A_Guide_to_your_Child_Growth___Assessment

If you answer yes to any of the above questions, you will have to take necessary
precautions to avoid obesity at older ages in children. Some of them are discussed
below.

 If your child has an unhealthy eating habit like eating high energy snacks (e.g.
French fries, fried chips etc) replace it with nutritious foods. Prepare food
using less fat and sugar.

 Encourage physical activity in the child. Make him participate in active
physical play.

 As a parent, reduce feelings such as anxiety or insecurity or boredom that can
cause over feeding your child.

 Avoid watching T.V while having meals and encourage positive interaction
during meals.

 Adopt healthy lifestyle among family members because the best way to
persuade children to have healthy lifestyles is for the parents to model the
desired behaviors in them.

Lastly, it is not recommended for an overweight child to lose weight but
instead the rate of weight gain is to be decreased and consequently with the
increasing height, the weight will become appropriate for the child’s length
and age. But since one cannot predict the rate of growth in a child, one cannot set a
specific time. Hence it is advisable to slow the weight gain and eventually normalize
weight for height.

Set 2-3 goals for improving your child’s health. Set a reasonable time and set a
general goal.

Exercise: 4.1

1. Anay is 2 years old and his height is 88 cm. Given below are his
measurements of weight and length. From past few months he has been
staying with his grandparents for whole day as his parents have a very hectic
work schedule. Plot his measurements on growth graph and note your
observations. Recommend your advice.

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Weight Length
(kg) (cm)
10.5 80
13 87
17 100
21 110

2. Anika has developed rashes when her mother started complementary feeding
at the age of 5 months. She also breastfeeds her. Her rash looks like a nappy
rash. Anika is underweight. Her z score is between -1 and -2 z score line.
What do you think is the reason behind her rashes?

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V. Feeding for first Six months of Life

Objective
 Practice breastfeeding regularly
 Identify problems with breastfeeding
 Applying correct breastfeeding practices

Breastfeeding

“The Global Strategy for Infant and Young Child Feeding recommends that infants
be exclusively breastfed for the first six months of life in order to achieve optimal
growth, development and health.”

Breastfeeding and breast milk both are important for a healthy growth in a child. Let
us study its advantages and the nutrients obtained from breastfeeding.

Breast Milk Breastfeeding

Perfect nutrients Helps bonding and development
Easily digested & efficiently used Helps delay a new pregnancy
Protects against infection Protects mother’s health

Nutrients in Human milk and Animal milk

Human Cow

Fat Fat
Protein Protein
Lactose Lactose

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Goat

Fat
Protein
Lactose

Human milk Animal milk

Human milk also contains Animal milk contains more protein
essential fatty acids that are which makes difficult for the
needed for a baby's growing baby's immature kidney to excrete
brain and eyes, and for healthy the extra waste from protein in
blood vessels which are not animal milk.
present in animal milk
Animal milk(cow's milk) contains
Contains Whey protein which is Casein which forms thick
anti-infective and protects baby indigestible curds in baby's
against infection stomach

Formula milks contain artificially added fatty acids and are far perfect from human
milk. Artificially fed babies may develop intolerance to protein from animal milk
causing diarrhoea, abdominal pain, rashes or other symptoms.

Another benefit of breastfeeding is that it contains Colostrum. Colostrum is
produced in the first few days after delivery. It contains more protein than
mature milk.

 Colostrum protects against allergy and infection
 Clears meconium
 Helps to prevent jaundice
 Helps intestine to mature
 Prevents intolerance
 Reduces severity of infection

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Problems in breastfeeding

Difficulty in breastfeeding can be a main problem for causing Undernourishment in a
child. You need to identify the root problem in order to correct it. This section will be
particularly useful for children from 0 to 6 months of age.

To begin with, study your child’s growth record charts (charts for age 0-6 months).
If the growth trend is downwards or below the median, then it indicates that your
child is undernourished. The most common cause of Undernourishment or poor
weight gain in a baby is not getting enough milk. How will you know if your baby is
not getting enough milk? Below table shows signs that indicates your baby is facing
problems with breastfeeding.

 Baby not satisfied after breastfeeds
 Baby cries often
 Very frequent breastfeeds
 Very long breastfeeds
 Baby refuses to breastfeed
 Baby has hard / dry / green stools
 Baby has infrequent small stools
 No milk comes out when mother expresses 
 Breasts did not enlarge (during pregnancy)
 Milk did not ‘come in’(after delivery)

Each child has its own pattern to gain weight and the weight gain for each child is
variable. Hence you need to weigh several times over a few days or week to assess
the growth trend.

If the weight gain is slow or not enough for its age even after the end of second
weeks, the child needs medical intervention. Because, a child gains sufficient
weight from 500 gm to 1 kg or more from its second weeks who is breastfeed
regularly. Hence, refer the growth record to assess if your baby is gaining weight
and if you notice a slow growth consult your child specialist.

A baby with enough breastfeed urinates 6-8 times in 24 hours. But this alone
cannot make sure if the baby is indeed getting sufficient milk as the baby can urinate
6-8 times in 24 hours if it is given water along with milk.

Reliable signs of baby not getting enough milk is poor weight gain

and small amount of concentrated urine i.e. less than 6 times a day.

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There are few more reasons for not getting enough breast milk to the baby.
Few of them are stated below.

Refer the below chart and correlate the symptoms with mother’s
psychological/physical condition.

Possible factors

Reasons of insufficient breast milk common uncommon

Delayed start for breastfeeding Lack of confidence contraceptive pill
Feeding at fixed times Worry, stress Pregnancy

Infrequent feeds Dislike of Severe malnutrition
No night feeds breastfeeding Alcohol
Short feeds Rejection of baby Smoking
Tiredness

Poor attachment Retained piece of
placenta (rare)
Bottles, pacifiers
Other foods/fluids Poor breast
development (very
rare)

Assessing Breastfeeding

Let us study in detail the possible reasons of not getting enough breast milk
and helping you to gain weight in your baby.

1. Low milk intake

55

As stated above if your baby is not getting enough milk, you need to find out the
reason behind it. Is it because of positioning or attachment? Or are you feeling
pressurized due to other people? Sometimes it is found that mothers feel they have
insufficient milk for their children. All mothers always have enough milk for their
babies.

Let us learn about the correct way of attaching or positioning your baby for a good
milk flow.

5 key points of attachment are;
a) More areola above baby’s top lip than below bottom lip
b) Baby’s mouth wide open
c) Lower lip turned outwards
d) Baby’s chin touches breast
e) Baby’s body close, facing breast and attention from mother

Correct attachment Poor attachment

Left hand side picture shows the correct way of attachment to the breast whereas
the right side picture shows the baby is poorly attached.

56

The Left side picture shows correct way for positioning your baby and the Right side
is the wrong way of positioning where baby’s body is away from mother, neck twisted
and no mother baby eye contact.

Mother should rest her fingers on her chest wall so that her 1st finger forms a support
at the base of the breast as shown in the left and not holding her breast too near the
nipple as shown in the right.

Results of poor attachment

a) It is painful for mothers if the baby sucks the nipple instead of breast.

57

b) If the baby sucks hard to try to get the milk he pulls the nipple in & out causing
sore nipples. Over a long period it damages nipple skin & causes cracks
known as fissures.

c) Poor attachment results into not being able to remove milk effectively causing
them to engorge and making less milk.

With the above reasons, baby may fail to gain weight and the mother may get
psychologically disturbed thinking she does not have enough milk.

Mothers always have sufficient milk for their babies. If you feel that you ‘do not
have enough milk’ and that is the reason of your baby crying, you need to find out
the correct cause for it. It is important for you to feel positive and happy for it
affects the flow of milk. Feeling of anger, frustration or tiredness usually affects the
babies. Assess your baby’s suckling position and length of a feed. Make sure
that you baby is not ill or in pain and is growing well.

2. Crying baby

Another reason found to stop breastfeeding by mothers is handling a
‘crying baby.’ A common misconception is that the mother often feels the baby
need outside foods resulting in feeding them with unnecessary fluids. Such
mothers often feel that they do not have enough milk or baby is not able to take
sufficient milk. They often fail to understand that giving food other than breast milk
makes the baby cry more. This eventually results in causing more tension
between mother and her child. Let us find some reasons as to why a baby cries.

A baby can cry for the following reasons.

 Discomfort caused due to dirty, heat, cold.

 Tiredness caused because of too many visitors.

 Body Illness or pain, if you observe a changed pattern of crying.

 Hunger - if your baby is not getting enough milk due to growth spurt. A baby
around 2 weeks, 6 weeks and 3 months, (and not restricted to these days)
seems to be very hungry for few days. This happened possibly because the
baby is growing faster than before. They show signs such as suckling often
than before. During this time the milk supplies increases and later breastfeeds
less.

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 Mother's food – You will have to observe if your baby is disturbed when you eat
a particular food. This is because substances from the food pass into your
breast milk. In such situations, it is advisable to observe the kind of food you
eat and avoid it if you notice a problem.

 Drugs - if a mother takes caffeine, cigarettes or other drugs it can irritate her
baby.

 Colic – Such babies cry a lot. The reason is unclear or does not fall in the
above listed reasons. There is a pattern in which they cry usually in the
evenings. They may have active gut or wind but the cause is unclear. Such
babies cry less after 3 months and usually grow well.

 ‘High needs’ babies – Some babies cry more than others and needs to be held
and carried everywhere. Crying is less common in babies whose mothers carry
them as compare to mothers who put their child down on their own or make
them sleep in separate cots.

Different ways of holding colicky baby

Holding the baby Holding the baby Father holding the baby
along your forearm round his abdomen, against his chest

on your lap

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3. Refusal to breastfeed

Refusal by a baby to breastfeed can cause you to feel rejected or frustrated.
Though it seems to be a common problem, it can be overcome. We will study
the same in this section.

Babies often refuses breast by crying and fighting at the breast when he is fed
or when he takes one breast and refuses the other. Sometimes, babies does
not suckle or suckle weakly or suckle for a minute and comes off the breast
crying, chocking. He can do this several times in a single feed.

Reasons of breast refusal Underlying causes
Illness, pain or sedation Infection
Brain damage

Pain from bruise (vacuum, forceps)
Blocked nose
Sore mouth (thrush, teething)

Difficulty with breastfeeding Use of bottles and pacifiers whilst breastfeeding
technique
Not getting much milk (e.g. poor attachment)

Pressure on back of head when positioning
Mother shaking breast
Restricting length of feeds
Difficulty co-ordinating suckle

Change which upsets baby (for Separation from mother (e.g. if mother returns to
babies 3 to 12 months) work)

New carer or too many carers

Change in the family routine

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Mother ill

Mother has breast problem e.g. mastitis
Mother menstruating
Change in smell of mother

Apparent refusal Newborn - rooting
Age 4-8 months - distraction
Above one year - self-weaning

What to do when your baby refuses breast

 Give plenty of skin-to-skin contact at all times, not just at feeding times
 Sleep with your baby
 Ask for help from other people, when needed

 Offer your baby breast whenever the baby is willing to suckle
 Offer your breast when your baby is sleepy, or after a cup feed
 When you feel your ejection reflex working.

 Express breast milk into your baby's mouth
 Position your baby to get attach easily to the breast
 Avoid pressing the back of your baby's head or shaking your breast.

 Give your own expressed breast milk and if necessary give artificial
feeds

 Avoid using bottles, teats, pacifiers.

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4. Mother away from child

There are times when a mother has to leave her child and go out for work. In
such circumstances it is best to express breast milk and leave it for the baby.
Expressing breast milk is also important when a baby cannot be breastfed or
who cannot suckle enough or a sick baby. It is also helpful to prevent leaking
when away from the baby or in conditions such as breast engorgement.

To understand the significance of breastfeeding, it is necessary to be aware of
the disadvantages for artificially feeding a child.

Disadvantages of artificial feeding to a child

 More and persistent diarrhoea
 More frequent respiratory infections
 Malnutrition; Vitamin A deficiency
 More allergy and milk intolerance
 Increased risk of some chronic diseases
 Obesity
 Lower scores on intelligence tests

These above mentioned reasons can cause severe Undernourishment in
a child. Hence it is advisable to express and leave breast milk for the
baby instead of feeding him with artificial milk.

Advantages of expressing breast milk

 To feed a low-birth-weight (LBW) baby
 To feed a sick newborn baby – express at least every 3 hours to keep up the

milk flow to feed a sick baby.
 To leave milk for a baby while the mother is out at work
 To relieve symptoms such as engorgement
 To avoid leaking at work.

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Expressing breast milk: Procedure

A woman should express her own breast milk and the most useful way to express
milk is by hand. To express milk choose a cup with wide opening, wash it with soap
& water, pour boiling water to kill most of the germs and when ready pour the water
out. Now hold the cup near the breast. Press the breast inwards towards the chest
wall and behind the nipple and areola between your fingers and thumb. It is possible
to feel the ducts in lactating mother so press the larger duct beneath the areola. After
pressing and releasing for several times, the milk will start dripping out if the oxytocin
reflex is active. Press from the sides to empty all segments of the breast and avoid
squeezing the nipples. Express for 3-5 minutes until the flow slows and then express
the other breast. Repeat both sides. To adequately express milk it takes 20-30
minutes for the first few days. Once done, the milk can be stored for 8 hours at room
temperature and 24 hours in refrigerator.

How much milk should a mother express?

 Express milk as often as baby would breastfeed.
 General rule is to express every 3 hours (including nights).
 Remember if the mother expresses milk few times or with long intervals, then

there are chances that she will not be able to produce adequate milk later.

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5. Breastfeeding in different breast and nipple shapes

Breasts: Many mothers with small breasts fear of producing not enough milk for
their babies. However breast size does not affect milk production and no matter
what size or shape breast a woman has she can produce enough milk for her
child.
Flat or inverted Nipples: Nipples improve around the time of delivery without any
treatment. Stimulating the nipple may be all that a mother needs to do before
breastfeeding. Making the nipple stand out before a feed can also helps a baby to
attach.
There is another method called the syringe method that is used to manage flat or
inverted nipples.

64

Remember, a baby suckles from the breast and not from the nipple. To get
sufficient milk, baby needs to take a large mouthful of breast. During breastfeeds;
baby will stretch the nipple out hence always give plenty of skin-to-skin contact. Let
the baby attach to the breast on his own. All you must do is, try different position to
help the baby attach better to breastfeed sufficiently.

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Breast, nipple health problems and its treatment

In this section, we will discuss about breast conditions and nipples that can interfere
with breastfeeding leading to lesser flow of breast milk.

1. Engorged breasts
2. Mastitis

Engorged breasts: Engorged breasts are painful, tight especially the nipple,
shiny, red in appearance, oedematous, milk not flowing fever for 24 hours.
Engorgement occurs when milk is not removed effectively from the breast. This
happens due to various reasons such as poor attachment of the baby, restricted
length of breastfeeds, delay in starting breastfeeding or infrequent breast milk
removal.

Treating engorged breasts
 Do not ‘rest’ the breast. Remove milk.
 If baby is able to suckle he should feed frequently.
 Position your baby, so that he attaches well to the breast and suckle it.
 Before feeding or expressing, stimulate the oxytocin reflex.
 After a feed, put a cold compress on the breasts.
 Build confidence and have faith that breastfeeding will soon become
painless

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Mastitis of breast: When milk stays in part of a breast, because of a blocked

duct, or because of engorgement, it is called milk stasis.
If the milk is not removed, causing inflammation of the breast tissue, it is called non-
infective mastitis and if it becomes infected with bacteria, it is called infective
mastitis. Mastitis affects part of the breast, and usually only one breast unlike
engorgement which affects whole breasts and both of them.
Symptoms: Lump, redness of skin over the lump, lump tenderness.
Causes: infrequent breastfeeding, ineffective suckling, no time to breastfeed or
express milk, tight clothes (bra), finger pressure blocking milk flow.

How to Stimulate Oxytocin reflex before
breastfeeding
Build confidence by thinking good
thoughts about the baby.
Apply a warm compress, or warm water,
or have a warm shower.
Stimulate nipples by gently pulling or
rolling nipples with fingers.
Massage or stroke breasts lightly.
Massage your back and neck with a
helper.

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Treatment: Treatment

Causes

Poor drainage Correct poor attachment, release pressure
Infrequent breastfeeding coming from a tight bra, check if you are blocking
any duct by pressing it at areola.

Feed whenever baby is willing.

Gently massage the breast while baby is
suckling and massage over the blocked area,
and over the duct that leads from the blocked
area, to the nipple.

Apply warm compresses to her breast between
feeds.

Wrong positioning Breastfeed the baby in different positions at
different feeds, which helps to remove milk from
Refusal due to bad taste different parts of the breast equally.
Severe symptoms, fissure, no
improvement after 24 hours Milk from infected area may taste differently and
so the child refuses to breastfeed. It is important
to express milk as if it stays it may cause
abscess.

Antibiotics, analgesics and rest.

Sore Nipple and Nipple Fissure:

The most common cause of sore nipples and a nipple fissure is poor
attachment to the breast.

Poor attachment results in baby pulling nipples in and out while sucking. This results
in rubbing breast skin against baby's mouth.

If baby continues this way, it damages the nipple skin causing a fissure.

Treatment: change baby's position for better attachment, not washing breast more
than once a day, not use soap or rub with a towel as it removes natural oil.

Do not use lotions and ointments. Remove expressed breast milk over areola with
finger. This promotes healing the fissure.

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After doing the above recommended treatment, if the nipples still show soreness
then the cause can be an infection with Candida. It is characterized by deep shooting
pain into the breast. Baby may have white patches inside his cheeks or on his
tongue. Treating with nystatin can help both mother and the baby.
If the baby is still not receiving enough breast milk, use adequate replacement
milk feeding until six months of age. But avoid adding complementary foods
early.

Exercise 5

1. Rohan is 5 months old and cries frequently from past few days. His mother
has shifted to another place and her regular diet has been changed. She
maintains proper hygiene and correct breastfeeding practices. What do you
think is upsetting the baby? Rohan sometimes develop red rash on his hands.

2. Mrs. Patel complains of swollen and painful breasts. Her baby sucks the milk
but breastfeeding is very painful for her. She started breastfeeding on the 4th
day of delivery. As it is very painful for her she is not breastfeeding often.
What do you think is the diagnosis? What could have saved the condition?
What do you think needs to be done?

3. What will you do in the following situations?
1) If your baby needs frequent breastfeeding & has hard stools?
2) If you have a low birth baby?
3) If the nipples are inverted?
4) If your baby refuses to suckle breast milk?

4. Mrs. Raut is a very busy lady. She has a crying baby. Her baby is 4 months

old and has gained 250 gm from the last month. Mrs. Raut feels she does not
have enough milk and hence the baby cries. What is your diagnosis?

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VI. Feeding low birth babies

Objective
 Apply appropriate breastfeeding practices in low birth babies to catch up
growth.

Babies who are born with less than 2.5 kg are termed as low birth babies. This age
is irrespective of the gestational age. Babies which are born before 37 weeks of
gestational age are known as premature babies. Such babies have low birth
weight.
Such babies are at higher risk of catching infection and hence needs to be taken
special care. They are often hungry and need breastfeeding more than other
babies. Preterm babies may have problem in sucking at birth but usually they
suckle effectively later.

Babies of 32 weeks gestational age or more Suckle breast
Babies between 32 weeks - 30 weeks Feeding from cup or a spoon
Babies below 30 weeks Feeding by a tube in hospital

 Mothers should not force babies for breastfeeding. Let the child be on the
breast so that he can suckle when he is ready.

 Such babies suckle with a pause. (4-5 suckle with pause up to 4-5 minutes).
 Good attachment makes breastfeeding in early days effective.
 Breastfeeding should be expressed within 6 hours of delivery as it contains

Colostrum.
 Follow up regularly with the paediatrician to make sure if the baby is getting

all the breast milk that is needed to catch up growth.

Best positions to hold low birth babies for good attachment is by holding the
baby across mother’s body, with the arm on the opposite side to the breast or
an Underarm position

.

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VII. Feeding during illness

Objective
 Applying correct breastfeeding practices in ill babies for faster recovery
When body is recovering from illness, it needs more energy and nutrients to fight
the infection. Even children needs extra food to recover. If children do not get the
required food during illness, their body uses fat and muscle tissue for energy.
This can lead to thinning or stunted growth.

Give nutrient rich
foods & drinks.

Breastfeed more
frequently.

Feed small quantity
of food frequently.

 Feed appropriate food such as children need breast milk over other foods
when recovering from diarrhoea.

 He may refuse to eat during illness, so give that extra attention to feeding
during and after the illness.

 Appetite usually increases after as illness, hence use this opportunity in
feeding some extra food to catch up the lost weight.

Young children need extra food until they have regained all their lost weight and
are growing at a healthy rate.

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VIII. Feeding after 6 months of life – Complementary Foods

Objective
 Use complementary feeding for optimal growth and development.
 Restate the importance of continuing breastfeeding
 Recognise why there is an optimal age for children to start complementary
feeding

For the first six months of life, exclusive breastfeeding can provide all the nutrients
and water that a baby needs. From the age of six months, breast milk is no longer
sufficient by itself. All babies need complementary foods from six months, in addition
to breast milk. However, breast milk continues to be an important source of energy
and high quality nutrients beyond six months of age. The time from six months of
age until two years is also of critical importance in the child’s growth and
development. After six months of age, all babies require other foods to complement
breast milk which we call it as complementary foods.

Complementary feeding

Complementary feeding means giving other foods to your child in addition to breast
milk. Additional foods and liquids are called complementary foods. Complementary
foods must be nutritious foods and in adequate amounts so that your child can
continue to grow at a healthy rate. During the period of complementary feeding, the
young child gradually becomes accustomed to eating family foods.
Our body uses food for energy. If young children do not have enough good food,
they will not have the energy to grow and be active.

Let us study the energy gap with the help of graph

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900 Energy Gap
800
700 Energy (Kcal/day) from
600 breast milk
500
400
300
200
100

0
0-2 3-5 6-8 9-11 12-23

months months months months months

.

Each column represents the total energy needed at that age. The columns become
taller to indicate that more energy is needed as the child becomes older, bigger and
more active. The blue part shows how much of this energy is supplied by breast milk.

100% Gap
90%
80% Provided by 550 ml of
70% breast milk
60%
50%
40%
30%
20%
10%
0%

Energy Protein Iron Vitamin A

Each column represents total amount of energy, protein, iron and vitamin A require
after 6 months of age. The blue part shows nutrients obtained by breast milk and red
represents gap in the required nutrients.

Therefore, for most babies, six months of age is a good time to
start complementary foods.

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After six months, the foods that fill the energy gap more than liquids are thick
porridge, puree and mashed foods. After completion of six months babies can
control their tongue, move food around their mouth, and munch food with their jaws
and their digestive systems are getting matured to digest range of foods.

Risks of starting complementary food too late
 the child does not receive the extra food required to meet his/her growing
needs
 the child grows and develops slower
 might not receive the nutrients to avoid malnutrition and deficiencies such
as anaemia from lack of iron.

Foods that fill energy gap

Children after 8 months of age have a stomach than can hold 200 ml of food at one
time. Hence it is necessary to feed him them thick food as thin food or liquids make
their stomach fill quickly. Foods of a thick consistency help to fill the energy gap.
We all have a staple food specific to the region we live in. This staple food not only
gives us the required energy but also provides other proteins and nutrients. Along
with the staple food it is also necessary to feed other foods to get the necessary
nutrients to your child.

Let us see a list of enriching foods in the next table.

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Making porridge / Staple Enriching food
Soups / stew
Prepare porridge by adding less water and making it a
thick than thinner or runny. Before grinding the flour, toast
it as toasted flour does not thicken.

Instead the liquid part of the soup, take out the
vegetables, beans, meat and mash them to make a thick
puree to feed the child.

Add nutrients in the soup or Mix legume, pulses, bean flour with the staple food for
porridge cooking. Add spoonful of ghee or oil. Add milk powder
after cooking. Replace cooking water with milk, coconut
milk.

Jaggery, honey These can be added to the food to increase energy
Oils and fats concentration.

Adding a teaspoon of oil or fat in the food bowl gives
energy even in small volumes of food and makes the
porridge thicker, softer and easier to eat.

Essential Fatty acids Fish, nuts, vegetable oil, animal source-food, avocado all
contains essential fatty acids that are needed for child's
growing brain & eyes and for healthy blood vessels.

Grains Grains can be mixed with water and kept overnight for
fermentation to make porridge. Such porridge made from
fermented germinated grain is less thick than plain
porridge, made using less water with more quantity of
grains. It is high in energy and absorption of nutrients &
iron is better. It also deters growth of harmful bacteria.

Cereal and legumes Cereals & legumes soaked in water for sprouting and then
after drying grounded into flour. Use this germinated flour
to make porridge and as it doesn’t thicken during cooking,
so less water is required. Add this germinated flour to
thick porridge and cook for few minutes. It is easier for
children to eat because of its softness.

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Food rich in Iron and Vitamin A

Iron

Child needs iron to…

 make new blood
 help body fight against infection
 assist growth and development

Although a baby is born with enough stores of iron for the first 6 months, for the later
months he needs to fill the gap of iron. Let us look at the following table which shows
iron provided by breast milk but when the child is growing faster in his 1st year the
need for iron increases and stored iron proves insufficient for growth assistance.

1.2 Iron from birth store

1 Iron from breast milk
(mg/day)
0.8

0.6

0.4

0.2

0
0-2 3-5 6-8 9-11 12-23

months months months months months

The ‘white area’ on 6-8 months, 9-11 months and 12-23 months indicates iron
gap. This iron gap needs to be filled with complementary foods.

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Iron rich foods:

Meat and meat liver are good source of iron and zinc.
Fish, Shell fish, foods prepared from fish are also a good source.
Legumes are good source of iron as well.
Pulse and dark green colored leaves are also a source of iron.

Points to remember
Some foods increases iron absorption and some reduces it.
Eating these foods at the same meal increases the amount of iron absorbed from
eggs and plant foods such as cereals, pulses, seeds, and vegetables:

 Foods rich in vitamin C such as tomato, broccoli, guava, mango,
pineapple, papaya, orange, lemon and other citrus fruits.

 Small amounts of the flesh or organs/offal of animals, birds, fish and other
sea foods.

Food such as tea, coffee, fibre rich foods or calcium rich foods decreases iron
absorption

To make beans easier to eat & digest soak beans before cooking, boil
beans then sieve to remove coarse skins. Add them to soups or stews.
Mash cooked beans well.

77

Eating a variety of foods at the same meal can improve the way the
body uses the nutrients.

Zinc is another nutrient
that helps children to
grow and stay healthy. It
is usually found in the
same foods as iron.

Vitamin A

Breast milk has a large amount of vitamin A required by the child each day. However
after 6 months of age when the growth accelerates, breastfeeding alone cannot fulfill
requirement for vitamin A. This gap needs to be filled by complementary foods.
Following is a table showing vitamin A gap in a child from 6 months to 23 months of
age denoted in white.

78

400 Vitamin A from birth stores
Vitamin A from breast milk
300

200

100

0
0-2 3-5 6-8 9-11 12-23

months months months months months

Sources of Vitamin A:

 Meat liver
 Milk and milk product, Dried milk powder
 Egg yolks
 Dark green and yellow coloured vegetables
 Yellow coloured fruits.
 Unbleached red palm oil

Vitamin A is needed for healthy eyes and skin. Vitamin A helps
body to fight infections.

79

Foods Its Nutrients

Milk and Milk products Source of vitamin A
(cheese, yoghurt) Calcium strengthening bones
High in proteins and nutrients
Egg and egg yolk
Vitamin A & other nutrients

Legumes or pulses (beans, peas, and Proteins and iron (in legumes)
lentils, nuts and seeds)

Complementary foods should not be marketed or used in ways that undermine
breastfeeding.

80

Fluid needs of the young child
Do’s

 Breastfeed baby receives all liquids from breast milk. Baby not on
breastfeeding needs no extra water and can be given milk replacements only.

 Little water during meals or several times a day can be given, if the baby is
thirsty.

 A non-breastfeed child of age 6-24 months needs 4-6 cups of water in hot
climate & 2-3 cups of water at normal temperature.

 Water can be incorporated in stews or porridges.

Don’ts

 Packaged fruit juices makes child thirstier as the body has to deal with extra
sugar present in the juices. Soda (frizzy) drinks are complete no.

 Teas and coffees too are less beneficial as they reduce iron that is absorbed
from foods.

 Drinks should not replace foods or breastfeeding.

81

Feeding Frequency and quantity

Feeding frequency differs with child’s age and other factors. You will have to decide
the frequency of complementary feeding depending on your child’s growth needs.
Complementary feeding also differs if the child has never been breastfed.
The below given points are advisable for feeding your child if he was a non-
breastfed baby.
Feeding non-breastfed child

 A non-breastfed child should receive the following foods, fluids:
 Drink 2-3 cups of water at temperate climate and 4-6 cups in hot climate.
 Animal sourced foods, fish, vegetable oil, nut pastes to provide essential fatty

acids.
 Animal sourced foods, fortified foods or supplements to supply adequate iron.
 1-2 cups milk per day.
 1-2 meals per day.
 1-2 snacks if hungry.

82

Amounts of food to offer

Frequency of meals 6-8 months 9-11 months 12-23 months

2-3 meals / day + 3-4 meals / day + 3-4 meals / day
breastfeeds breastfeeds + breastfeeds

1-2 snacks if 1-2 snacks if 1-2 snacks if
hungry hungry hungry

Amount of food at 2-3 1/2 of a 250 ml 3/4 to one 250
each meal (for tablespoonfuls, cup/bowl ml cup/bowl
average child)
increasing
gradually to 1/2 of

a 250 ml cup

Thick porridge, Fined family foods,
mashed foods
Texture of food chopped/mashed fined/chopped if

foods necessary

If baby not breastfed, give 1-2 cups milk and 1-2 cups of meals per day.

The amounts of food included in the table are recommended when the energy
density of the meal is 0.8 Kcal/g.

If the energy density of the meals is about 0.6 Kcal/g, increase the energy density of
the meal by adding special foods or increase the amount of food per meal. For
example:

 For 6-8 months; increase gradually to 2/3 of cup

 For 9 to 11 months give ¾ of cup

 For 12 to 23 months give a full cup

83

Weight (kg)Exercise 6

1. Shanaya is now 8 months old. She has stopped breast milk. Her weight and
height is within normal limit. What food will you recommend to her and ay what
frequency?

2. Ronit is 70 cm in length and 7 kg in weight. He is 11 months old. He has a z
score of -2. His mother is a working lady and stopped breastfeeding after 4
months but expressed milk for him. Since then Ronit’s weight has dropped. His
mother is worried and wants to increase his weight to normal limit. What will
you recommend her?

3. Doctor diagnosed deficiency of iron and vitamin A in Punit. He was exclusively
breastfed for 1 year without starting any complementary food after 6 months.
He is 20 months old. Which food will you offer to Punit to fill the nutritional gap?

4. Here is a growth chart of Riya. Interpret the chart and recommend appropriate
food for her.

Weight for Age growth chart for GIRLS (6 months to 2 years)
17 17
16 16
15 15
14 14
13 13 -3
12 12 -1
11 11 0
10 10 1

2
99

3
88

-2
77
66
55

Age (months)

84

Important points to remember

 Children with any of the following severe Undernourishment problems
should be referred urgently for specialized care:

 severely underweight (below −3 z-score for weight-for-length/height or
BMI-for-age)

 clinical signs of marasmus (e.g. appears severely wasted, like “skin and
bones”)

 clinical signs of kwashiorkor (e.g. generalized oedema; thin, sparse hair;
dark or cracking/peeling patches of skin)

 oedema of both feet

 An undernourished child may have a current illness (such as diarrhoea) or a
chronic health problem that could be contributing to Undernourishment. If so,
treat the contributing illness or problem if you are able to. If not, refer the child
for appropriate treatment. If you know or suspect that a child has a chronic
health problem, refer the child for counselling or testing as appropriate.

 Refer children with obesity (above 3 z-score for weight-for-length/height) for
medical assessment and specialized management if these services are
available.

 Breastfeeding for two years of age or longer helps a child to develop and grow
strong and healthy.

 Starting other foods in addition to breast milk at 6 months helps a child to grow
well.

 Foods that are thick enough to stay in the spoon give more energy to the
child.

 Animal-source foods are especially good for children, to help them grow
strong and lively.

85

 Peas, beans, lentils, and nuts and seeds, are good for children.
 Dark-green leaves and yellow-colour fruits and vegetables help the child to

have healthy eyes and fewer infections.
 A growing child needs 2-4 meals a day plus 1-2 snacks if hungry: give a

variety of foods
 A growing child needs increasing amounts of food
 A young child needs to learn to eat: encourage and give help with lots of

patience.
 Encourage the child to drink and to eat during illness and provide extra food

after illness to help them recover quickly.

86

Growth charts

Height -for-Age growth chart for Girls (2 years to 5 years)
125 125

120 120

115 115

Height (cm)110 110 -3

-2
105 105

-1
100 100

0

95 95 1

3
90 90

2

85 85

80 80

75 75

Age (years)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

87

88

Weight (kg) Weight for Height growth chart for Girls (2 years to 5 years) -3
32 32 -2
30 30 -1
28 28 1
26 26 2
24 24 3
22 22 0
20 20
18 18
16 16
14 14
12 12
10 10

88
66
44

65 70 75 80 85 90 95 100 105 110 115 120

Height (cm)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

89

Weight (kg) Weight for Age growth chart for GIRLS (6 months to 2 years) 17
17 16
15
16 14
13
15 12 -3

14 -1
11 0
13
1
12 10 2

11 3
9 -2
10 8
7
9 6
5
8
90
7

6

5

Age (months)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

Height (cm) Lenght for Age growth chart for Girls (6 months to 2 years) 100
100 95
90
95 85

90 -3
80
85
-2
80 -1
75 0
75 2
3
70 70 1
65
65 60
55
60
91
55

Age (months)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

Weight (kg) Weight for Length growth chart for girls (Birth to 2 years) -3
26 26 -2
24 24 -1
22 22 0
20 20 2
18 18 3
16 16 1
14 14
12 12
10 10

88
66
44
22
00

45 50 55 60 65 70 75 80 85 90 95 100 105 110

Length (cm)

Severely
-3 underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

92

Weight (kg) Weight for Length growth chart for Boys (Birth to 6 months)
14 14

13 13

12 12

11 11

10 10

99
-2

8 8 -1
0

7 71
2

6 63
5 5 -3

44

33

22

11
45 50 55 60 65 70 75 80

Length (cm)

Severely
-3 underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

93

Weight (kg) Weight for length growth chart for Boys (0 to 2 years) -3
24 24 -2
22 22 -1
20 20 0
18 18 1
16 16 2
14 14 3
12 12
10 10
88
66
44
22
00

45 50 55 60 65 70 75 80 85 90 95 100 105 110
Length (cm)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

94

Weight (kg) Weight for Height growth chart for Boys (2 years to 5 years) -3
30 30 -2
28 28 -1
26 26 1
24 24 2
22 22 3
20 20 0
18 18
16 16
14 14
12 12
10 10

88
66
44

65 70 75 80 85 90 95 100 105 110 115 120
Length (cm)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

95

Weight (kg) Weight for Age growth chart for Boys (Birth to 6 months)
12 12

11 11

10 10

99

88
-2
-1

7 70
1

6 62
3

5 5 -3

44

33

22

Age (weeks)
0
1
2
3
1 month
5
6
7
2 months
9
10
11
12
3 months
14
15
16
4 months
18
19
20
21
5 months
23
24
25
6 months

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

96

Weight (kg) Weight-for-age growth chart for Boys (6 months to 2 years) -3
17 17 -2
16 16 -1
15 15 0
14 14 2
13 13 3
12 12 1
11 11
10 10

99
88
77
66
55

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Age (months)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

97

Length (cm) Length for age growth chart for Boys (6 months to 2 years)
100 100

95 95

90 90

85 85
-3
-2

80 80 -1
1
2

75 75 3
0

70 70

65 65

60 60
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age (months)

-3 Severely underweight
-2 Underweight
-1 Thin
0 Normal limit
1 Heavy
2 Overweight
3 Obese

98