80  Nutrition

80.1 Introduction

Adequate nutrition is fundamental to the growth, development, and survival of children. Optimal nutrition during infancy and childhood supports physical growth, brain development, immune function, and overall well-being. Malnutrition — encompassing both undernutrition and overnutrition — remains a major public health concern in low- and middle-income countries, including Ghana.

Child nutrition must be understood within the context of developmental stages, dietary requirements, feeding practices, and common nutritional disorders. The health worker’s role is to promote appropriate feeding, prevent malnutrition, and manage nutritional deficiencies promptly.

80.2 Objectives

At the end of this session, learners should be able to: 1. Describe the principles of nutrition and growth in children. 2. Outline nutritional requirements at different ages. 3. Discuss breastfeeding and complementary feeding practices. 4. Recognize and manage common nutritional disorders. 5. Explain preventive strategies for malnutrition.

80.3 Overview of Nutrition in Children

Nutrition refers to the intake and utilization of nutrients to maintain health, support growth, and enable bodily functions. It involves macronutrients (carbohydrates, proteins, fats) and micronutrients (vitamins, minerals, and trace elements).

Children have higher nutrient requirements per kilogram of body weight than adults due to rapid growth and development, particularly in the first two years of life.

80.4 Components of a Balanced Diet

A balanced diet provides adequate amounts of all essential nutrients. The key components are:

Nutrient Function Major Sources
Carbohydrates Energy source Cereals, grains, fruits, tubers
Proteins Growth and tissue repair Legumes, milk, meat, fish, eggs
Fats Energy storage, cell membranes, absorption of fat-soluble vitamins Oils, nuts, dairy, meat
Vitamins Metabolic functions Fruits, vegetables, fortified foods
Minerals Bone health, enzyme function Milk, fish, leafy vegetables, iodized salt
Water Solvent, thermoregulation Drinking water, fruits, soups

80.5 Nutritional Requirements by Age

80.5.1 Neonates and Infants (0–6 months)

  • Exclusive breastfeeding is recommended for the first 6 months.
  • Breast milk provides all nutrients except vitamin D (and sometimes vitamin K).
  • Breastfeeding should be on demand, day and night.

80.5.2 Infants (6–24 months)

  • Complementary feeding begins at 6 months while continuing breastfeeding up to 2 years or beyond.
  • Start with pureed or mashed foods, progressing to family foods.
  • Energy-dense meals: 2–3 times daily at 6–8 months, 3–4 times after 9 months, plus snacks.

80.6 Preschool Children (2–5 years)

  • Require a variety of foods from all groups.
  • Encourage family meals, adequate protein, fruits, and vegetables.
  • Avoid excessive sugary snacks and drinks.

80.6.1 School-Age Children (6–12 years)

  • Nutrition supports steady growth and school performance.
  • Meals should be balanced with sufficient carbohydrates, proteins, and iron.
  • Promote hygiene and safe water intake.

80.6.2 Adolescents (10–19 years)

  • Period of rapid growth and hormonal changes.
  • Increased need for calories, protein, calcium, iron, and vitamins.
  • Girls require additional iron due to menstruation.

80.7 Breastfeeding

80.7.1 Importance of Breastfeeding

  • Provides ideal nutrition and antibodies.
  • Reduces risk of diarrhoea, pneumonia, and sudden infant death syndrome.
  • Promotes bonding and optimal neurodevelopment.

80.7.2 Composition of Breast Milk

Component Function
Lactose Main carbohydrate; energy and promotes gut flora
Whey and casein Proteins aiding digestion and immunity
Lipids Energy, essential fatty acids, brain development
Vitamins and minerals Nutritional balance
Antibodies and immune cells Protection against infections

80.7.3 Stages of Breast Milk

  • Colostrum: Yellow, thick milk secreted in first 3–5 days; rich in antibodies.
  • Transitional milk: 5–14 days postpartum.
  • Mature milk: From 2 weeks onwards.

80.7.4 Common Breastfeeding Challenges

  • Poor latch or positioning.
  • Cracked nipples, mastitis.
  • Perceived low milk supply.
  • Management: counselling, proper technique, frequent feeding, expressing milk if needed.

80.8 Complementary Feeding

Complementary feeding is the process of introducing solid and semi-solid foods alongside breast milk from 6 months of age.

80.8.0.1 Principles

  1. Timely introduction at 6 months.
  2. Adequate — providing sufficient energy, protein, and micronutrients.
  3. Safe — hygienic preparation and storage.
  4. Appropriate — culturally acceptable, age-appropriate texture.

80.8.0.2 Common Complementary Foods in Ghana

  • Mashed yam, rice, or maize porridge with beans, fish, or groundnuts.
  • Fortified cereals, fruits, and vegetables.

80.8.0.3 Feeding Frequency

Age (months) Breastfeeds Meals/day Snacks
6–8 On demand 2–3 1–2
9–11 On demand 3–4 1–2
12–24 On demand 3–4 1–2

80.9 Nutritional Assessment

A comprehensive nutritional assessment includes anthropometry, dietary history, and clinical examination.

80.9.1 Anthropometric Measures

Measure Purpose Indicators of Malnutrition
Weight-for-age Growth monitoring Underweight
Height/length-for-age Chronic malnutrition Stunting
Weight-for-height Acute malnutrition Wasting
MUAC Screening in 6–59 months <12.5 cm indicates wasting

80.9.2 Clinical Assessment

  • Look for signs of deficiency: pallor, oedema, hair changes, skin lesions, angular stomatitis, goitre, rickets.

80.9.3 Dietary Assessment

  • 24-hour recall, food frequency questionnaire.
  • Identify inadequate intake or inappropriate feeding practices.

80.10 Common Nutritional Disorders

80.10.1 1. Protein–Energy Malnutrition (PEM)

80.10.1.1 Types

  • Marasmus: severe wasting, due to calorie deficiency.
  • Kwashiorkor: protein deficiency with oedema.

80.10.1.2 Clinical Features

Marasmus Kwashiorkor
Severe wasting Oedema (especially feet, face)
Alert but irritable Apathetic, moon face
No oedema Dermatosis, sparse hair

80.10.1.3 Management

  1. Stabilization phase (1–2 days): Treat hypoglycaemia, hypothermia, dehydration, infections.
  2. Transition phase (2–7 days): Gradually increase feeding.
  3. Rehabilitation phase: Catch-up growth using F-100 or locally fortified diets.
  4. Provide micronutrient supplements (vitamin A, folate, zinc).

80.10.2 2. Micronutrient Deficiencies

80.10.2.1 a) Iron Deficiency Anaemia

  • Most common deficiency globally.
  • Causes: inadequate intake, blood loss, infections (hookworm, malaria).
  • Features: pallor, lethargy, poor cognition.
  • Management: iron supplementation, dietary education.

80.10.2.2 b) Vitamin A Deficiency

  • Causes xerophthalmia, night blindness, increased infection risk.
  • Prevention: vitamin A supplementation every 6 months (per national guidelines), foods like mango, palm oil, liver.

80.10.2.3 c) Iodine Deficiency

  • Causes goitre, cretinism, developmental delay.
  • Prevention: universal salt iodization.

80.10.2.4 d) Zinc Deficiency

  • Causes growth retardation, diarrhoea, impaired immunity.
  • Prevention: dietary zinc and supplementation in diarrhoeal disease.

80.10.2.5 e) Vitamin D Deficiency

  • Causes rickets in children.
  • Prevention: sunlight exposure, fortified foods.

80.11 3. Overnutrition and Childhood Obesity

  • Increasingly common with urbanization and sedentary lifestyles.
  • Associated with diabetes, hypertension, dyslipidaemia.
  • Prevention: promote physical activity, reduce sugary and processed foods.

80.12 Prevention of Malnutrition

  1. Promote exclusive breastfeeding and appropriate complementary feeding.
  2. Routine growth monitoring and promotion (GMP).
  3. Micronutrient supplementation and fortification programs.
  4. Nutrition education for caregivers.
  5. Control of infections (immunization, deworming, malaria prevention).
  6. Food security and poverty reduction initiatives.

80.13 Nutrition in Special Conditions

80.13.1 Preterm Infants

  • Require higher protein and energy intake.
  • Use fortified breast milk or preterm formulas.

80.13.2 Children with Chronic Illness

  • Monitor growth closely (e.g., in congenital heart disease, HIV, cystic fibrosis).
  • Supplement calories and micronutrients.

80.13.3 HIV-Infected Children

  • Require increased caloric intake (10–30% higher).
  • Nutritional counselling and food support are vital.

80.14 Nutritional Counselling and Health Promotion

  • Educate caregivers on balanced diets using local foods.
  • Encourage family meals and regular feeding schedules.
  • Monitor and discuss growth charts during child welfare visits.
  • Address myths and misconceptions around feeding (e.g., withholding protein in diarrhoea).

80.15 Key Takeaways

  • Nutrition is critical for child survival, growth, and development.
  • Exclusive breastfeeding for 6 months, followed by appropriate complementary feeding, is essential.
  • Malnutrition may present as undernutrition or overnutrition.
  • Prevention strategies include education, supplementation, and infection control.
  • Health professionals must advocate for and monitor good nutrition in all children.

80.16 Suggested References

  1. World Health Organization. Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. WHO, 2009.
  2. Ghana Health Service. Infant and Young Child Feeding Policy and Strategy, 2021.
  3. UNICEF. The State of the World’s Children: Nutrition Edition, 2023.
  4. World Health Organization. Pocket Book of Hospital Care for Children, 3rd Edition, 2023.
  5. Black RE et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2021;397(10283):138–154.