Desde la LME hasta la etapa
Alimentación Complementaria.
Dr. José Luis Gonzales Benavides
Gastroenterología 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.
EDUCAR
SUPLEMENTAR
FORTIFICAR
Effect size for weight growth of different
intervention strategies
Effects size for weight growth
Max
Min
Mean
1.50
1.25
1.00
0.75
0.50
0.25
0.00
-0.25
ED
FD
FD+ED
FT
EN
-0.50
Intervention strategy
ED = Education; FD = Complementary food; FD+ED = Education + complementary food; FT =
Fortification of comp. foods; EN = Increased energy density
Excluding Obatolu, 2003 (outlier)
Effect size for linear growth of different
intervention strategies
Max
Min
Mean
Effect size for linear growth
1.00
0.75
0.50
0.25
0.00
ED
FD
FD+ED
FT
EN
-0.25
-0.50
Intervention strategy
ED = Education; FD = Complementary food; FD+ED = Education + complementary food; FT =
Fortification of comp. foods; EN = Increased energy density
Excluding Obatolu, 2003 (outlier)
.
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
interventions
Kathryn G. Dewey, PhD
Seth Adu-Afarwuah, PhD
Program 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 3montholds
• 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)