Nutrition of infants and young children in Poland – Pitnuts 2016

The adequate nutrition of young children plays a crucial role in their optimal mental and physical development. This happens due to the reduction of risk for several diseases, including respiratory and digestive tract infections, as well as diet-related diseases, such as obesity, type 2 diabetes mellitus and cardiovascular disease [1, 2, 3]. Nutrition affects the maturation and normal functioning of all systems of the child’s body during the entire developmental period. It applies especially to the so-called critical periods, including the prenatal period and the first two years of life [1].

Epidemiological observations and clinical trials concerning the impact of nutrition on the nutritional status indicated that incorrect nutrition, including inadequate profile of nutrients in the child’s diet, leads to disorders of the nutritional status and increases the risk of nutritional deficiencies [1, 4, 5, 6, 7, 8, 9]. Four basic elements describing the rules of adequate nutrition have been identified in the models of safe nutrition, which should be understood as a system of nutritional recommendations developed on the basis of objectivised studies in the field of medical nutrition. These include: the organisation of the meals/eating frequency, selection of products in daily diet, energy and nutrient intake meeting the child’s requirement, and other factors, including cultural patterns, familial, environmental and behavioural determinants, dietary habits, as well as physical activity [10].

The Polish standard of feeding children in their first year of life (tab. I), which was developed in 2014 and modified in 2016 by a group of experts appointed by the national consultant in paediatrics, promotes breastfeeding and presents guidelines for feeding breastfed and non-breastfed infants. It also reveals the suggested number and types of meals and the portion size the child should receive at a given age [5, 11, 12, 13]. The gradual accustoming the child to new products and encouraging it to try new $avours and textures of food has a positive impact on the process of expanding the diet. The standard contains information on what kind of food the child should receive and when, yet it is the child, who decides how much he/she eats.

The recommendations concerning post-infancy nutrition were developed based the objectivised scientific studies evaluating the impact the nutrition in the first two years of life has on the nutritional status of the child. The results indicate that it is most beneficial for the health and development of the child to continue breastfeeding until approx the. 12th month of life. Such feeding practice may also be used in the second and third year of life, as long as the mother and child wish. No upper age limit for breastfeeding has been established [13, 14].

The aim of this study was to evaluate the feeding practices in children aged 5 to 36 months with regard to models of safe nutrition on the basis of the outcome of the population study performed in 2016.

The study evaluating the feeding practices and the nutritional status of children aged 5 to 36 months in a general, Polish, representative population (n=1059) was carried out from May to July 2016. The trial was performed as part of project No. 161/2016 entitled „Comprehensive evaluation of diet of children aged 5 to 36 months - nation-wide Polish trial 2016”, (pol. “Kompleksowa ocena sposobu żywienia dzieci w wieku od 5 do 36 miesiąca życia – badanie ogólnopolskie 2016 rok”) financed by the Nutricia Foundation.

The sample selection and parents/caregivers enrolment was performed by the research provider (TNS Polska). The children were randomly selected for the study using personal identification numbers (PESEL). The subjects came from all over Poland, so that appropriate territorial representativeness was obtained. Two subgroups were distinguished - children in their first year of life (n=447) and children in their second and third year of life (n=612).

The nutritional status was evaluated based on anthropometric features and indices - body weight [kg], body length/height [m] and body weight-for-height ratio standardized according to the reference WHO growth charts [15]. The anthropometric measurements were performed by the medical personnel or trained interviewers/dieticians with regard to the selected methodology [15, 16].

The feeding practices were evaluated by the questionnaire method (original questionnaire, including 3-day record of children’s diet carried out by the parents/caregivers according to the directions given). Based on the diet records we estimated the consumption of the products and the nutritional value of the diets was calculated using the “Dieta 5” nutritional computer programme [17, 18]. The results obtained were compared with age-adjusted nutritional recommendations – for infants aged 5-12 months and children aged 13-36 months [19].

The distribution of variables was analysed and the appropriate descriptive statistics were calculated (medians and interquartile ranges).

According to the guidelines of the World Health Organisation (WHO) and European nutrition societies, exclusive breastfeeding is the optimal method of feeding infants for 6 months followed by the appropriate complementary feeding introduction in the second half of their first year of life [11, 12, 20, 21]. Breastfeeding ensures that all the nutritional requirements of the child are met and optimally stimulates his/her development. The qualitative and quantitative composition of mother’s milk is ideally adjusted to the requirements of the infant. Apart from vitamin D and K, this applies to all nutritional elements, including proteins. It was shown that breastfeeding of babies from their birth till the age of 2 years is associated with a lower intake of protein and reduced risk of being overweight later in life, when compared to formula-fed children [4]. The model of safe infant nutrition emphasises the fact that exclusive breastfeeding is an optimal feeding method in the first six months of life, whereas nutrition during the second half of the first year of life should be based not only on breastfeeding but also on incorporating complementary foods according to recommendations [10, 20].

In the first 6 months of life 54.1% of infants from the studied group were breastfed, including 5.9% exclusively. The data obtained are similar to those gathered during epidemiological studies carried out by other authors [14]. The studies performed in 2014 evaluated the nutrition of infants (n=1679) and revealed that 38% of them were breastfed in their sixth month of life, 4% of whom exclusively [22]. These data differ from the results of previous studies performed in Poland and other European countries, which indicated a greater percentage of exclusively breastfed children (13-14%) [14, 23]. The question remains, however, why despite the widespread promotion of natural feeding presented during antenatal classes and with the use of different educational forms − the rate of breastfeeding women remains on a similar level. This issue requires separate studies.

Since the sixth month of life natural feeding or that carried out with the use of infant formula no longer provides an adequate supply of energy, protein, iron, zinc and some vitamins. Therefore, the introduction of complementary foods is necessary. According to current recommendations, it is considered that complementary foods should be introduced no sooner than in the 17th week of life, but no later than in the 26th week of life [21].

According to the ESPGHAN guidelines, exclusive or full breastfeeding should be promoted at least until the end of the fourth month of life (17 weeks), whereas exclusive or predominant breastfeeding for approx. six months of life (26 weeks) [21]. It is recommended that complementary foods (fluids and solid foods other than mother’s milk and infant formula) should not be introduced before the age of 4 months and delayed beyond 6 months. The diet should be supplemented with products of diverse texture and taste, including green vegetables with a bitter taste. Breastfeeding should be continued alongside with the introduction of complementary foods. Small amounts of cow’s milk should be used to prepare complementary foods, yet it should not be used as the main milk product until the age of 12 months. Potentially allergenic food may be introduced when the complementary feeding is commenced (but not before the fifth month of life), yet such practice requires supervision by a specialist. Gluten-containing products may be introduced between the 4 and 12th months of age. Nevertheless, it should be noted that their amount should be limited during the first few weeks. All infants should receive iron-fortified foods (e.g. cereal products) and food being a natural source of iron (meat). Adding salt and sugar to the products and meals intended for children should be avoided, as well as drinking sweet beverages. The consumption of fruit juices should be limited. Vegan diets require the supervision of a paediatrician and/or dietician and appropriate supplements. The parents should be aware of the health consequences of such a diet. Parents’ alertness to nutritional requirements of their child, signalled as a feeling of hunger or satiety, is equally important. It has been proven that such a practice is important from the nutritional, developmental and health point of view, because it is associated with a significant reduction of the risk of contracting infectious, especially gastrointestinal and respiratory, allergic and autoimmune diseases. Moreover, it has no negative impact on the rate of growth, body composition and does not increase the risk of becoming overweight or obese [21].

In the studied group 61.1% of the children received complementary feeding earlier than it is recommended (before the 5th month of life) and only 30.2% of the infants received their first non-dairy foods (baby cereals, vegetable and/or fruit purees, juices, infant teas) between the 17th and 26th week of life. These results unequivocally indicate that almost two-thirds of the mothers of the studied children did not know the optimal age for the introduction of complementary foods. Therefore, it is necessary to monitor the feeding practices of infants and to provide nutritional counselling for the mothers of young children alongside routine inpatient paediatric care.

The energy and nutrient intake in children’s diet should meet nutritional recommendations [19]. The protein requirement of children was estimated at approx. 1 g/kg body mass, yet it should not exceed 15% of the total recommended energy intake (1000 kcal/day). Fats should deliver 20-35% of total energy, so that they cover the energy expenditure of the child, including the part required for growth. The intake of fat of adequate quality is very important as well, including the sources of fatty acids, especially long chain polyunsaturated fatty acids (LCPUFA). Carbohydrates should account for 55-60% of energy. The amount of added sugars should be limited (less than 10% of total energy). Products delivering complex carbohydrates should be preferred in the diet of children. Recommended dietary allowance (RDA) for calcium in a 1-3 year old child is 700 mg/day, while the population estimated average requirement (EAR) is 500 mg/day. According to medical standards, a child requires approx. 15 Zg (600-1000 IU) vitamin D₃/day [5, 19, 24].

When it comes to the group of children over 1 year old, it is worth noticing that 10% of this group were still breastfed and 43.3% were receiving junior formula, whereas the proportion of children drinking such formula decreased significantly after the 18th month of life. The share of junior formula in the nutrition of children aged 1 year and older significantly impacts the nutritional value of their diet [25]. The adequate supply of energy and nutrients, especially proteins, DHA, vitamin D, iodine and iron still significantly in$uences the processes associated with the metabolic and nutritional programming in a child, and reduces the long-term risk of diet-related diseases, including obesity [25]. The nutrient profile in the analysed diets of children did not meet the recommendations. The results showed insu? cient intake of many nutrients important for the normal development of the child, i.e. LCPUFA, vitamin D and potassium. Furthermore, the increased risk for energy, fat, fibre, vitamin E and calcium deficiency was observed in the diet of almost every second or third child. Such results prove the poorly diversiThed selection of products used in nutrition of the youngest children. The research of other authors, who analysed the quantitative and qualitative composition of children’s diets, revealed a similar trend [8, 9, 26, 27, 28]. These data confirm that it is necessary to popularise the model food ration for children aged 1-3 years among parents. It seems that the results obtained should provide the basis for reformulation of the quantitative and qualitative composition of dietary products/food intended for infants and young children.

The population study conducted on the group of children aged 5 to 36 months indicates the problem of excessive intake of sucrose and salt in children’s diet. The WHO mission for 2015-2020 emphasises the necessity to reduce the amount of such nutrients in children’s nutrition [29].

Therefore, it is necessary to develop such forms of educational impact for the parents of young children, which will eventually change their attitude towards healthy nutrition.