Desde la LME hasta la etapa Alimentación Complementaria.

Dr. José Luis Gonzales BenavidesGastroenterología Pediátrica y

Nutrición Infantil. INSN

PREMISA: LACTANCIA MATERNA EXCLUSIVA POR LOS PRIMEROS SEIS MESES.

• En mayo del 2001, la 54a Asamblea Mundial de la Salud exhortó a los Estados Miembros a promover la lactancia materna exclusiva por seis meses como una recomendación mundial de salud pública

• (Asamblea Mundial de la Salud, 2001).

• Esta recomendación fue elaborada por una Reunión de Expertos sobre la Duración Optima de la Lactancia Materna Exclusiva convocada por la OMS (OMS, 2001).

• Los expertos consideraron los resultados de una revisión sistemática de las pruebas existentes (Kramer y Kakuna, 2002) y concluyeron que la lactancia materna exclusiva por seis meses proporciona varios beneficios al niño y a la madre.

PREMISA: LACTANCIA MATERNA EXCLUSIVA POR LOS PRIMEROS SEIS MESES. PROTECCIÓN DE MORIR

PREMISA: LACTANCIA MATERNA EXCLUSIVA POR LOS PRIMEROS SEIS MESES. PROTECCIÓN DE ENFERMEDADES.

Riesgo relativo de diarrea por categorías. Brown

PREMISA: LACTANCIA MATERNA EXCLUSIVA POR LOS PRIMEROS SEIS MESES. NO EXISTE VENTAJA DE INCLUIR AC ANTES DEL SEXTO MES.NO HAY MEJOR CRECIMIENTO.

PREMISA: LACTANCIA MATERNA EXCLUSIVA POR LOS PRIMEROS SEIS MESES. NO EXISTE VENTAJA DE INCLUIR AC ANTES DEL SEXTO MES.NO HAY MEJOR CRECIMIENTO.SE REDUCE LAS CALORIAS DE LM.

PREMISA: LACTANCIA MATERNA EXCLUSIVA POR LOS PRIMEROS SEIS MESES. NO EXISTE VENTAJA DE INCLUIR AC ANTES DEL SEXTO MES.NO HAY MEJOR OPORTUNIDAD DE CRECIMIENTO AUN EN NIÑOS DE BAJO PESO.

CUALES SON LOS OBJETIVOS QUE PERSIGUE UNA ADECUADA NUTRICIÓN.

ES SUFICIENTE EL INCREMENTO DE PESO Y GANANCIA DE TALLA ?

SI LO QUE EVALUAMOS ES EL CRECIMIENTO INFANTIL EL MEJOR INDICADOR ES LA VELOCIDAD DE CRECIMIENTO.

UNA ADECUADA NUTRICIÓN PUEDE SER EVALUADA POR UNA BUENA VELOCIDAD DE CRECIMIENTO

HE SEGUIDO EL MENSAJE, HE DECIDIDO POR LA LME A MI NIÑO.

LME EXCLUSIVA LOS PRIMEROS SEIS MESES. NO INICIAR LA AC ANTES DEL SEXTO MES. NO HAY VENTAJAS Y SI MUCHOS RIESGOS

HACIENDO MATEMÁTICAS MATERNAS….

ETAPA DE ALIMENTACIÓN COMPLEMENTARIA.QUE OPINAN LOS EXPERTOS.

EDUCARSUPLEMENTARFORTIFICAR

Effect size for weight growth of different intervention strategies

ED = Education; FD = Complementary food; FD+ED = Education + complementary food; FT = Fortification of comp. foods; EN = Increased energy density

Excluding Obatolu, 2003 (outlier)

-0.50

-0.25

0.00

0.25

0.50

0.75

1.00

1.25

1.50

ED FD FD+ED FT EN

Intervention strategy

Eff

ects

siz

e fo

r w

eigh

t gr

owth

Max Min Mean

Effect size for linear growth of different intervention strategies

ED = Education; FD = Complementary food; FD+ED = Education + complementary food; FT = Fortification of comp. foods; EN = Increased energy density

Excluding Obatolu, 2003 (outlier)

-0.50

-0.25

0.00

0.25

0.50

0.75

1.00

ED FD FD+ED FT EN

Intervention strategy

Effe

ct s

ize

for

line

ar

gro

wth

Max Min Mean

.

Krebs N F J. Nutr. 2007;137:511S-517S

©2007 by American Society for Nutrition

Systematic review of the efficacy and effectiveness of

complementary feeding interventionsKathryn G. Dewey, PhD

Seth Adu-Afarwuah, PhDProgram in International and Community Nutrition

University of California, Davis

Supported by the Mainstreaming Nutrition Initiative with funding from the World Bank

Conclusions

• No single universal “best” package of components in complementary feeding interventions

• Impact is context-specific– Initial prevalence of malnutrition– Degree of household food insecurity– Energy density of traditional complementary

foods– Availability of micronutrient-rich local foods

Conclusions – Micronutrient intake• Very difficult to achieve adequate Fe intake

from local foods without fortification, at 6-12 mo

• Fortification increased Fe intake by 5-11 mg/d• Can achieve adequate Zn and Vit A intakes

from local foods, but requires careful attention to dietary choices

• Fortification can help ensure Zn and Vit A intakes when nutrient-rich local foods are costly or unavailable (e.g. seasonally)

Conclusions – Micronutrient status

• Education can have a positive impact on Fe status if Fe-rich foods are emphasized

• A larger impact on Fe status can be expected from use of fortified products (reduction of 13-21 percentage points in prevalence of anemia)

• Little or no impact of fortification on plasma zinc – due to low absorption?

• Results mixed regarding fortification with Vit A– Positive impact in several studies– Little impact in some studies, probably due to concomitant

vit A capsule distribution programs

AC: LO QUE DEBERÍA APORTAR….

Gracias por su atención.

Conclusions – Growth (cont.)

• Educational approaches more likely to have impact if there is an emphasis on nutrient-rich animal-source foods

• Provision of food – variable results– Greater impact in Africa & S Asia – due to food

insecurity?– 2 studies compared food + education vs.

education only: somewhat greater impact when food included

Conclusions – Growth (cont.)• Most of the foods provided were fortified, so

can’t distinguish impact of increased energy/protein/fat from micronutrients– In Ghana, impact on weight gain partially

explained by increased energy intake, but impact on length gain related to change in plasma fatty acid profile

• Micronutrient fortification alone has little effect on growth– Exception: relatively large study in India in which

many children stunted at baseline & fortified product resulted in reduced morbidity

Overall Conclusions

• Educational approaches can be effective, but in many situations a greater impact may be seen when combined with home-fortification or provision of fortified foods

• To be most cost-effective and avoid displacement of breast milk, the amount of food provided should be modest: no more than 200 kcal/d at 6-12 mo

• Biggest challenge: going to scale with a combination of the most cost-effective components, while assuring adequate delivery and sustainability

EN MI PAIS QUE ALIMENTOS SE FORTALECEN…….

POR QUE SE FORTALECEN…..

QUE DICEN LOS COMITÉS DE EXPERTOS SOBRE LOS CEREALES

ES POSIBLE Y RACIONAL RECOMENDAR UN PRODUCTO INDUSTRIALIZADO DE CEREAL…..

EL INICIO DEL CEREAL PUEDE ARRIESGAR A REDUCIR LA OFERTA DE LECHE MATERNA….

QUE DEBO ESPERAR DEL CEREAL CON EL QUE ALIMENTO A MI NIÑO…

QUE RIESGOS PUEDO ENFRENTAR IMPLÍCITOS AL CEREAL…..

COMO EMPLEO LAS RECOMENDACIONES DEL FABRICANTE…

CUALES SON LAS VARIABLES QUE DEBO CONSIDERAR PARA MI EJERCICIO MATEMÁTICO

EL INSTINTO Y EL LEGRADO CULTURAL DE LAS FAMILIAS COMO FACTORES QUE INFLUYEN EN LA DECISION DE ALIMENTAR

• Uno de los beneficios principales es el efecto protector contra infecciones gastrointestinales, que ha sido observado no solo en países en vías de desarrollo sino también en países industrializados (Kramer y col., 2001).

• Algunos estudios sugieren que el desarrollo psicomotor mejora con la lactancia materna

• exclusiva por seis meses (Dewey y col., 2001)

• La Reunión de Expertos observó que, en términos poblacionales, la lactancia materna exclusiva por

• seis meses no tiene efecto adverso en el crecimiento infantil. Las necesidades nutricionales de los

• niños normales nacidos a término son generalmente cubiertas por la leche materna durante los

• primeros 6 meses siempre que la madre esté bien alimentada (OMS/UNICEF, 1998). Sin embargo, en

• ciertas situaciones, puede haber problema con algunos micronutrientes antes de los 6 meses.

CUANTA SEGURIDAD ME OFRECE LA LACTANCIA MATERNA.

POR QUE NO SEGUIR LACTANDO EN FORMA EXCLUSIVA POR MAS TIEMPO AL NIÑO

UN NIÑO QUE RECIBE LACTANCIA MATERNA VS UN NIÑO QUE RECIBE FÓRMULA INFANTIL TIENEN UN ESTANDAR DIFERENTE DE CRECIMIENTO.

• Current recommendations for the duration of exclusive breastfeeding are

• based on a systematic review of intervention trials and observational studies

• carried out in both lower income and more affluent countries, which assessed

• the rates of growth of infants who were breastfed exclusively for 6 months

• versus those who were partially breastfed or nonbreastfed, as well as their

• respective rates of infections

• In the• first of these studies, infants were randomly assigned to one of three feeding• regimens: (1) exclusive breastfeeding until 6 months of age, (2) exclusive• breastfeeding until 4 months of age at which time high-quality, packaged• complementary foods were started and breastfeeding was continued ad libitum,• or (3) exclusive breastfeeding until 4 months at which time complementary• feeding was initiated as above along with explicit encouragement to• maintain breastfeeding frequency [9]. There were no significant differences in• the children’s total energy intakes despite the additional energy provided by• complementary foods, and there were no differences in their growth velocities• from 4 to 6 months. The authors concluded that there was no advantage• of introducing complementary foods before 6 months, whereas there may be• considerable risks of inadequate nutrient intakes and food-borne infections if• the nutritional and hygienic quality of the foods cannot be assured.

• Exclusive breastfeeding during the first months of life is associated with• reduced rates of diarrhea and other infections [5, 6], and a multicenter

study• by WHO in Brazil, Pakistan and the Philippines indicated that both

exclusive• and predominant breastfeeding are associated with reduced infant

mortality• [7]. The pooled odds ratios of mortality associated with nonbreastfeeding• declined progressively with increasing infant age, ranging from 5.8 (95% CI• 3.4–9.8) during the first 2 months of life and 4.1 (2.7–6.4) for 2- to 3-

montholds• to 1.4 (0.8–2.6) for 9- to 11-month-olds.

COMO CRECEN DESDE EL SEXTO MES HACIA ADELANTE DIFERENTES COMUNIDADES DE NIÑOS

QUE COMEN LOS NIÑOS EN AMERICA LATINA

QUE COMEN LOS NIÑOS EN EL PERU

Conclusions - Growth

• Growth may not be the most sensitive indicator of impact

• Impact may be greater in younger age groups: should begin CF programs during infancy

• Effect sizes generally modest (0.1-0.5), but potential larger if optimal design and implementation (0.5-0.6)