synthesis will be prevented.

Taken in large amounts thiocyanates can cross the placental barrier and high concentration in foetal plasma results in severe congenital hypothyroidism. However, as they are not concentrated in the mother's milk, breast-fed infants are protected.

With addition of thiocyanates as a preservative and its subsequent consumption by pre-school and school children with marginal iodine in the diet and consumption of other goitrogenic foods, goitre and impairment of physical growth and mental development may result.'

Micronutrients

These are very small amount of nutrients required for vital metabolic function.

Magnesium

Magnesium is important in metabolic functions. Most of the magnesium is in the bones along with phosphate. Magnesium is bound to proteins. In the cells it is concentrated in the mitochondria and is essential for many enzyme systems for transfer of energy. Cereals and vegetables are good sources of magnesium. Normally there is adequate magnesium in the vegetarian foods and there is adequate storage in the body. However, in children with chronic diarrhoea, and in severe malnutrition, particularly kwashiorkor, there may be well marked deficiency which produces twitching, tremors and convulsions.

Zinc

It is necessary for protein and carbohydrate metabolism. The vegetarian foods, particularly unmilled cereals and legumes, are rich in zinc. Prolonged deficiency of zinc in infants and children with severe chronic diarrhoea may lead to stunted growth. Deficiency of zinc may also produce excessive crying in infants, lack of concentration in older children and skin rash. However, under usual situations deficiency of zinc is rare.

Importance of Adequate and Balanced Diet

In a normal healthy child carbohydrate supplies 45 to 50%, fats 25 to 35 % and proteins 10 to 15% of the total calories. A child of one year needs about 1000 to 1100 calories which is met with by giving him a diet which supplies 600 to 650 calories from carbohydrate, 40 to 50 calories from proteins and 300 to 350 calories from fats. Apart from the supply of these nutrients of carbohydrates, fats and proteins other nutrients like vitamins and minerals are essential as mentioned earlier.

Undernutrition-Mild, Moderate and Severe (Marasmus)

If a child gets lesser calories than the recommended intake, he develops undernutrition and in severe cases marasmus i.e.loss of subcutaneous fat all over the body, marked wasting of the muscles and the child appears thin and wasted having mainly skin and bones. (Fig. 3) If these children have inadequate intake of vitamin A and iron and at the same time, they get frequent infections and have intestinal parasites like worms, they get signs of vitamin A and iron deficiency. This is a very common condition seen in children of poor socioeconomic groups.

Kwashiorkor: (Fig. 5 plate)

This is a condition in which the child fails to grow, gets swelling or oedema of the legs, puffiness of the face or moon facies. Hair becomes brittle and less dark. The child gets severe weakness of muscles and the liver becomes fatty with adverse effects on its functions. However, the most important effect is on its brain and mental development. Such children may remain physically stunted and mentally subnormal inspite of various methods of developmental intervention and rehabilitation. We can prevent these conditions by the following advice: (1) By encouraging breast feeding; (2) By increasing yield of mother's milk by proper advice on her diet which is suitable and cheap, and most important, by education of the mother and health personnel on the importance of breast feeding; (3) By early supplementary feeding at 4 to 6 months of age with mixtures of cereals and pulses, i.e.rice, or wheat roti and dal and addition of mashed vegetables and fruits like bananas at 5 to 6 months of age. However, breast milk is the most suitable milk for the baby as, over and above its nutrient value, it has protective value against infection. Fig. 3 A and B shows the defences in a healthy child and adverse effects of severe malnutrition on immune defences.

Intrauterine Malnutrition and Foetal Growth Retardation

In one of our other studies carried out on malnourished mothers of low socioeconomic groups it was found that the low birth weight babies had many disadvantages. Because of the intrauterine malnutrition and foetal growth retardation these babies particularly if they were not nutritionally rehabilitated, morbidity and mortality was high and some of them developed progressive undernutrition because of failure of supplementary feeding at 4 to 6 months of age. Studying the brain weights of these babies of different nutritional groups it was found that the brain weights were lower in the newborns and infants with lower intrauterine weights and growth. Because of the intrauterine malnutrition these babies had immune incompetence, had very frequent infections because of the ecological condition and way of life. The follow up of these children who had severe malnutrition in infancy and early childhood over a period of 5 to 10 years revealed that their intelligence quotient or the mental development was poorer compared to the healthy controls. These results indicate the importance of diet of the pregnant mothers. To have a healthy baby from the point of view of physical growth and mental development adequate supply of breast milk and supplementary vegetable foods, initially double mix (rice and dal or khichadi) and later triple mix (khichadi and mashed vegetables and fruits) are necessary (Fig. 1 and 2 and coloured plate Fig. 1 and Fig 2)

Lactation

Mother's diet during lactation should be around 3000 calories of which milk and milk products should supply nearly 600 to 900 calories and protein 24 to 40 gms per day. The remaining diet should consist of usual family diet containing cereals, pulses, vegetables, fruits etc. It is not necessary that the mother should have expensive or costly fruits as one or two ripe bananas a day will provide 100 to 150 calories along with iron and calcium. The diet of the mother throughout the lactation period should be adequate enough and should contain around 3000 calories from the diet items mentioned above, because a well nourished mother will be able to provide a higher yield of breast milk per day and over a duration of 6 to 9 months or more. Apart from the diet the most important aspect of good production of human milk is the attitude of the mother to breast feed the baby. The mothers of lower socio-economic groups are able to supply the breast milk easily as they know that the breast milk is the only food for the babies. They have seen their mother, aunts and other relatives feeding their babies on the breasts as they have been brought up either in a joint family or extended family systems. The only advice these mothers need in some parts of our country is that the first fluid secretions of the breast i.e. colostrum is the most important nutrient as it not only gives concentrated calories but also supplies large amount of the antiinfective substances. It is essential to emphasize that the babies' mouth, stomach and intestine should have the first contact only with colostrum which will supply the various anti-infective factors to the baby. Not only colostrum and human milk will strengthen the local immunity in the gut but it will prevent the entry of any allergens which might do damage to the baby locally in the gut or systemically to other organs. Table 1 gives the com parable advantages of the chemical composition of the human milk for its digestibility and utilisability compared to cow's milk. Human milk contains required amount of proteins for the baby 10.6 gm. per lt. (1.06G%) as opposed to 28 to 36 in cow's milk per litre (2.08 to 3.6 gms%) which is meant for the calf and not for human babies. Moreover, the proteins of the mother's milk are quite different in quantity and quality. Fat of the human milk is a special one containing essential fatty acids which are also rich in calories for the fast growing brain of the baby. Milk sugar or lactose is much higher in human milk. Human milk, also supplies digestive substances for the digestion of fat. It is a dynamic secretion supplying milk of proper composition. For example, if the baby is pre-term or born at 7 months of pregnancy the composition of mother's milk is changed by Nature (there is no scientific explanation for this change) to provide higher content of protein. Mother's milk also contains hormones and hormone-like substances which promote growth and many substances like the amino-acid taurine, which is a growth modulator. Table 2 provides various constituents of human mills which are responsible for the anti-infective property of human milk. With these anti-infective substances in human rnilk infections in the breastfed babies are rarely serious or lifethreatening. Human milk contains a large number of living cells which not only synthetize various bio-chemical substances but also provides antibodies especially secretory IgA. Nature has given a remarkable enteromammary immune system in which the T and B lymphocytes and other cells from the mother's gut get stimulated by any infection in the child or the mother, and these activated cells from the lymphatic tissues in the gut of the mother migrate to the blood, and later transferred to her mammary glands (breasts). Ultimately they are passed into the baby's gastrointestinal tract through the breast milk to protect against various infections in the baby. However, the most important part of human milk is its economic consideration. If the mothers in India decide not to breastfeed their baby we will never have enough animals to provide adequate milk for our babies. Breast feeding is also one of the most important ways of family planning; mothers who breastfeed their babies have lactation amenorrhoea (i.e. absence of menstruation) which may last for 6 to 12 months. This makes breast-feeding the baby as one of the most important strategies for family planning particularly in our country.However, other family planning devices like copper-T should be introduced in the uterus desirably by about 6 Months of the lactation period so as to prevent second pregnancy. The interval between the two pregnancies should be at least 3 to31/2 years.

Table I

Composition of Mature Human Milk and Cow's Milk (Extracted from Documenta Geigy Scientific Tables, 7th Edition, Basle, 1970. Courtesy CIBA-GEIGY Iimited Basle, Switzerland)

Constituent Mature Human Milk Cow's Milk
(except where stated) Mean Range s.d. Mean Range s.d.
Energy(kcal) 747 446-1192 93 701 587-876  
M.J. 3.127 1.867-4.989 0.389 2.934 2.457-3.666  
Protein            
Total 10.6 7.3-20 4.6 32-46 28.16-36.76  
Casein 3.7 1.6-6.8 0.8 24 21.90-28.0  
Lactalbumin 3.6 1.4-6.0 1.0 2.4 1.4-3.3  
Lactaglobulin 2.0*          
Amino acids            
Total 12.8 9.0-16.0   33.0 27.0-41.0  
Essential total 5.39**     19.59**    
Histidine 0.24 0.12-0.30 0.041 1.2 1.1-1.3  
Isoleucine 0.61 0.41-0.92 0.121 2.5 2.1-2.9  
Leucine 0.97 0.65-1.47 0.174 3.6 3.2-3.9  
Lysine 0.70 0.36-0.93 0.127 2.6 2.3-3.1  
Methionine 0.12 0.07-0.16 0.023 0.8 0.6-0.9  
Cystine 0.29* 0.25-0.25   0.29*    
Phenylalanine 0.40 0.24-0.58 0.069 1.8 1.5-2.2  
Tyrosine 0.62* 0.46-0.52   1.9*    
Threonine 0.52 0.30-0.66 0.085 1.7 1.3-2.2  
Tryptophan 0.19 0.14-0.26 0.030 0.6 0.4-0.8  
Valine 0.73 0.45-1.14 0.155 2.6 2.4-2.8  
Fats            
Total (g) 45.4 13.4-82.9 10.0 38.0 34.0-61.0  
Essential total            
(% weight of
total fatty acids)
12.02*     4.2    
Linoleic (18.2) 10.6   2.9 2.1   0.7
Linolenic (18.3) 0.85     1.7   0.7
Arachidonic            
(20.4) 0.57     0.4    
Saturated total 50.3**     70.9**    
C4.0-C10.0 1.4     70.9**   1.1
Lauric (12.0) 4.7   2.2 3.6   1.5
Myristic (14.0) 7.9   1.5 11.6   4.7
Palmitic (16.0) 26.7   2.7 36.6   3.2
Stearic (18.0) 8.3   1.7 8.1    
Arachidic (20.0) 1.3       1.7  
Unsaturated            
C10: 1-C16:1 3.8       5.4  
Oleic (18.1) 37.4   3.7 17.7   4.2
Eicosenoic (20:1) 0.9     3.7 17.7 4.2
Cholesterol 0.130 0.088-0.202 0.025 0.110 0.070-0.170  
Carbohydrates            
Lactose 71 49-95   47 45-50  
Citric acid   0.35-1.25   2.45 2.15-2.90  
Minerals            
Electropositive (m Eq./l) 41     149    
Sodium (g./l) 0.189 0.080-0.350 0.008 0.768 0.392-1.390  
Potassium (g./l) 0.553 0.425-0.735 0.070 1.430 0.380-2.870  
Calcium (g./l) 0.271 0.207-0.372 0.030 1.370 0.560-3.810  
Magnesium (g./l) 0.035 0.018-0.057 0.007 0.130 0.070-0.229  
Electronegative (mEq./l) 28     108    
Phosphorus (g/1) 0.141 0.068-0.268 0.025 0.910 0.500-1.120  
Sulphur (g./l) 0.140 0.050-0.300 0.030 0.300 0.240-0.360  
Chlorine (g./l) 0.375 0.088-0.374 0.090 1.080 0.930-1.410  
Excess electropositive Elements (mEq./l) 13     41    
H 7.01 6.4-7.6   6.6    
Trace elements            
Cobalt (mg./l) trace          
Iron (mg/l) 0.50   0.20-0.8   0.45 0.25-0.75
Copper (mg/l) 0.51   0.046   0.102  
Manganese (mg/I/) trace       0.02 0.005-0.067
Zinc (mg/l) 1.18 0.17-3.02     3.9 1.7-6.6
Fluorine (rng./l) 0.107 0.0-0.24       0.10-0.28
Iodine (mg./l) 0.061 0.044-0.093   0.116 0.036-1.05  
Selenium (mg./1) 0.021       0.04 0.005-0.067
Vitamins            
Vitaniin A (mg./l) 0.610 0.150-2.260 0.250 0.270 0.170-0.350  
Carotenes (mg./l) 0.250 0.020-0.770 0.110 0.370 0.120-0.790  
Vitamin D (mg./l)   0.1-2.5     0.1-0.1  
Tocopherol (rng./l) 2.4 1.0-4.8   0.6 0.0-1.0  
Thiamine (mg./l) 0.142 0.081-0.227 0.024 0.430 0.280-0.900  
Riboflavin (mg./l) 0.373 0.189-0.790 0.087 1.560 1.160-2.020  
Vitamin B6 (mg/l) 0.180 0.100-0.220   0.510 0.400-0.630  
Nicotinic acid (mg./l) 1.83 0.66-3.30 0.48 0.74 0.50-0.86  
Vitamin B12 (ug. /1) trace     6.6 3.2-12.4  
Polic acid (ug/l) 24.0 7.4-61.0   37.7 16.8-63.2  
Biotin (ug. /1) 2 1-3   22 14-29  
Pantothenic acid (mg./l) 2.46 0.86-5 0.63 3.4 2.2-5.5  
Ascorbic acid (mg./l) 52 0-112 19 11 3-23  

Table 2
Anti-lnfective Substances in Human Milk

  1. Secretory: Immunoglobin IgA (SlgA)
    (Antibodies Against Different Bacteria and Viruses)
  2. Complement
  3. Enzymes (Lysozyme Stimulated Lipase)
  4. Bifidus Factors
  5. Resistance Factors Against Staphylococcus
  6. Lactoferrin
  7. Cells: Phagocyting Granulocytes and Macrophages and Lymphocytes (90% of which seem to be of T types) and enteromammary immune system
  8. Special Chemical Properties (Low Buffering Capacity)
  9. Lipid Factors and Fatty Acids

Udani P.M., Text Book of Pediatrics with Special reference to Problems of Child Health in Developing Countries 1989-90, in press)

Table 3
Advantages of Breast Feeding on the Baby and the Mother

  1. Biochemical and Digestive Advantages of Human Milk: As it is specific for babies.
  2. Immunological: Anti-infective locally and systemically
  3. Practical: Easy to feed—anytime—anywhere—self demand
  4. Psychological and emotional: Bonding between mother and child
  5. Maternal: Breast cancer incidence 1/5th in mothers who breast feed their baby
  6. Contraceptive: At least for a period of 6 months of lactation
  7. Economic: Enormous expense if breast milk is not available
  8. Antiallergic: Prevents entry of allergens and thus reduces allergic disorders in the baby
  9. Obesity: Reduces chances of future obesity and its hazards
  10. Brain Development and Mental Functions: improved because special nutrients in human rnilk and emotional bonding with the mother.
  11. Prevention of Hypernatraemia (SIDS): Because of required amount of electrolytes like sodium and chlorides in human milk. High sodium and chloride in animal milks can produce hypernatraemia and Sudden Infant Death Syndrome (SIDS)
  12. Calcium Phosphorus Balance: Better absorption of calcium and phosphorus
  13. Development: Breast fed infants are better because of constant contact with the mother.
  14. Morbidity and Mortality: The rate of disease and death is low in breastfed, babies and high in top milk fed babies.

(Udani P.M., Text Book of Pediatrics with Special Reference to Problems of Child Health in Developing Countries 2 Volumes in Press 1989-90)

Table 4
Infection-Related Morbidity in Breast-fed and Formula-fed Infants in India & Canada

Disorder Number of episodes of illness over a 24 month period
  INDIA CANADA
  Breast- fed Formula- fed Breast- fed Formula- fed
  (n=35) (n=35) (n=30) (n=30)
Respiratory infection 57 109 42 98
Otitis 21 52 9 86
Diarrhoea 70 211 5 16
Dehydration 3 14 0 3
Pneumonia 2 8 - -

(R.K. Chandra, 1979, UNICEF 55/56, 1981)

Table above gives low incidence of various infections, particularly life-threatening, in breastfed infants.

Damage Done to the Lactation (Breast Feeding) by Medical and Health Personnel:
While rural mothers are able to breast feed babies almost 95 to 100%, lactation failure or inability to breast feed the baby is common in urban areas. In metropolitan cities like Bombay this is mainly because of the hospital delivery where adequate attention is not given by the medical personnel and nurses to emphasize the importance of breast feeding. Many of them actually discourage breast feeding instead of encouraging it, which is almost criminal on the part of the health personnel. The babies should be put to the breasts within 4 hours of birth. The baby should be kept with the mother and not be taken out and kept in the nursery. The baby and the mother being together, the mother can feed the baby on self demand schedule during the day and the night. Bottle feeding is the biggest danger, as giving the bottle to the baby reduces the mother's milk and leads to lactation failure. Government of India has recommended that bottles should not be used for feeding babies. However, there is no legal provision to prevent the use of the bottle. The medical and health personnel are mainly responsible for the causation of lactation failure in urban mothers. The urban mothers need supportive care from the very beginning and should be educated and motivated to breast feed the babies. It is now well established that breast cancer is 5 times less common in mothers who are able to breast-feed their babies.

Table 5
Incidence of Allergic Disorders

Parameter Number of infants affected or showing positive test
  Breast- fed Formula- fed
  (n=37) (n=37)
Eczema 4 21
Recurrent wheezing 1 8
Serum IgE 60 lU/ml 6 29
IgE-antibodies to cow's milk 1 15
Complement activation in vivo after milk challenge 0 6
Haemagglutinating antibodies to beta-lactaglobulin 3 31
Eosinophilia 400 per mm3 0 5

(Chandra R.K., 1979 ACT-PED. Scand)

Infant Milk Feeds

It may be emphasized that there is no breast milk substitute, as human milk is live dynamic secretion from the mammary glands of the mother which provides all the necessary nutritional constituents to the baby apart from the substances for prevention of infection.

All the infant milk foods are now modified to supply lower proteins of 1.2 to 1.6 gm% after realising that high protein content of 3 to 3.5 gm% was harmful particularly to neonates and infants. However, inspite of various modification to simulate the breast milk composition they cannot have the advantages of mother's milk. These infant milk foods have an adverse effect on breast feeding, since if the baby is given infant milk foods, the breast milk supply declines. Moreover, as the infant milk foods are usually given by a bottle they further lead to lactation failure. Hence the Government of India has recommended that infant milk powders should not be used.

Disadvantages and Dangers of Bottle Feeding

Lactation Failure or Failure of Breast Feeding

It should be emphasized that bottle feeding should be strongly discouraged as by a large number of studies, it has been well established that bottle feeding leads to the child's refusal to suck the breast with the result that the mother's milk supply declines and there is a failure on the part of the mother to continue the breast feeding. Thus the most important advantages of breastfeeding mentioned earlier are lost. There is a vicious circle of bottle feeding leading to reduction in breast milk supply because the baby refuses to suck the breast and will prefer to take the bottle feeding more and more. The ultimate result is that the child gets addicted to the bottle and develops the bottle addiction syndrome which was described by us in 1961. It tnay be pointed out that the child may drink water from a cup but refuses to take milk except by a bottle.

There are many adverse effect of bottle feeding apart from its important cause of lactation failure.

In comparatively well-to-do families adequate milk is available for the child so that he may continue to take 1-2 litres of milk usually with the addition of 2 teaspoonful of sugar. These children develop the condition of protein overload syndrome (Figs 4 and 5) which was first described by us in 1964. The younger the child, the more adverse are the effects of protein overloading. These children are under-nourished and often their weight is around 6 kg at 10 to 12 months of age (as opposed to expected 9 to 10 kg) inspite of an intake of a large quantity of milk. It must be emphasized that human milk contains 0.9 to 1 gm% of protein, and this protein has highest biological value, meaning thereby that it is most digestible and is utilised fully. On the other hand the child fed on buffalo's or cow's milk with an intake of 1 to 1 1/2 litre of milk each day, consumes almost 40 gms to 60 gms of animal proteins. The infant weighing around 6 to 7 kg takes 7 to 8 gms of protein per kg body weight per day instead of normal requirement of 1.8 gm per kg per day. This particular condition results in a characteristic symptoms complex in the child, which we have described as protein overload syndrome. The child has excessive appetite, cries a lot, gets intestinal colic, wants milk all the time, gets abdominal distension, is constipated and gets large or bulky, hard or formed, foul smelling stools and passes large amount of foul smelling urine. The child also gets well marked enlargement of the liver because of the excessive load of fat and proteins on the liver. High protein leads to adverse effects on the body metabolism with the result that the child gets well marked tachycardia or a very fast heart rate and very rapid and laboured breathing. At times there is enlargement of the heart which is probably caused by retention of sodium in the body as the cow's or buffalo milk contains 3 to 4 time more sodium chloride than in mother's milk. There are also other causes of tachycardia and cardiac enlargement which are probably related to endocrine dysfunction. However, the most important effects of the diet containing high proteins are loss of weight and failure to grow inspite of the child's intake of high calories from the large quantity of irnbalanced food. This can be worsened by the addition of non-vegetarian foods like eggs, chicken, fish etc. as they add a further load of proteins in the diet. The diet is very much imbalanced as it contains high proteins, high fat and usually low carbohydrates particularly when the sugar is not added adequately to the milk or the child refuses to take other carbohydrate foods like rice and wheat cereals or other foods. There is another adverse effect of high protein diet which is particularly well marked on younger infants and neonates. This is seen in low birth weight babies who do not receive mother's milk but receive cow's or buffalo's milk or full strength infant milk formula which contains 3 to 3 1/2 gms of protein per 100 ml of the formula. These infants particularly neonates or low birth weight babies with large intake of proteins in the diet get high blood urea, increase in blood ammonia levels, acidosis and disturbance in the electrolyte balance. High ammonia levels in the blood are harmful as they can produce damage to the brain particularly of neonates, low birth weight babies and young infants. We have described this condition as Nutritional Hyperammonaemia. Some of the American workers have followed the low birth weight babies given high protein diet in the neonatal period and infancy and found that progress of these children at school even at the age of 7 years was found to be slower. Such an adverse effect on the development of infants has also been reported by us.

Other Effects of Too Much Intake of Animal Milk Which Leads to Imbalanced Diet

There are other adverse effects of imbalanced diet which results from high intake of protein from animal milk and the non-vegetarian diet like eggs, meat, fish, chicken which may be given to the child of 1 to 1 1/2 years. This results in severe constipation, large foul-smelling stools, foul smell in the breath and these children may get severe attack of intestinal colic from large curds formed from high protein milk of buffalo or cow. The imbalanced diet also causes moderate to severe anaemia in the child due to deficiency of iron. These children have haemoglobin values 3 to 8 gms% i.e. 25 to 60% of the normal values.

Tetany: Tetany is a condition in which the child gets fits due to low blood levels of calcium. Infants with high intake of animal milk get a very large amount of phosphorus from it and often get what has been described as hyperphosphataemic hypocalcaemic convulsions. The condition is further aggravated if the child has associated rickets because the animal milks are poor in vitamin D.

Effect of Bottle Addiction in Children of Poor Socio-economic Group:

Fortunately poor mothers usually feed their babies on the breasts and hence the infants are protected against infection and imbalanced diet which is likely to happen in non-breast fed babies. However, when the mother from a poor family cannot breast feed the baby it is almost a catastrophe. These mothers often imitate the rich mothers in whose house they may be working. However, because of the poverty and unsanitary and unhygienic conditions the bottle feeding has tragic consequences. As they cannot afford good quality of milk or if they are using infant milk foods, often the milk is overdiluted because of ignorance and poverty. Usual dilution of an infant milk food is one measure or one teaspoonful to 30 ml of water and normally the child is.given 5 to 6 measures of powder with 150-180 ml of water. Often in 200 to 240 ml of water 1 l/2 to 2 teaspoonful of powder is added. This results in the child consuming large amount of water from the milk but relatively much lower intake of total calories which are required for growth and development. It is worthwhile to tell a true story of a grandchild of a doctor, who was kept on powder milk formula. As the child had diarrhoea earlier, he was given 1 to 2 teaspoonful of powder with 240 ml of water. The child was consuming a large quantity of the formula which contained l/4th the required amount of milk powder and too much of water with the result that this infant whose weight was 5 1/2 kg or 11 1/2 pounds at 3 months of age actually weighed 4 1/2 kg or 10 lbs at 11 months of age. As this was a doctor's grandchild, the living conditions were good. However, the child developed severe malnutrition as he got only 240 calories in a day instead of getting 800 to 1000 calories from a balanced milk formula containing lower proteins. What usually happens in poor socio-economic groups is that apart from the unhygienic surroundings, lack of proper drinking water, lack of proper washing of the bottle, which are often medicine bottles used for feeding with dirty teats, these infants get a diluted unhygienic milk contaminated with bacteria with which they usually get diarrhoea and they become malnourished. This condition has been described as diarrhoea-marasmus syndrome in bottle fed babies in poor socio-economic groups. Unless early intervention takes place and diet is corrected and the bottle discontinued these children get severely marasmic and die of diarrhoea, pneumonia and at times of tuberculosis (Fig. 4 coloured plate).

Carbohydrate Malnutrition

This is another condition which we described as carbohydrate malnutrition The condition was due to the lack of addition of carbohydrates like adequate amount of sugar, in the milk or other carbohydrates, like rice or other solid carbohydrate diet. The infants have poor intake of carbohydrate foods which provides 20-25% of total calories these children have a higher intake of calories from proteins and fats. They develop severe malnutrition because of deficiency of carbohydrate which start the process of imbalanced diet containing high proteins and fats but lower carbohydrates (Fig. 6). The condition becomes worse in older infants or toddlers with addition of non-vegetarian diet like eggs, meat, fish or chicken which provided extra calories from proteins but not carbohydrates, which are normally supplied in vegetarian food by sugar, jaggery, rice, wheat, vegetables like potatoes, fruits like bananas and to some extent by pulses. These are the various syndromes which can occur on infant because of imbalanced diet and which cannot occur in breastfed babies (Fig. 7).

Health and Growth of Preschool Children and Adolescents with Different Calorie Intake from the Diet

We have discussed the health and its impact on growth in infancy and early childhood.

Preschool Child Population

Preschool child population or the children from 1 to 6 years constitute this group. Preschoolers form 17 to 18% of the population in the community though in recent years with family planning it constitutes about 15% of the community.

Health, Growth and Diet During Preschool Period

(Preschoolers): Health, growth and nutrition during the preschool period are so much interrelated that they could be called synonyms. There are various dietary and other factors which are responsible for undernutrition and growth failure during pre-school period. However, we are concerned here with the dietary aspects. Tables 6,7 show the calorie intake of a preschool child. It can be seen that the mean calorie intake is about two-third of the recommended calorie allowances, however, the mean protein intake is fortunately not significantly less. The reduced calorie intake is mainly because of poverty but often also due to ignorance. It is essential that the preschooler should get 1200 to 1500 calories in a day. It can be met with from half a litre of milk with sugar and wheat or rice cereal, pulses or dad vegetables and fruits like bananas. It is essential that food should not be bulky. The children should have 4 meals a day so that the bulk at one time is reduced and the calorie intake meets with the demand of protein, carbohydrates, minerals and vitamins. Moreover, it is undesirable to eat 'too much' of snacks like chocolates, biscuits, groundnut, or gram dal preparation in-between the main four meals as excess of these snacks will reduce the appetite for a balanced diet. Table 8 gives simple low cost diet for young children from 2 to 6 years of age. As per the prices in 1986 compared to those in 1976 the cost is 3 to 4 times higher which means that diet of the child of around 2 years will cost about Rs. 40 to 50 a month, 3 to 6 years about Rs. 60 to 70 per month. Such a diet will provide adequate amount of calories, proteins, carbohydrates, fats and essential nutrients like vitamins and minerals. The recommended vegetarian diet which is economical can be used for the preschoolers as this is a very important period of excessive physical and mental activity and social interaction. In our study (Fig. 8) of preschool children from different socio-economic groups, it was found that the preschoolers from poor socio economic groups were lagging behind in weight by a period of 1 to 5 years. This meant that a child of 3 years from lower socioeconomic groups weighed around 10 kg which was the weight of the child of 1 year in the upper income groups, or a child of 11 years from the poor socio-economic groups weighed 22 to 25 kgs which was the weight of child of 6 to 7 years of age in the upper socio-economic group. The main cause of differences between the lower and upper income groups was reduced food intake. The inadequate amount of food intake was due to not only financial constraints but also to ignorance. If the balanced vegetarian diet mentioned in the Table is given to these children in adequate amounts their weight (nutrition) and height (growth) will both improve significantly. Moreover, the vegetarian diet mentioned in the Table is 2 to 3 times cheaper than the non-vegetarian foods which the vast majority of the population cannot afford.

Table 6
Caloric Intake of a Preschool Child
(Arora S., 1985)

Age in years Body weight Calories intake recommended
    Cal/day Cal/day allowance
1-2 7.8 610 79 1200 to 1400
2-3 9.1 810 96
3-4 10.1 910 86
4-5 12.4 910 73
1-5 years 10.4 810 84 1200

Table 7
Proteins Intake of Preschool Children

Age in years Body weight Protein intake Recommended allowance
    Gms/day Gms/per kg. Gms/day Gms/per kg.
1-2 7.8 14.0 1.8 16.5 1.9
2-3 9.1 19.8 2.2 18.0 1.7
3-4 10.0 21.2 2.0 20.0 1.7
4-5 12.4 20.0 1.6 22.0 1.7

(NIN, 1985)

Health and Growth of School Cbildren and Adolescents

The health and growth are adversely affected by inadequate intake of food inspite of the fact that adequate calories and nutrients can be given from the simple vegetarian diet mentioned in the Table with the only change being that the calorie intake should be increased from 1600 to 2000 for school children and 2200 to 3000 in adolescents. The calories should be from various balanced constituents of the food. The graph shows the growth curves of adolescent children in poor rural population compared to the one prepared by Indian Council of Medical Research after studying 5 million children of all age groups from all over the country and are compared to the growth of adolescents at Harvard (USA). It may be emphasized that mainly by increasing calorie intake from the various nutrients, the growth curves will certainly improve.

The cost of diet in the school child will be about Rs. 80 per month while in the adolescent it will be about Rs100 to 120 per month. Moreover, it is a practical diet as the vegetarian diet is affordable by a large section of the population and should be advised so as to improve health and growth of these children. At the same time with improved health and growth there will be a reduction of disease, better development of resistance, better intellectual school performance, as well as improvement in sport activities. This is of importance for the nation as these are the children who will be entering into the 21st century as the builders of the nation, as the future citizens of the country.

Adolescent Rickets (Fig. 7A & Fig. 7B)

A passing mention may be made on another condition which is preventable by a proper diet and or by getting adequate ultraviolet rays of the sun in the early morning or in the evening which converts provitamin D in the skin to active vitamin D.

Table 8
Simple Low Cost Diets for Young Children Below 2 Years and Older Pre-school Children

  Grams/per day Grams/months Approximate cost
as in 1976
cal. daily Protein daily
  2 yrs. 3-6yrs.   2yrs. 3-6yrs.
Under
2 yrs.
3-6yrs. 2 yrs. 3-6yrs.
1. Rice or wheat 100 200 3000-6000 5 10 350 700 16 12
or other cereals 100 200 3000-6000 4 8 350 700 10 20
2 Bengal gram or 50 100 1500-3000 3 6 175 350 11 22
Tuver or other pulses 50 100 1500-3000 3 6 175 350 11 22
3. Oil or dry 15 20 450-600 6 7 135 180    
coconut 15 20 450-600 6 7 135 180    
4. Vegetables (green) 20 30 600-1000 2 3 20 30 2 3
5. Jaggery 20 25 600-750 1.50 2 80 100    
       
6. Plus breast milk feeds upto 2 years
or top milk feeds 100-150 ml per day.
      Rs. 16.50 Rs. 27 760 cal. 1330 cal. 20 daily protein plus milk protein 40

(As per prices in 1976) Table above gives the simple low cost diet for young children from 2 to 6 years. Table gives the requirements of the various nutrients and their cost per month worked out in 1976. In 1989 the cost is 4 to 5 times higher than in 1976.

One of our studies carried out in Bombay revealed an increasing number of cases of vitamin D deficiency rickets, in adolescent children. This is often seen in Muslim girls who observe purda and hence their skin is not adequately exposed to ultraviolet rays of the sun. Even if they are exposed to some extent, the polluted atmosphere, glass windows and dark dingy rooms prevent them from getting adequate ultraviolet rays. These adolescent children in all communities get rickets which could be mild, moderate or severe. After our initial observations in the late 60s on the prevalence of adolescent rickets, the epidemiological studies have been carried Out by other Indian workers. Similar observations have been made by British workers in children of Indian subcontinent origin in UK. Moreover, significant numbers of school children of adolescents even upto 16 years of age will require admission into the hospital for treatment of deformities. The lesson to be learnt from these observations is that pre-adolescents arid adolescent children of the underprivileged group in our cohntry from 12 to 16 years of age should receive 6,00,000 units of vitamin D prophylaxis every 6 to 12 months. From various studies it appears necessary to implement such a programme for our school age children.

The article gives the advantages of vegetarian foods, description of various vegetarian foods used in Indian diet, and the value of balanced foods from cereals and pure carbohydrates, pulses, fats, vitamins, minerals and micronutrients. It also briefly describes the common disorders caused by deficiency foods. Moreover it emphasizes the vital importance of breast feeding both for the health and growth of the baby as well as immunity and also of the importance of the introduction of semisolids in the diet of the infant like mixture of cereals, pulses, green vegetables and fruits between 4 and 6 months. The disadvantage and dangers of bottle feeding emphasized by the World Health Organization (WHO), Indian Academy of Pediatrics and even by the Government of India have been discussed along with various syndromes like carbohydrate malnutrition, protein overload syndrome in good socio-economic groups and marasmus diarrhoea syndrome though in all groups but mainly in underprivileged populations. A short description is given about the health and growth of preschoolers, school children and adolescent by a balanced vegetarian diet which is possible to use in children and pregnant and lactating mothers in all socioeconomic groups. A passing mention has been made on the problem of adolescent rickets in both sexes more in girls and osteomalacia in mothers who have frequent pregnancies with short birth intervals between the babies. Some of the beneficial effect of traditional practices have also been mentioned.

Advantages of vegetarian diet to reduce or prevent some of the conditions in children and their long term sequelae seen in adults particularly in upper socio-economic group families

Prevention of hypercholesterolernia in children and subsequent coronary heart disease in adult life:

It has been well established that caronary heart disease in adults is related to high serum cholesterol levels. This high risk can be avoided by feeding practices in infancy and childhood.

Boulton (1989) studied serial serum cholesterol levels of infants and children and compared them with those of mother and father. He found that there was increase in serum cholesterol levels with age, which by the age of 2 years got stabilised when serum cholesterol levels of the mother were compared with the child. While they were stabilised by the age of 11 years when the levels of the serum cholesterol in the father and the child were serially tracked. Hence using vegetarian diet which is rich in fibre will bring down the serum cholesterol levels or prevent its rise by using the vegetarian foods during weaning. period. It is desirable that the animal fats like butter, ghee and other saturated fats should be restricted in the diet so as to prevent increased levels of serum cholesterol in the children whose maternal serum cholesterol levels are high. Thus prevention of hypercholesterolemia should be started from infancy.

Hypertension: Hypertension is a very common problem in adult population and it is not uncommon in adolescents. One of the nutrients which has effect on blood pressure is salt or sodium chloride (Holliday, 1989). It is desirable that in families where hypertension is a problem, the salt intake in the child's vegetarian diet should be reduced and it should not exceed 35 to 45 mm per day. The diet rich in potassium lowers the blood pressure while the diet low in calcium is associated with high blood pressure as low ionic calcium and high parathormone levels lead to high blood pressure. Vegetarian diet low in saturated fat, high fibre, low salt high potassium and high calcium are likely to reduce hypertension particularly in high risk families

Obesity: Incidence of obesity is low in children in underprivileged communities. However, its incidence is increasing in children of upper socio income group families in India. It has been found that human milk has a protective effect against obesity. This is probably because breastfed infants have relatively lower weight gain compared to the infant fed on animal mink formula which is used commonly in upper socio income group families where the incidence of lactation failure is high. Children fed on infant milk formula in the upper socio income groups have not only increased weight gain but have an increase in fastw ing levels of lipoprotein lipase activity, a key enzyme which helps in storage of fat in the tissues of children. This is another important reason for encouraging breast feeding and discourage infant milk formulas specially in the upper socio income groups (Hamosh 1989).

Cardivascular manifestation a long term consequences of nutrition in childhood (Lloyd 1989):

It is well documented that cardiovascular manifestations in adult life is of multifactorial origin but may be attributed to dietary practices in childhood. Hence to prevent the complications of atherosclerosis and hypertension and their complications of coronary, cerebral and other peripheral vascular disease, it is desirable to give breast feeding to infants and give vegetarian diet which as mentioned before can reduce the serum cholesterol levels because of its high content of fibre. At the same time animal fats, namely butter, ghee and some oils rich in saturated fatty acids should be reduced along with reduction of salt intake and increase of potassium and calcium. Thus a proper vegetarian diet in infancy and childhood is of great importance in reducing the high risk problems of obesity, hypertension and cardiovascular diseases which are major problems in adults.

Summary to Addendum

Recent studies on diets in infancy and childhood and their long term consequences in adults like hypercholesterolemia, obesity, hypertension and atherosclerosis and its cerebral, coronary and peripheral vascular disease have been included with the aim of prevention of these complications by proper vegetation diet in infancy and childhood.

REFERENCE

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ADDlTIONAL REFERENCES & BIBLIOGRAPHY

  • Boulton J.: The concept of serial Tracking of serum cholesterol levels iri children and their parents, Long term Consequences of Nutrition in infancv and childhood. Abstract, Book for Plenary lectures and symposia, XlXth International Congress of Pediatrics in Paris, P. 25, 1989.
  • Hamosh M. and Hamosh P.: Obesity, Long Term consequence of Nutrition in infancy and childhood, Abstract, Book for Plenary lectures and Symposia, XIXth, International Congress of Pediatric, Paris, Z5, 1989.
  • Holliday MA.,: Nutrition and hypertension a Long Term consequences of Nutrition in infancy and childhood. Abstract book forplenary lecturer and symposia XIXthe International Congress of Pediatrics in Paris, P. 25, 1989.
  • Lloyd JK.: Cardiovascular Manifestations as a long term consequence of Nutrition in childhood Abstract book for Plenarv lectures and Symposia XlXth, International Congress of Pediatrics, Paris p. 25, 19S9.

 

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