nutritional requirements of infants and young children...

TM

Corazon VC Barba, PhD Professor Emeritus, University of the Philippines Los Baños

Nutritional Requirements of Infants and Young Children in ASEAN: What do we know?

1. The Philippine Experience: PDRI 2015

• Brief history

• Underlying concepts

• Components

2. Updates on IYC energy and nutrient needs

3. Comparison of RNIs Among Recommending Bodies and SEA countries

4. Issues in the derivation of DRIs in infants and young children, and research needs

Contents The Philippines

The Food and Nutrition Research Institute is the lead agency in the review and revision of nutrient standards.

Timeline of Nutrient Standards

1941 – Recommended Dietary Allowances, 1st edition

1947 – RDA, 1st revision

1953, 1965, 1970, 1976, 1989 – RDA, succeeding revisions

2002 – Recommended Energy and Nutrient Intakes

ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition – Updates on Cambodia, Lao PDR and MyanmarAugust 11, 2016, Phnom Penh, Cambodia

2015 Philippine Dietary Reference Intakes

• Replaces, updates and expands the 2002 Recommended Energy and Nutrient Intakes (RENI) for Filipinos

• Adopts the multi-level approach for setting nutrient reference values

• Collective term comprising four reference values for energy and nutrient levels of intakes: EAR, REI/RNI, AI and UL

• Based on best available scientific evidence reviewed by a committee of health and nutrition experts

Key concepts in setting PDRI 2015 1. Both nutrient requirements and intakes are

distributions.

2. The dietary reference intakes (DRIs) would satisfy the needs of apparently healthy Filipinos.

3. The endpoints of the DRIs are to ensure nutrient adequacy (prevention of nutrient deficiency) and to avoid excess.

4. The reference weights for infants, children and adolescents reflect the WHO CGS and Growth Reference, while those for adults are based on weight to achieve BMI of 22.

5. Adjustment in age groups reflects biological patterns and current feeding guidelines.

6. Most recent researches served as references.

Key concepts in setting PDRI 2015 Components of PDRI 2015

• Estimated Average Requirement (EAR)

• Recommended Energy Intake (REI) /

Recommended Nutrient Intake (RNI)

• Adequate Intake (AI)

• Tolerable Upper Intake Level or Upper Limit (UL)


-2sd +2sd Average

LEVEL OF REQUIREMENT

NUTRIENTS

Recommended

Nutrient Intake

-2sd +2sd Average

LEVEL OF REQUIREMENT

ENERGY

Estimated Average

Requirement

Recommended

Energy Intake

For macronutrients:

• Acceptable Macronutrient Distribution Ranges (AMDR)

Additional recommendations for prevention of chronic disease risk:

• Maximum intakes (free sugars, sodium)

• Target intake (potassium)

Components of PDRI 2015

Energy and nutrient needs of infants and young children: What’s new?

Infants

• New breast milk volumes

• Gender group-specific DRIs

Young children

• Revised age groups

Infants and young children

• New child growth standards

• AMDRs

Breast milk volume

• New volumes of average daily breast milk consumption are adopted

– 780 mL for 0–5 mos (vs. 750 mL in RENI 2002)

– 650 mL for 6–11 mos (vs. 600 mL in RENI 2002)

• Values are based on pooled data derived from standardized stable isotope studies


780 mL/d for 0–5 months

1. Scientific basis:

Da Costa T, Haisma H, Wells J, et al. 2010. How much human milk do

infants consume? Data from 12 countries using a standardized stable isotope methodology. J Nutr 140:2227-2232.

• Data on human milk intake of infants 0–24 months from 12 countries (Bangladesh, Brazil, Chile, Gambia, Kenya, Malawi, Mexico, Senegal, PNG, UK, USA, Zambia) using isotope (deuterium) method. Majority of the infants were in the age range 2–4 months; data for > 10 mos were only from 2 countries (PNG and Gambia).

• Mean weight for age for 0–6 months may be comparable to Philippine data (NNS)

• The overall HM intake estimate from the model excluding age effects was 0.778 kg/d (95% CI = 0.717, 0.839)

Breast milk volume

Growth curve for weight-for-age for male (A) and female (B) infants included in the Human Milk Intake Analysis. Values are mean ± SD, n = 8–142 (A) or 12–124 (B). Lines are WHO standards for 5th, 50th, and 95th percentiles. There are no data available for 11-month-old infants.

Da Costa T, Haisma H, Wells J, et al. 2010. How much human milk do infants consume? Data from 12 countries using a standardized stable isotope methodology. J Nutr 140:2227-2232.

Da Costa T, Haisma H, Wells J, et al. 2010. How much human milk do infants consume? Data from 12 countries using a standardized stable isotope methodology. J Nutr 140:2227-2232.

0.778 kg/d (95% CI: 0.717-0.839)

*

* *

*

* * *

*

(* HM intakes reported by WHO for exclusively HM-fed infants from developing countries)

713 mL

Butte N, Lopez-Alarcon M, Garza C. 2002. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva: WHO.

*

* Used deuterium method


782.4 mL


650 mL for 6–11 months

Scientific basis:

Butte N, Lopez-Alarcon M, Garza C. 2002. Nutrient adequacy of exclusive

breastfeeding for the term infant during the first six months of life. Geneva: WHO.

World Health Organization. 1998. Complementary feeding of young children in developing countries: A review of current scientific knowledge. Geneva: WHO.

Breast milk volume

Pooled ave = 620.9 mL


World Health Organization. 1998. Complementary feeding of young children in developing countries: A review of current scientific knowledge. Geneva: WHO.

Pooled ave = 648.3 mL


Disaggregation by gender group

• Energy requirements are based on measurements of total energy expenditure, which in turn is derived from doubly-labelled water studies in infants

• This method involves consideration of gender, body weight and length/height, among others.

• As energy requirements vary with body weight and composition even in infants, recommendations are needed for each gender group.

• Nutrient recommendations differ by gender because of growth standards by gender.

• AIs, EARs and RNIs of older infants were at times extrapolated or calculated following metabolic weight formula, hence, the need for reference values by gender.

Disaggregation by gender group

Revised age groups

Age groupings reflect established biological patterns as well as the application of current guidelines for breastfeeding duration and complementary feeding.

Age groups Rationale

2002 2015

1–3 1–2 Early childhood, period of complementary feeding

4–6 3–5 Start of preschool, steady growth

7–9 6–9 Primary school years, steady growth

• The period from birth to two years of age (so-called first 1,000 days) is a “critical window” for the promotion of optimal growth, health and behavioral development.

• Based on WHO recommendation, infants should be exclusively breastfed for the first 6 months of life, and thereafter should receive appropriate complementary food with continued breastfeeding up to two years and beyond.

Revised age groups


• The greater growth velocity during ages 1 through 2 compared with ages 3 through 5 provides a biological basis for dividing this period of life.

• Because children in the Philippines from 3 onwards and those from 6 onwards begin to enter preschool and primary school, respectively, starting this life stage (3-5 y) at age 3 and ending it prior to 6 seemed appropriate.

Revised age groups New child growth standards

• In 2006, the WHO released a new international standard for assessing the physical growth, nutritional status and motor development in all children from birth to age five

• These standards were developed using data collected in the WHO Multicentre Growth Reference Study involving more than 8,000 children from Brazil, Ghana, India, Norway, Oman, and the US

The WHO-CGS is adopted for the following reasons:

• The WHO standards establish growth of the breastfed infant as the norm for growth. – Breastfeeding is the recommended standard for infant feeding. The

WHO charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and still breastfeeding at 12 months.

• The WHO standards provide a better description of physiological growth in infancy. – Previous growth charts such as the International Reference Standards

are references; they identify how typical children did grow during a specific time period. Typical growth patterns may not be ideal growth patterns. The WHO growth charts are standards; they identify how children should grow when provided optimal conditions.

New child growth standards

The WHO-CGS is adopted for the following reasons:

(Continuation)

• The WHO standards are based on a high-quality study designed explicitly for creating growth charts. – The WHO standards were constructed using longitudinal length and

weight data measured at frequent intervals.

New child growth standards


PDRI 2015: Age groups and corresponding reference weights

New child growth standards Acceptable macronutrient distribution ranges (AMDRs)

• A growing body of evidence shows that a major imbalance in the relative proportions of macronutrients can increase risk of chronic disease and may adversely affect micronutrient intakes.

• Certain ranges of relative intakes of proteins, carbohydrates and fats are acceptable in terms of chronic disease risk (i.e., AMDRs).

• The risk of chronic disease, as well as the risk of inadequate micronutrient intake, may increase outside these ranges.

Acceptable macronutrient distribution ranges (AMDRs)

• It is well recognized that chronic diseases have not only affected adults but also children.

• National nutrition surveys have documented rising childhood overweight and obesity prevalence in the Philippines.

• The WHO/FAO and the IOM have recommended specific AMDRs for all age groups including children and adults, citing that energy balance is critical for ensuring healthy body weight, even for children.

Acceptable macronutrient distribution ranges (AMDRs)

• There is sufficient evidence that unhealthy weight (overweight and obesity) is an important risk factor to hypertension, dyslipidemia, metabolic syndrome and other chronic diseases later in life.


Life stage/

age group

Range (% of Energy)

Protein Total Fat Carbohydrate*

Infants, mo

0–5 5 40–60 35–55

6–11 8–15 30–40 45–62

Children, y

1–2 6–15 25–35 50–69

3–18 6–15 15–30 55–79

Adults, y

≥ 19 10–15 15–30 55–75

PDRI 2015: Acceptable Macronutrient Distribution Ranges

Acceptable Macronutrient Distribution Range (AMDR) is the range of intakes for a particular energy source (carbohydrate, protein or fat) that is associated with reduced risk of chronic diseases while providing adequate intakes of essential nutrients, expressed as a percentage of total energy intake. *The AMDR for carbohydrate is the percentage of total energy available after taking into account that consumed as protein and fat, hence the wide ranges.

PDRI 2015 Committee and Task Forces

Recommending

body/ country

Infants , mos Children, 1 - 3 y

0 - 5 6 - 11

M

IOM-FNB, 2000 7.0 9.0 13.0

FAO-WHO, 2004 6.0 9.0 12.0

ILSI-SEA, 2005 6.0 9.0 14.0

Philippines, 2015 6.5 6.0 9.0 8.0 12.0* 11.5*

Singapore, 2014 7.0 1 8.5 2 ; 9.5 3 11.0*

Malaysia, 2005 6.0 6.0 8.0 8.0 12.0 11.0

Indonesia, 2013 6.0 9.0 13.0

Thailand, 2006 5.0 8.0 13.0

Vietnam - - - - - -

Reference weights, kg

* 1 – 2 y ; 1 3 - <6 mos ; 2 6 - < 9 mos; 3 9 - <12 mos


Recommending

body/ country

Infants, mos Children, 1 - 3 y

0 - 5 6 - 11

M

IOM-FNB, 2005 570 520 743 676 1046 992

FAO-WHO, 2001 472 432 697 645 948 865

ILSI-SEA, 2005 555 710 1180

Philippines, 2015 620 560 720 630 1000* 920*

Singapore, 2014 410 - 570 1 370 -520 1 600 - 680 2 560 - 640 2

880* 3

1080* 4

810* 3

1000* 4

Malaysia, 2005 560 550 640 630 980 910

Indonesia, 2013 550 725 1125

Thailand, 2006 - 800 1000

Vietnam, 2016 550 500 650-700 600-650 1000 930

ENERGY, kcal

* 1 – 2 y ; 1 1 to 5 mos; 2 6 to 11 mos ; 3 1 y ; 4 2 y

Recommending

body/ country

α-Linolenic Acid Linoleic Acid

Infants , mos Children,

1 – 3 y

Infants , mos Children,

1 – 3 y 0 - 5 6 - 11 0 - 5 6 - 11

M

IOM-FNB, 2005 0.5 0.5 0.7 4.4 4.6 7.0

FAO-WHO, 2008 0.2 - 0.3 0.4 - 0.6 0.4 – 0.6* HM** 3.0 – 4.5 3.0 – 4.5*

ILSI-SEA, 2005 - - - - - -

Philippines, 2015 0.5 0.5 0.5* 4.5 4.5 3.0*

Singapore - - - - - -

Malaysia, 2005 - - - - - -

Indonesia, 2013 0.5 0.5 0.7 4.4 4.4 7.0

Thailand, 2006 - - - - - -

Vietnam, 2016 0.5 0.5 0.5 4.5 4.5 3.0

Essential Fatty Acids, %E

Recommended Nutrient Intake (RNI) are presented in bold font, and Adequate Intake (AI) in italics;

* 1 – 2 y; ** Human milk composition as % E of total fat

Recommending

body/ country


0 - 5 6 - 11

M

IOM-FNB, 2005 9.1 11 13

FAO/WHO/UNU, 2001 9.1 11.0 12.1

ILSI-SEA, 2005 11a 14a 16a; 20b ; 23c

Philippines, 2015 9 8 17 15 18* 17*

Singapore, 2014 16 d 17 e 18 f 19*

Malaysia, 2005 11 11 12 12 17 17

Indonesia, 2013 12 18 26

Thailand, 2006 - 15 18

Vietnam, 2016 11 18-20 20 19

PROTEIN, g

Recommended Nutrient Intake (RNI) are presented in bold font, and Adequate Intake (AI) in italics; * 1 – 2 y ; a

High quality Protein Diet; b Adj for 80% Protein Quality; c Adj for 70% Protein Quality ; d 3 - <6 mos; e 6 <9 mos; f 9 -<12 mos

Recommending

body/ country


0 - 5 6 - 11

M

IOM-FNB, 2001 400 500 300

FAO-WHO, 2004 375 400 400*

ILSI-SEA, 2005 375 400 400

Philippines, 2015 380 380 400 400 400* 400*

Singapore, 2014 300 a 300

250*

Malaysia, 2005 375 375 400 400 400 400

Indonesia, 2013 375 400 400

Thailand, 2006 - 400 400

Vietnam, 2016 300 400 400 350

VITAMIN A, µg RE


* 1 – 2 y ; ** 3 - <6 mos


Recommending

body/ country

Infants , mos Children, 1 – 2 y

0 - 5 6 - 11

M

IOM-FNB, 2011 15 15 15

FAO-WHO, 2004 5 5 5

ILSI-SEA, 2005 5 5 5

Philippines, 2015 5 5 5 5 5* 5*

Singapore 10** 10

10*

Malaysia, 2005 5 5 5 5 5 5

Indonesia, 2013 5 5 15

Thailand - 5 5

Vietnam, 2016 10 10 15

Vitamin D, µg


* 1 – 2 y ; ** 3 - <6 mos

Recommending body/ country

Infants , mos Children, 1 – 3 y

0 - 5 6 - 11

M

IOM-FNB, 2001 0.27 11 7

FAO-WHO, 2004 a 6.2 (15%); 7.7 (12%); 9.3 (10%); 18.6 (5%) b

3.9 (15%); 4.8 (12%); 5.8 (10%); 11.6 (5%) b

ILSI-SEA, 2005 0.93 c (7.5% / 10%) 12.4 (7.5%); 9.3 (10%) b 7.7(7.5%); 5.8 (10%) b

Philippines, 2015 0.4 0.4 10 9 8* 8*

Singapore, 2014 7 7 7*

Malaysia, 2005

a

a 9 (10%); 6 (15%) b

9 (10%); 6 (15%) b

6 (10%); 4 (15%) * b

6 (10%); 4 (15%)* b

Indonesia, 2013 - 7 8

Thailand, 2006 - 9.3 5.8

Vietnam, 2007 0.93 (10%) 18.6 (5%); 12.4 (10%);

9.3 (15%) b 11.6 (5%); 7.7 (10%);

5.8 (15%) b

Iron, mg

Recommended Nutrient Intake (RNI) are presented in bold font, and Adequate Intake (AI) in italics; * 1 – 2 y; a Neonatal iron stores are sufficient to meet iron reqmt in full term infant; b RNI based on bioavailability of dietary iron ; c Breast-fed infant



0 - 5 6 - 11

M

IOM-FNB, 2001 2 3 3

FAO-WHO, 2004a 1.1 (High) b ;

2.8 (Moderate) ; 6.6 (Low)

0.8 b / 2.5 c (High); 4.8 (Moderate); 6.4 (Low)

2.4 (High) ; 4.1 (Moderate); 8.3 (Low)

ILSI-SEA, 2005 1.1b ; 2.9 d 4.2 4.8

Philippines, 2015 2.1 2.1 4.2 3.7 4.1* 4.0*

Singapore, 2014 - - -

Malaysia, 2005 1.1 b; 2.8 d 1.1b ; 2.8 d 3.7 3.7 4.1 4.1

Indonesia, 2013 - 3 4

Thailand, 2006 - 3 2

Vietnam, 2007e 1.1 (Good); 2.8 (Moderate);

6.6 (Poor)

0.8 f- 2.5 (Good); 4.1 (Moderate) ; 8.3 (Poor)

2.4(Good); 4.1 (Moderate); 8.4 (Poor)

Zinc, mg

Recommended Nutrient Intake (RNI) are presented in bold font, and Adequate Intake (AI) in italics; * 1 – 2 y; a RNI based on

bioavailability of dietary zinc; b Breast-fed infant, the bioavailability of zinc from human milk is assumed to be 80% (CV 12.5%) ; c Not applicable to infants consuming human milk only; d Formula-fed infant; e By absorption amount/quality of dietary zinc; f Not applicable to purely breastfed infants.


Infants , mos Children, yrs

1 - 3 0 - 5 6 - 11

M

IOM-FNB, 2011 200 260 700

FAO-WHO, 2004 300 a; 400 b 400 500

ILSI-SEA, 2005 300 a; 400 b 400 500

Philippines, 2015 200 200 400 400 500* 500*

Singapore 300 a ; 400 b 400 500*

Malaysia, 2005 300a; 400b 300a; 400b 400 400 500 500

Indonesia, 2013 200 250 650

Thailand, 2006 - 270 500

Vietnam, 2016 300 400 500

Calcium, mg


* 1 – 2 ; aBreastfed infant; b Formula-fed


Issues in the Derivation of DRIs for Infants*

• No EARs were set for infants due to lack of appropriate data; AIs were used instead. AI for all nutrients for 0-6 mo old infants was obtained by: Average daily milk volume x concentration of nutrient in breast milk. Nutrient values for human milk, however, vary widely.

• AIs/EARs for 6-11 mo old infants were obtained by extrapolating up from younger infants/ or down from older age groups. Dietary data on nutrients from solid food were unavailable for many nutrients.

*Dietary Reference Intakes Research Synthesis Workshop Summary, IOM-NAS

Issues in the Derivation of DRIs for Young Children*

• Many different methods were used to set EARs and RNIs, e.g. protein (nitrogen balance, protein deposition), iron and zinc (factorial), others (extrapolation).

• Issues raised about the different approaches used for extrapolating values from one group to another. Growth factor values used may not be appropriate for all nutrients.

* Dietary Reference Intakes Research Synthesis Workshop Summary, IOM-NAS

Research needs* • More analysis of breast milk, collected appropriately

• If extrapolating, use WHO growth standards

• More dietary/nutrient intake data related to biomarkers that are validated in children

• Studies with stable isotopes and nanotracers to determine vitamin and mineral bioavailability, kinetic studies, etc.

• Doubly labeled water studies to measure energy expenditure and water turnover

• Determination of Vit D requirements based on relationships of intake with 25-(OH) D, parathyroid hormone, bone markers

* Dietary Reference Intakes Research Synthesis Workshop Summary, IOM-NAS


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