Author: Stanley H. Zlotkin
Position: Head of the Division of GI/Nutrition
Institution: Hospital for Sick Children, Toronto, Ontario, Canada
E-mail: Stanley.Zlotkin@sickkids.ca
Additional Authors: Claudia Schauer, Anna Christofides, Waseem Sharieff, Melody C. Tondeur, and S. M. Ziauddin Hyder are researchers in the Programs in Metabolism and Integrative Biology at the Research Institute of the Hospital for Sick Children
Submitted Date: May 12, 2005
Published Date: June 10, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

To The Editor,

We are writing in response to the letter by Stacia Nordin. Independent of where a child is born in the world, the most appropriate feeding regimen is breast milk until six months of age followed by a weaning or complementary food [1]. It is known that breast milk provides all essential nutrients for the growing infant, except for vitamin D. It is also known that complementary foods should contribute to providing all of the essential nutrients when breast milk is no longer the sole source of nutrition after the first few months of life. However, as early as 1930, it was realized that typical complementary foods were generally poor sources of micronutrients (minerals and vitamins) and were often not sufficient to meet the micronutrient needs of growing children. For example, per 100 g, rice-based complementary foods contain about 1 mg of iron and wheat-based complementary foods contain about 0.8 mg of iron [2]. Even a meat-based complementary food, like commercial toddler beef stew contains only 1.2 mg of iron in each 170 g jar. Since the RDA for iron is 11 mg/day (for ages 7 12 months) [3], clearly a rice- or wheat-based complementary food, or even a dilute meat-based stew would not provide an adequate amount of iron to the growing infant.

Pablum, the first fortified baby food, was invented at the Hospital for Sick Children in Toronto, Canada in the 1930s [4]. Consequently, by the early 1960s, in North America, all commercially manufactured infant cereals were fortified with iron. Today, the major source of iron in the diet of a North American child is fortified commercial infant cereals. And indeed, the low rates of iron deficiency anaemia in Canada and the USA are thought to be partly a result of the wide-spread use of commercially available iron fortified cereals [5].

Another good example of a fortified food for young children in North America is fluid milk products, which are fortified with vitamin D in order to prevent the development of rickets. It is currently well accepted among nutritionists and pediatricians that most young children in North America depend on fortified foods to meet their micronutrient needs.

In most developing countries, access to commercially processed baby foods (fortified with iron) is very limited mainly due to their high cost and limited availability [6]. It is noteworthy that recent research has demonstrated that, even if dietary diversification and modification (such as soaking, fermentation and germination) strategies are used at the household level, they may not be sufficient to overcome the deficits in iron and other micronutrients [2]. As a result, other options need to be considered for young children living in underdeveloped and poor countries to ensure that all of their nutrient requirements are met [7]. The use of Sprinkles is one such option [8,9]. One of the greatest advantages of the Sprinkles concept is its emphasis on complementary food consumption because Sprinkles have to be mixed with food. When educating caregivers about anaemia and the use of Sprinkles, healthy weaning practices can be concurrently promoted to ensure the timely introduction of complementary foods at six months of age in addition to continued breast feeding (as recommended by WHO) [1]. This is an important benefit as it is well known that, in many developing countries, poor weaning practices are common [2]. As a home-fortificant, Sprinkles ensure that the food eaten contains adequate amounts of essential micronutrients. Indeed, Sprinkles are meant to improve the nutritional value of home-made baby foods, which are otherwise poor in micronutrient content. Sprinkles can enrich foods not only with iron but also with other essential micronutrients such as zinc, folic acid, vitamins A and C. In addition, as Sprinkles can be easily mixed with any home-made semi-solid foods, their use does not require any change in food practices and thus, they can be easily accepted in diverse cultural settings.

With anaemia rates as high as 80% in young children in some developing countries, current food-based strategies alone are clearly not effective. All children should have the right to eat foods that meet their nutritional needs. The use of Sprinkles is one way to help these children meet their nutrient requirements. Unfortunately, a food-based strategy alone, using locally available unfortified foods, in most circumstances is simply inadequate and may further predispose the growing child to various micronutrient deficiencies [7].

References

1. World Health Organization (2000) Malnutrition: The Global Picture. Geneva World Health Organization. Available: http://who.org
2. Gibson RS, Ferguson EL, Lehrfeld J (1998) Complementary foods for infants feeding in developing countries: Their nutrient adequacy and improvement. Eur J Clin Nutr 52: 764-770
3. Food and Nutrition Board, Institute of Medicine (2000) Dietary Reference Intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium and zinc. Washington DC: National Academy Press. Available: http://www.nap.edu/books/...
4. Tisdall FF, Drake TGH, Summerfeldt P, Brown A (1930) A new whole wheat irradiated biscuit containing vitamins and mineral elements. Can Med Assoc J 22: 166-170
5. Ramakrishnam U, Yip R (2002) Experiences and challenges in industrialized countries: control of iron deficiency in industrialized countries. J Nutr 132: 820S-824S
6. Yip R, Ramakrishnam U (2002) Experiences and challenges in developing countries. J Nutr 132: 827S-830S
7. Dewey KG, Brown KH (2003) Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr Bull 24 (1): 5-28
8. Zlotkin SH, Schauer C, Christofides A, Sharieff W, Tondeur MC, Hyder SM (2005) Micronutrient Sprinkles to Control Childhood Anaemia. PLoS Medicine 2(1):e1
9. Zlotkin SH, Christofides AL, Hyder SM, Schauer CS, Tondeur MC, Sharieff W (2004) Controlling iron deficiency anemia through the use of home-fortified complementary foods. Indian J Pediatr 71(11):1015-1019