The recent WHO/UNICEF review of complementary feeding in developing countries recognized that iron and zinc requirements may be difficult to meet from nonfortified complementary foods.1 This may be compounded by iron and zinc deficiency in mothers,2 predisposing to deficiency in young and especially low birth weight infants.3 Diarrheal illnesses and helminthiasis may increase micronutrient requirements. Figure 1 shows plasma levels for retinol-binding protein and zinc among young infants presenting with diarrhea in Karachi, Pakistan, indicating that plasma zinc concentration was significantly lower among those who were considered “small” at birth.
Although low rates of exclusive breastfeeding are a major predisposing factor to high infant morbidity rates, delayed introduction of suitable complementary foods, sometimes to beyond 12 months of age, is another contributory factor to malnutrition.3Table 1 summarizes complementary feeding practices in Pakistan; complementary foods were often introduced late and in too small amounts.4–23 The majority of culturally acceptable and affordable complementary foods are plant- and cereal-based with relatively high phytate content which decreases iron and zinc bioavailability.24Tables 2 and 3indicate the iron, zinc, and phytate content of the complementary foods most commonly consumed by young infants in Pakistan, as well as the estimated daily intakes and absorption from these diets.25–29 The intakes were barely sufficient to meet requirements for growth, and replenishment of depleted body stores. Various dietary strategies are available eg, improved bioavailability of iron and zinc by fermentation and malting of cereal-based staples, adding vitamin C to increase iron uptake, fortification of complementary foods, and maternal/infant supplementation. These strategies require evaluation in large-scale effectiveness studies.
Research Issues for Improving Iron and Zinc Intake From Complementary Foods
The following merit further effort:
The effect of maternal iron and zinc supplementation in pregnancy on micronutrient needs of young infants.
An evaluation of exclusive breastfeeding for 6 months on micronutrient, especially iron, status in diverse populations, particularly among those with high rates of maternal malnutrition and low birth weight.30
Qualitative studies of diet preferences for feeding young infants in traditional populations.
Effectiveness studies to assess impact of soaking, germination, or fermentation of foods on bioavailability of iron and zinc from home-available diets.
Impact of improving intake of citrus fruits and fermented milk (yogurt) on iron and zinc status in infancy.
Fortification of dietary staples with iron or zinc (eg, iron supplementation of wheat flour, low-phytate maize). Alternatively, production of genetically modified staples eg, rices with improved micronutrient content and bioavailability.
Evaluation of multiple micronutrient supplements in developing countries in comparison with balanced food-based approaches such as with multimixes.
- WHO/UNICEF. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: WHO; 1998. WHO/NUT/98.1
- Kilbride J,
- Baker TG,
- Parapia LA,
- Khoury SA,
- Shuqaidef SW,
- Jerwood D
- Rahimtoolah RJ, Qureshi AF. A Nutrition Survey in Mahmoodabad, Karachi (1976–1979). Final Report. Karachi, Pakistan: Pakistan Science Foundation; 1979
- Ahmad A. Collaborative Study on Infant Feeding and Weaning Practices in Some Countries of Eastern Mediterranean Regions of WHO (EMRO). World Health Organization/EMRO; 1982
- Mahmood S. Breastfeeding in Pakistan. Karachi, Pakistan: Report Planning & Development Division, Government of Pakistan; 1984
- Latif S. A Study of the Attitudes of Fifty Young Mothers Attending a Local Private Clinic Toward Breast Feeding and Weaning Practices and Its Effect on the Infant's Health. Karachi, Pakistan: University of Karachi; 1984. MSc Thesis
- Ilyas Z. A Study of Environmental Condition and Dietary Patterns of Children Under 2 Years of Age, Suffering From Gastrointestinal Disorders and the Type of Diet Suggested by the General Practitioners in Such Condition. Karachi, Pakistan: University of Karachi; 1986. MSc Thesis
- Khan M, Lambert J. Feeding Patterns and Nutritional Status of Karachi Infants: Report for UNICEF. Karachi, Pakistan: UNICEF; 1984
- Memon IYM. Study on Health and Nutrition in Rural Karachi: Report. Karachi, Pakistan: Pakistan Council for Scientific and Industrial Research; 1986
- Nagra SA,
- Gilani AH
- UNICEF. Complementary Foods: Practices and Perceptions in Rural Baluchistan, Vol I. Quetta, Pakistan: UNICEF; 1988
- Nutrition Division, National Institute of Health, Government of Pakistan. National Nutrition Survey. Karachi, Pakistan: Nutrition Division, National Institute of Health, Government of Pakistan; 1985–1987
- Pakistan Demographic and Health Survey. MD: National Institute of Population Studies, IRD/Macro International Inc; Islamabad, 1992
- Ashraf RN,
- Jalil F,
- Khan SR
- UNICEF. Situation Analysis of Children and Women in Sindh. Sindh, Karachi: UNICEF; 1993
- Ali FM. To Compare the Weaning Practices of Educated and Uneducated Mothers. Karachi, Pakistan: University of Karachi; 1994. MSc Thesis
- Paracha PI, Khan AH. Growth Monitoring and Nutritional Status of Infants and Toddlers in North West Frontier Province, Pakistan: Report. Karachi, Pakistan: Pakistan Science Foundation; 1994
- Ministry of Health, Government of Pakistan, UNICEF and Gallup Pakistan, Government of Pakistan. Multiple Indicators Cluster Survey of Pakistan. Ministry of Health, Government of Pakistan, UNICEF and Gallup Pakistan, Government of Pakistan; 1995
- CIET International and Bureau of Statistics Government of Sindh and UNICEF. The Bond of Care: Technical Report Sindh Province. CIET International and Bureau of Statistics Government of Sindh and UNICEF; 1998
- The Asia Foundation. Taking Charge—What Families in Pakistan Can Do to Improve the Health of Mothers and Young Children: Report. The Asia Foundation; 1998
- Nutrition Cell, Planning & Development Division, Islamabad. Khan MA, Hussain T. Supplementary Weaning Food Mixes. Nutrition Cell, Planning & Development Division, Islamabad, 1981
- Gopalan C, Rama Sastri BV, Balasubramanian SC. Nutritive Value of India Foods. NIN, India Council of Medical Research, Hyderabad, India, 1996
- Pakistan Council for Scientific and Industrial Research. Food Composition Tables for Pakistani Foods. Peshawar, Pakistan: University of Agriculture; 1988
- World Health Organization. Zinc absorption and bioavailability. Trace Elements in Human Nutrition & Health. Geneva, Switzerland: World Health Organization; 1996:87–92
- Yip R, Dallman PR. Iron. In: Ziegler EE, Filer LJ, eds. Present Knowledge in Nutrition. Washington, DC: ILSI; 1996:277–289
- Dewey KG,
- Cohen RJ,
- Rivera LL,
- Brown KH
- Copyright © 2000 American Academy of Pediatrics