Iron & Cognition

Iron & Cognition
Dr.Mahesh Hiranandani
Medical Director, Kare Mother & Child, PKL

Learning Objectives
Neurodevelopment Process and Role of Nutrition
Iron and Cognition: An Intricate Link
Section 3
Section 2
Section 1
Micronutrients as Foods for Brain: Iron
Fortification for Brain Development

Neurodevelopment Process and Role of
Nutrition

Case 1
B 8 month Girl R/O PKL
Failure to thrive
Regression of motor milestones
Born by LSCS( Short stature, Anemia) to G4 P2
B wt 2.7 kg OFC 34 cms
Exclusively breast fed till 7mths
No inclination to eat semisolids.
O/E Wt 5.6 kg OFC 41cms Length 65cms
Pallor+++ Coarse skin Pigmented patches on back
Liver 3cms Spleen NP
Soft systolic murmur
Mild hypotonia of all limbs
Irritable
Could sit with support, Head lag & shaky weight bearing

Initial clinical impression
Malnutrition Grade II Severe Anemia
Hypotonia Cause ? Anemia ?? White matter degeneration
Ix
Hb 4.8gm PBF Microcytic hypochromic anemia Retic 6%
Hb electr WNL Serum Iron studies s/o severe iron depletion
Rx
Packed cell trasfusions 2 Post BT Hb 8.9Gm
Oral Iron 4mg/kg
Semisolid diet
FU
Could sit unaided, no head lag, playful & was eating like…..

Timeline of Major Events in Neurodevelopment
Number of Synapses in Human Brain2
1. Nyaradi A, et al. Front Hum Neurosci. 2013 Mar 26;7:97.
2. Stiles J, et al. Neuropsychol Rev. 2010;20:327-348.
6-24
Months
of Age
Perinatal period
Mature cortical
neurons1
2 Years of age
Peak synaptic
development1
Preschool age
Synaptic density
reaches adult level1

Cognitive Development Peaks During Early Childhood
Time courses for Synaptogenesis and Cognition1
Brain volume doubles during first year of life and reaches 80%–90% of adult
volume by age two. Environmental and nutritional insults during this sensitive period
alter neurodevelopment.3
First Year
Memory performance is directly related to the size of hippocampus

Is Myelination crucial for Cognitive development ?
Myelination is important for efficient signal transmission and
information processing
0-3 Months
Process initiated at the
base of brain
6 Months
Myelination of internal
capsule and corpus
callosum
8-12 Months
Myelination of frontal,
parietal and occipital
lobes
Stages of Myelination During Infancy
Paterson SJ, et al. Neurosci Biobehav Rev. 2006;30(8):1087-1105.
Advanced myelination in infants may lead to improved and earlier cognition than
those with less developed myelination

Development of Synapse (Intelligence)
Repeated experiences Use it or Lose it

Radlowski EC, et al. Front Hum Neurosci. 2013;7:585.
Important Functions of Iron
Haemoglobin formation
Myoglobin formation
Gene transcription
Cellular enzyme reactions
Oxidation-reduction actions
Neurogenesis
Dendrite growth
Myelination
Synaptogenesis
Neurotransmitter synthesis
Role of Iron
Infant below 6 months cannot regulate iron
transport across blood –brain barrier.
Insults in this period is detrimental to brain
development.

Early Nutrition Fosters Intelligence
Human brain reaches 80% of its adult weight during initial 2 years
of life and is vulnerable to dietary deficiencies1
DNA: Deoxyribonucleic acid
1. Nyaradi A, et al. Front Hum Neurosci. 2013;6;7:97.
2. Rosales FJ, et al. Nutr Neurosci 2009;12(5):190-202.
Role of Nutrition in Cognitive Development
Proliferation
of cells1
Synthesis of
DNA 1
Promote
hormone and
neuro-
transmitter
metabolism 1
Maintain
enzyme
systems in
the brain1
Modify gene
structure
enabling
brain
growth2
Forms basic
structural
components
of synapses
and
neuronal
cell-bodies2
Increased demand for omega3 fatty acids, IRON ,Vit B12,Zinc & IODINE

16
25
40
67
0
20
40
60
80
100
Infant (0-12
months)
Children (1-5
years)
Industrialised Countries Developing Countries
Percentage(%)
Prevalence of Iron Deficiency Anaemia in
Industrialised and
Developing Countries3
India Health Report: Nutrition (2015)3
50% of children are anaemic in almost all
states of India
NFHS-4 (2015-2016)2
Alarming Rise in Iron Deficiency in Infants and Young Children
Indian children aged 1-3 years consume only one-third of the RDA for iron3
69.5%
Children 6-59 months
old with anemia
Premature babies Infant of diabetic mothers

Iron Deficiency: Contribution to hidden hunger
Iron is the most common micronutrient deficiency
affecting children in developing countries1
Specifically common in the first two years of life
due to
Maximum demand
Inadequate dietary
intake2
Irreversibly affects cognitive, motor, and emotional
development even without anaemia2,3
ID with no anaemia also causes significant cognitive delay

The Three Units of the Human Brain
20
1. The Archipallium
or primitive
(reptilian) brain
2. The Paleopallium
or intermediate (old
mammalian) brain
3. The Neopallium,
also known as the
superior or rational
(new mammalian)
brain

Cognition
‘The mental processes by which knowledge is acquired.
These include perception, reasoning, acts of creativity,
problem solving, and possibly intuition.’
Oxford Concise Medical Dictionary. Oxford University
Press, 2002
Iron and Cognition:
An Intricate Link

• Are babies ill equipped “Subhuman” creatures…???
• Sigmund Freud : Theorised that a child was not
mature enough to feel or experience meaningfully
until 2nd year.
The Secret Life Of The Unborn Child (1981) VERENY
• The fetus is a hearing, sensing, feeling being
WHEN DOES THE FETUS DEVELOP 5 SPECIAL SENSES?

Different principles for body
growth and brain growth
At four years of age this animal
weighs 1 ton but its brain weighs
only 350g
Brain Growth in HUMAN :
The newborn brain weighs 400 grams. At one year
of age the brain weighs 1,000 grams. By 2 years of
age the brain has reached 80 percent of its adult
size. By 18 years of age the brain has reached its
adult weight of 1400 grams.

Early primates ………Purely Satwik

Influenced by others around them…and took to
meat eating

3 million years ago...Dietary choices transformed

And is feasting till date ………
Meat could have been a
worm, caterpillar or
termite. It wasn’t
necessarily to be Kasauli
broilers meat ”

Evolution of human race over 3 million years
Appreciate the head size, muscle mass, curvature of spine & size of jaw

Brain size : Humans & their ancestors
And see how did they leave behind their ancestors

Optimum Iron Status Affects Long-Term Cognition
1. Walter T. Food and Nutrition Bulletin. 2003;24(4)(Suppl):S104-S110.
2. Algarin C, et al. Dev Med Child Neurol. 2013; 55(5): 453–458.
At 5 years of age, iron deficiency anaemia led to lower scores on many of the
cognition tests compared with children having higher haemoglobin levels during
infancy
A 5-point drop in intellectual quotient (IQ) was consistent in both studies
Iron deficiency anaemia in infancy was associated with
slower reaction times and poorer inhibitory control at 8
to 9 years even after iron therapy2

Iron-Deficiency and Psychomotor Development
Pala E, et al. Food Nutr Bull. 2010;31(3):431-5.
A study by Pala et al. assessed the impact of iron deficiency
anaemia on psychomotor development in childhood
DDST-II scores were abnormal in 67.3%
of subjects with IDA and in 21.6% with
iron deficiency
Difference in percentage of abnormal
scores from the control group was
significant for children with IDA
(p<0.01)
Iron-deficiency anaemia may be linked to impaired psychomotor development
during childhood
DDST=Denver II Developmental Screening Test, IDA=iron deficiency anaemia

Iron Gaps are Huge From 6-23 Months of Age
Gaps to be filled by complementary foods for a breastfed
child 12–23 months
World Health Organization. Complementary feeding: Report of the global consultation [Internet]. 2001
0
25
50
75
100
Energy Protein Iron Vitamin A
Percentageofdailyneeds(%)
Nutrient
Gap
Provided by 550 ml
Breast milk

Section 3
Food Fortification to Bridge Micronutrient Gaps

Meat efficiency index
18 mg RDA iron exchange foods

Children in developing
countries are fed on plant-
based complementary
foods that are rarely
fortified with iron2
Iron needs of children in
resource-poor families are
nearly impossible to meet
without fortification3
High Iron Requirements in Young Children Warrants Fortification
1-6 years
Body iron content is doubled; high iron needs2
6-12 months
Low iron status due to low dietary iron1
4-6 months
Increased iron requirements2
Immediately after birth
High iron accumulation in brain1
1. Radlowski EC, et al. Front Hum Neurosci. 2013;7:585. 2. Abbaspour N, et al. J Res Med Sci. 2014; 9(2):164–174.
3. Kotecha PV, et al. Indian J Pediatr. 2010;77(4):41948–424.

Supplementation Vs. Fortification
Supplementation1–3 Fortification1–3
Delivery
Requirements
Requires an exhaustive delivery
system
Suitable food vehicle and organised
processing facilities
Time Frame A temporary or short term
approach
A medium–to–long–term approach
Coverage Reaches only particular
populations receiving the
service
Reaches all segments of target population as
the nutrients are imbibed in regular food
sources
Compliance Requires sustainable
motivation of participants
Does not require intensive cooperation, no or
minimal behaviour change is required
Cost Of
Maintenance
Relatively high financial
resources needed
Low cost compared to supplementation
Potential
Downside
Over–supplementation may be
possible
No such incidences
1.The Micronutrient Initiative. Micronutrient Fortification of Foods [Internet]. 1998 [cited 30 July 2015]. 2.Berry J, et al. Taken with a Grain of Salt? Micronutrient
Fortification in South Asia [Internet]. 2012 [cited 30 July 2015]. 3.Mora J. American Society for Nutritional Sciences. 2003;133:2990S–2993S. 4. Das J, et al.
Systematic Reviews. 2013;2(1):67.
Fortification is a sustainable approach to help infants meet their
nutritional requirements4

Current evidence
indicates that food
fortification is a cost-
effective strategy for
addressing iron
deficiency, especially in
infants and young
children1
Micronutrient Fortification for Infants and Young Children
Should enable micronutrient to reach target
population1
Should not impose changes in dietary pattern1
Should be in a bioavailable form2
Should use centrally processed food vehicles2
Should not affect sensory properties of foods2
An ideal food fortificant

1. Detzel P, et al. Ann Nutr Metab. 2015;66(suppl 2):35–42.
2. Abbaspour N, et al. J Res Med Sci. 2014;19(2):164–174.
Iron Fortification for Infants is Safer Compared
to Supplementation
Fortified complementary foods has shown to be safer and more effective compared
to supplements for infants and young children1
Much lower iron
doses are used
compared with
supplementation
Similar to
physiological
environment and
reduced
gastrointestinal
side effects
Safe strategy for
regions prone to
malaria

Iron Fortification Improves Iron Status in Young
Children
1. Liu P et al. Indian J Comm Health. 2014;26, Suppl S1:59-74S.
2. Sazawal S, et al. J Health Popul Nutr. 2014;32(2):217-226.
3. Eichler K, et al. BMC Public Health. 2012;12:506.
• Iron fortification
in children
improved iron
and
haemoglobin
status in all
studies
Literature survey
in India1
• Fortified
complementary
food for 6
months
significantly
increase in
haemoglobin
levels
North Indian study
(6-23 months)2
• Fortified milk and
cereal-based
products
effectively
reduced anaemia
in developing
countries
compared to non-
fortified products
Meta-analysis
(n=5468;
6 months to 5 years)3

Iron Fortification Improves Cognition in School Children
Fiorentino M, et al. 2015. EJNFS, 5(5): 769-770.
Iron status and stunting are important determinants of cognitive
performance in school children
• Cognitive performance was significantly correlated to
total body iron at baseline and endline (P<0.05)
• Multimicronutrient fortified rice improved cognitive
performance in all children (P<0.001)
Results of Cluster-randomised, double-blinded, placebo-controlled trial (n=9500)

Iron fortification programmme World wide
• Vietnam
Fish sauce 1mg/ml ID & IDA improved in 6 mths.
• China
Iron fort Soya sauce..10000 children....in 3 mths.
• South africa
22% IDA to 5% .....Iron fort curry powder in 2 yrs

Iron fortification programme in India
• India Integrated Food Fortification Rajasthan
• 4,500 metric tonnes of wheat flour,
• 8,900 metric tonnes of oil and
• 41,000 metric tonnes of milk
• With Iron B12,FA, Vit-A,D
• reaching about 15 million people

Supplement iron pending a launch of
effective Iron Fortification programme
• All LBW & preterm to get IRON from 2 mths.
• Others to get IRON from 4-6 mths onwards
• Explain the absolute necessity of Iron supp.
• Insist on milk free complimentary foods.
• Encourage heme sources of Iron.
• Calculate number of bottles/month.
• Check Compliance...Warn about side effects
• Continue till 2 yrs....

Babaji Palwankar Baloo
BABAJI PALWANKAR BALOO (Born: March 1876, Died: July 4, 1955)
He is the father of Indian spin bowling who is remembered for his heroics on the field in the first
half of 20th century. It is a pity that he never got to play any international Test match because by
the time India played its first Test, Baloo was in his mid-50s.
But take a glance into his first class record and you will be amazed how an outcast Dalit of that
time could play against the English specialists and take 179 wickets in just 33 matches at an
astounding average of just 15.21, which not even the Hall of Famers that came after
him have come even close to achieving.

He writes "C.K. Nayudu is toppled from his
pedestal as India's first great cricketer as Guha pins
the badge on the little-known Dalit cricketer
Palwankar Baloo, who preceded him by many
years. The left arm slow bowler, who played very
successfully for the Hindus in the Quadrangular,
learnt his cricket by occasionally bowling at the
nets of a cricket club where he was paid to sweep
and roll the pitch. When he played for his first team
(the Poona Hindus), he was more than equal on the
field but less than equal off it (being served his
lunch on a separate table and his tea in disposable
matkas)".
Dr. Ambedkar was Inspired & Influenced by Baloo:
Dr.Bhimrao Ambedkar regarded Ballo as a Great
Hero of dalits and a great of Hero of Indian cricket.
Baloo should be respected and placed in the top of
Indian cricket history. The greatest of scholars and
humanitarians our father Bhimrao Ambedkar
himself was absolutely inspired by the fine qualities
and talents of Baloo.

Dashrath Manjhi’s hammer, chisel, and crowbars
which he purchased after selling his goat and land
After he had chipped at the
mountain for 10 years, people
saw the cleft
He had carved out a road 360 feet long, 30 feet wide. After 22 years, Dashrath Das Manjhi, the
outcast landless labourer had conquered the mountain: he had carved out a road 360 feet long,
30 feet wide. Wazirganj, with its doctors, jobs, and school, was now only 5 kilometers away.
People from 60 villages in Atri could use his road. Children had to walk only 3 kilometers to reach

High prevalence rate of anaemia is reported in Indian children aged 6 -59
months
Volume of the brain doubles during the first year of life and reaches 80%–
90% of adult volume by age two, making young children vulnerable to
deficiencies
Nutrient gap for iron is the largest during transition from
breastfeeding to complementary feeding
Iron deficiency in infants and young children impacts cognition,
learning, memory, and immunity
Food fortification is an assured means of addressing micronutrient
deficiencies, especially in infants and young children
Key Messages

Thanks for your cognitive attention

Child Mortality is Just the Tip of the
Iceberg!
• UNICEF. Improving Child Nutrition. The achievable imperative for global progress. 2013.
Child mortality
Hidden hunger
Impaired mental
abilities
Stunting
Underweight
Lost productivity
Recurrent
illnesses
Undernutrition leads to:
• Underweight
• Hidden hunger
• Stunting
• Impaired mental abilities
• Lost productivity
• Recurrent illness

Hidden Hunger is Subtle, Insidious
and Devastating
Hidden hunger (micronutrient deficiencies) affects 1 in 3 people
worldwide.
• Grebmer KV, et al. Global hunger index: The challenge of hidden hunger. [Internet] International Food Policy Research Institute. 2014.
Global Prevalence of Key Micronutrient Deficiencies1
Iron Almost 1.6 billion
Vitamin A 190 million under–5; 19 million pregnant women
Zinc 1.2 billion
Iodine 1.8 billion
The effects of hidden hunger from conception to the age of two are detrimental to
physical and cognitive capabilities of a child.

BENEFITS
Move towards a
knowledge
economy
Improve
cognition
Foster
intelligence
Food and tonic
for brains
Providing
support to
the head
helps in
improved eye
contact
Day 2 of life
with birth
asphyxia
Importance of Early Interventions in the Newborn Period
Consequent
improvement
in brain
wiring and
cognition
ILLUSTRATION
67

Infants and Young Children are
Vulnerable to Hidden Hunger
• 70% infants (6–59 months) anaemic1
Iron
• 51%– 82% of children(1–3 years) do not meet even 50% of
RDA2Calcium
• 30%–96%of children (1–3 years) do not meet even 50% of
RDA2Vitamins A, C
• ~40% of children (12–59 months) are vitamin B12 deficient3
Vitamin B12
• ~60% of children (12–59 months) are folic acid deficient (<4
ng/mL)3Folic acid
• Deficiency results in approximately 800,000 child deaths every
year4Zinc
1. Ministry of Health and Family Welfare Government of India. National Family Health Survey (NFHS–3) India 2005–06.
2. National Nutrition Monitoring Bureau. National Institute of Nutrition. Diet and Nutritional status of rural population, prevalence of hypertension and diabetes among adults and infants and young
child feeding practices–Report of Third Repeat Survey 2012.
3. Kapil U, et al. Biomed J. 2015;38(2):162.
4. UNICEF. Micronutrient Sprinkles Reduce Anemia among Young Children – Fact Sheets.

Micronutrient Fortification on Growth and
Cognitive Performance in Indian Schoolchildren
Muthayya S, et al. Am J Clin Nutr. 2009;89:1766–1775.
Effect of the intervention on the Mental Processing
Index (MPI) after 12 months compared with the
effect expected from a regression model of MPI
scores and age at baseline
* 2-by-2 factorial, double-blind, randomized controlled design and included
598 children aged 6–10 years.
0.0
0.2
0.4
0.6
0.8
1.0
High Low High Low
Improvementat12months(z-score)
Expected
improvement
over 12
months
High Low Micronutrient treatment
n-3 fatty acid treatment
Micronutrient fortification can help improve certain aspects of cognition and
growth in children with nutritional deficiencies
High micronutrient
fortification caused improved
short-term memory at 6
months and significantly
improved linear growth at 12
months (0.19 cm; 0.01, 0.36)
vs. fortification with a low
concentration of
micronutrients

Percentage of a day's needs at 12–23 months that can be met by breast milk and a
midday meal of rice + beans + orange.
Addition of a fruit has a small effect on the energy and protein gaps, improves the absorption of iron in the
rice and beans and has only a small effect on the iron gap and vitamin A gap.
Home Based Meals may not Bridge the
Nutrient Gap (1/6)
• World Health organization. Complementary feeding: Family foods for breastfed children [Internet]. 2000 [cited 22 July 2015]. Available at:
http://apps.who.int/iris/bitstream/10665/66389/1/WHO_NHD_00.1.pdf?ua=1&ua=1. Accessed on: 18 December 2015.
71

Section 3
Food Fortification to Bridge Micronutrient
Gaps

Supplementation Vs. Fortification
Supplementation1–3 Fortification1–3
Delivery
Requirements
Requires an exhaustive delivery
system
Suitable food vehicle and organised
processing facilities
Time Frame A temporary or short term
approach
A medium–to–long–term approach
Coverage Reaches only particular
populations receiving the
service
Reaches all segments of target population as
the nutrients are imbibed in regular food
sources
Compliance Requires sustainable
motivation of participants
Does not require intensive cooperation, no or
minimal behaviour change is required
Cost Of
Maintenance
Relatively high financial
resources needed
Low cost compared to supplementation
Potential
Downside
Over–supplementation may be
possible
No such incidences
1.The Micronutrient Initiative. Micronutrient Fortification of Foods [Internet]. 1998 [cited 30 July 2015]. 2.Berry J, et al. Taken with a Grain of Salt? Micronutrient
Fortification in South Asia [Internet]. 2012 [cited 30 July 2015]. 3.Mora J. American Society for Nutritional Sciences. 2003;133:2990S–2993S. 4. Das J, et al.
Systematic Reviews. 2013;2(1):67.
Fortification is a sustainable approach to help infants meet their nutritional
requirements4

Can Fortification Make a Difference?
• WHO. Guidelines on food fortification with micronutrients [Internet]. 2006 [cited 31 July 2015].
Type of fortification used depends on factors like national circumstances,
compliance, coverage required, effectiveness and practicality
Mass fortification
Targeted fortification
Market–driven fortification
Home fortification

• Sazawal S, et al. J Health Popul Nutr. 2014;32(2):217–226.
Fortified Complementary
Feeds may be a Better Choice
Complementary food fortified with
multiple micronutrients had a
higher compliance compared to
multiple micronutrient sprinkles
(micronutrients such as iron, folic
acid zinc, B vitamins, vitamins A, D,
E, C, etc.)
Compliance to Fortified Complementary Food
Compared to Sprinkles
81.40%
63.90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Fortified
complementary foods
Sprinkles
Compliancerate(%)
CF: Complementary feeding

Fortified Complementary Feeds may Help
Reduce Anaemia in
6 to 24-Month-Old Children
• Sazawal S, et al. J Health Popul Nutr. 2014;32(2):217–226.
1.29
0.37
0.23
0
0.5
1
1.5
Hb (g/dL)
MeanchangeinHbg/dL
Fortified complementary food
Sprinkles
Control
CF: Complementary feeding
67
27
22
0 20 40 60 80
Fortified complementary
feed
Sprinklers
Control
Percentage
Groups
Percentage reduction in children
with anaemia

Reference List (1/2)
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2. Algarin C, Nelson CA, Perirao P, et al. Iron-deficiency anaemia in infancy and poorer cognitive inhibitory control at age 10 years. Dev Med Child
Neurol. 2013; 55(5): 453–458.
3. Bailey RL, West KP, Black RE. The Epidemiology of Global Micronutrient Deficiencies. Ann Nutr Metab 2015;66(suppl 2):22–33.
4. Black MM. Micronutrient deficiencies and cognitive functioning. J Nutr. 2003;133(11 Suppl 2):3972S-3931S.
5. Conclusions and recommendations of the WHO Consultation on prevention and control of iron deficiency in infants and young children in
malariaendemic areas . Available at: http://www.who.int/nutrition/publications/micronutrients/FNBvol28N4supdec07.pdf Accessed date: 11
February 2016.
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study. J Nat Sci Biol Med. 2014;5(1):158-163.
7. Detzel P, Wieser S. Food fortification for addressing iron deficiency in Filipino children: Benefits and Cost effectiveness. Ann Nutr Metab
2015;66(suppl 2):35–42.
8. Eichler K, Wieser S, Ruthermann I, et al. Effects of micronutrient fortified milk and cereal food for infants and children: a systematic review. BMC
Public Health. 2012;12:506.
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http://www.who.int/nutrition/publications/micronutrients/9241594012/en/ Accessed date: 17 January 2016.
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18. Marin I, Kipnis J. Learning and memory and the immune system. Learn Mem. 2013 Sep 19;20(10):601-606.

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2016.
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28. Sahu SK, Kumar SG, Bhat BV, et al. Malnutrition among under-five children in India and strategies for control. J Nat Sci Biol Med. 2015;6(1):18-
23.
29. Sazawal S, Dhingra P, Dhingra U, et al. Compliance with home-based fortification strategies for delivery of iron and zinc: its effect on
haematological and growth markers among 6-24 months old children in North India. J Health Popul Nutr. 2014;32(2):217-226.
30. Stiles J, Jernigan TL. The basics of brain development. Neuropsychol Rev. 2010;20:327-348.
31. Un.org.in. First 1,000 Days » United Nations in India [Internet]. 2015 [cited 28 July 2015]. Available from: http://www.un.org.in/task-
teams/first-1000-days
32. UNICEF-India. Infant and Young Child Feeding. Available at: http://unicef.in/Whatwedo/7/Infant-and-Young-Child-Feeding.
33. Walker SP, Chang SM, Powell CA, et al. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and
education in growth-retarded Jamaican children: prospective cohort study. Lancet. 2005;366(9499):1804-1807.
34. Walter T. Effect of iron-deficiency anaemia on cognitive skills and neuromaturation in infancy and childhood. Food and Nutrition Bulletin.
2003;24(4)(Suppl):S104-S110.
35. World Health organisation. Complementary feeding: Family foods for breastfed children [Internet]. 2000 [cited 22 July 2015]. Available from:
http://apps.who.int/iris/bitstream/10665/66389/1/WHO_NHD_00.1.pdf?ua=1&ua=1

Healthy and Abused Brain
83
Front
Back
Front
Back
Temporal
lobes
Temporal
lobes
Most activity Least activity
Illustration based on actual PET scan images - Center for Disease Control and Prevention
Healthy brain An abused brain

If both optic tracts are damaged, the person has no visual
perception but light related diurnal rhythm is still possible, if
visual information can get to the pineal body via the small
suprachiasmatic nucleus (supra=above, nucleus above the
chiasm).

Early experiences affect the
development of brain
architecture, which provides the
foundation for all future learning,
behavior, and health
Brains are built over time, from
the bottom up
Brain architecture is comprised
of billions of connections
between individual neurons
across different areas of the
brain

 Growth retardation affects about 30% of children younger than age 5
years in developing countries and is associated with poor development.
 A trial of nutritional supplementation and psychosocial stimulation
in stunted children aged 9-24 months. Non-stunted children were also
assessed. Both types of intervention improved development. We now
present the effects of early interventions on cognition and education in
103 of the 129 stunted children and compare them with 64 of the 84
non-stunted children now aged 17-18 years.
Effects of early childhood psychosocial stimulation and
nutritional supplementation on cognition and education
in growth-stunted Jamaican children: prospective cohort
study
Lancet. 2005 Nov 19;366(9499):1804-7
No significant effects of nutritional supplementation were recorded. Compared
with no intervention, stimulation resulted in higher full scale IQ scores

• During the second trimester, the unborn baby will likely start sampling
the flavor buffet in the amniotic fluid – flavored by the food and
beverages that mother has consumed in the past few hours.
• By 20th week the fetus can hear whoosh sounds of blood in
vessels,gurgling in the stomach & mothers heartbeat.
• Vision is the last sense to develop in the fetus. because for about the
first 26 weeks of pregnancy, baby’s eyelids remain closed for the
retinas to fully develop. Around week 26, baby’s tiny eyelids open and
even begin to blink! Newborns have all the eye structures necessary to
see, but they still need to learn to use them by developing skills such
as focusing, teaming their eye movements, recognizing depth,
developing eye-hand coordination, and making spatial judgements.

Factors: Growth and Nutrition
• Growth
 Growth faltering observed between 3-6 months
 WHO/CDC deceleration in weight/length 3-12 months in breast fed
infants
 “Weanling dilemma”
• Nutrition
 Energy, Iron, Zinc

Zinc
• AI
 0-6 months: 2 mg/d
 7 months-3 years: 3 mg/d
• Breast milk content declines from 8-12 mg/L in first month to
1-3 mg/L at 4-6 months
• Bioavailability of Zn greater in breastmilk than formula
• Endowment at birth, birthweight, maternal status and growth
rate

• Mother is her child’s principal instructor even before
the baby comes out……
• A child learns & recalls what is heard in womb…..
• The fetus registers what makes the mother happy
and what brings her unhappiness.
• The foundation of human character is laid in the
womb, through the pregnancy tenure.
Our earliest teacher is the mother.

Requirement from Complementary
Feeding
• After 6 months most breastfed infants need
complementary foods to meet DRIs for energy, iron,
vitamin D, vitamin B6, niacin, zinc, vitamin E, and others
• In US Iron and vitamin D need special emphasis due to
prevelance of deficiency
• Little room for foods with low energy density in the diets
of infants

• There is no doubt that human evolution has been linked to
meat in many fundamental ways. Our digestive tract is not one
of obligatory herbivores; our enzymes evolved to digest meat
whose consumption aided brain growth and bigger bodies.
Cooperative hunting promoted the development of language
and socialization; the evolution of Old World societies was, to
a significant extent, based on domestication of animals; in
traditional societies, meat eating, more than the consumption
of any other category of foodstuffs, has led to fascinating
preferences, bans and diverse foodways; and modern Western
agricultures are obviously heavily meat

• Killing animals and eating meat have been significant components of
human evolution that had a synergistic relationship with other key
attributes that have made us human, with larger brains, smaller guts,
bipedalism and language. Larger brains benefited from consuming
high-quality proteins in meat-containing diets, and, in turn, hunting
and killing of large animals, butchering of carcasses and sharing of
meat have inevitably contributed to the evolution of human
intelligence in general and to the development of language and of
capacities for planning, cooperation and socializing in particular. Even
if the trade-off between smaller guts and larger brains has not been
as strong as is claimed by the expensive-tissue hypothesis, there is no
doubt that the human digestive tract has clearly evolved for
omnivory, not for purely plant-based diets. And the role of
scavenging, and later hunting, in the evolution of bipedalism and the
mastery of endurance running cannot be underestimated, and
neither can the impact of planned, coordinated hunting on non-
verbal communication and the evolution of language.

• It seems that our bodies had to adjust gradually, first getting
hooked on seeds and nuts, which are rich in fats but poor in
fiber. If our ancestors ate a lot of them, such a diet would
have encouraged the growth of the small intestine (where
the digestion of lipids takes place) and the shrinking of the
caecum (where fibers are digested). This would have made
our guts better for processing meat. A seed-and-nut diet
could have prepared our ancestors for a carnivorous lifestyle
in another way, too: It could have given them the tools for
carving carcasses. Some researchers suggest that the simple
stone tools used for pounding seeds and nuts could have
easily been reassigned to cracking animal bones and cutting
off chunks of flesh. And so, by 2.5 million years ago, our
ancestors were ready for meat: They had the tools to get it
and the bodies to digest it.
•

• How Humans Became Meat Eaters
• Our earliest ancestors subsisted on plants, seeds,
and nuts. What spurred them to change their
diets so dramatically?
• By 2.5 million years ago, our ancestors were
ready for meat: They had the tools to get it and
the bodies to digest it.

98
Neurobiology
Structures tend
to be fixed by
birth, but the
connections and
functions carry
on being sorted
until early
adulthood.
Frontal lobe
Motor speech
area of Broca
Parietal lobe
Reading
comprehension area
Occipital
lobe
Sensory speech area of
Wernicke
Cerebellum
Pons
Neglect and the
brain

National Level Supplementation Programs
are Far from the Reach of Vulnerable Infants
Dismal performance of the Iron–folic acid supplementation (IFA) and National
Iron+ Initiative(NIPI) in 6 to 59 months across wealth quintiles1,2
1. Ministry of Women and Child Development Government of India. Rapid Survey on Children.2013–2014. India fact sheet. [Internet]. [cited 10 August 2015].
2. Ministry of Health and Family Welfare Government of India. Guidelines for Control of Iron Deficiency Anaemia [Internet]. 2013 [cited 22 July 2015].
Only 13% of young children (6–59 months) reportedly benefit from national level iron
supplementation programs1
13.8% 12.9% 15.8%
8.6%
15.6%
0%
20%
40%
60%
80%
100%
Total Rural Urban Lowest WI Highest WI
WI–Wealth index

Can Mass Fortification
Benefit Infants in India?
• Micronutrient Initiative and the Indian Flour Fortification
Network (FFI)1
 Flour Fortification program
• Global Alliance for Improved Nutrition (GAIN)2
 Oil fortification in Madhya Pradesh (Vitamin A and Vitamin D)
 Oil fortification in Rajasthan (Vitamin A)
 Milk fortification in Rajasthan (Vitamin A)
 Wheat fortification in Madhya Pradesh and Bihar (B vitamins, Folic
acid, Vitamin A, Iron)
 Wheat fortification in Rajasthan (Iron and folic acid)
1.Micronutrient Initiative. Food Fortification – Micronutrient Initiative [Internet]. 2015 [cited 31 July 2015]. 2.Extranet.who.int. GAIN Nutritious Foods for
Mothers and Children – Complementary food fortification – Infants and young children and lactating women (LW)|Pregnant women (PW) [Internet]. 2015
[cited 31 July 2015].
Can these approaches help provide optimal nutrition to Infants from the portions of food
they eat?

Development Factors
• Oral motor changes
• Truncal stability
• Change in gag loci from midportion to posterior
of tongue (3-7 months)
• Experiential
• Repeat exposure

Development of Infant Feeding Skills
Birth
 Tongue is disproportionately large in comparison
with the lower jaw: fills the oral cavity
 Lower jaw is moved back relative to the upper jaw,
which protrudes over the lower by approximately 2
mm.
 Tongue tip lies between the upper and lower jaws.
 “Fat pad" in each of the cheeks: serves as prop for
the muscles in the cheek, maintaining rigidity of the
cheeks during suckling.
 Feeding pattern described as “suckling”

Developmental Changes
• Oral cavity enlarges and tongue fills up less
• Tongue grows differentially at the tip and attains
motility in the larger oral cavity.
• Gag locus moves from mid-portion to posterior
tongue (3-7 months)
• Elongated tongue can be protruded to receive and
pass solids between the gum pads and erupting teeth
for mastication.
• Mature feeding is characterized by separate
movements of the lip, tongue, and gum pads or teeth

•
The Jamaican Study:
Early childhood education can compensate for
developmental delays, boost earnings and
reduce inequality
The Heckman Equation

Myelination & Cognition …Is there a link ?

Feeding Development
Age Reflexes Oral, Fine, Gross Motor Development
1-3
months
Rooting and suck
and swallow
reflexes are
present at birth
Head control is poor
Secures milk with suckling pattern, the tongue projecting
during a swallow
By the end of the third month, head control is developed
4-6
months
Rooting reflex
fades
Bite reflex fades
Changes from a suckling pattern to a mature suck with
liquids
Sucking strength increases
Munching pattern begins
Grasps with a palmer grasp after head control
Grasps, brings objects to mouth and bites them
7-9
months
Gag reflex is less
strong as chewing
of solids begins
and normal gag is
developing
Choking reflex
can be inhibited
Munching movements begin when solid foods are eaten
Rotary chewing begins
Sits alone
Has power of voluntary release and resecural
Holds bottle alone
Develops an inferior pincer grasp
10-12
months
Bites nipples, spoons, and crunchy foods
Grasps bottle and foods and brings them to the mouth
Can drink from a cup that is held
Tongue is used to lick food morsels off the lower lip
Finger feeds with a refined pincer grasp
Gessell A, Ilg FL

Nutritional Status Impacts Motor, Cognitive, and
Socioemotional Development
Hypothetical scenario where nutritional status and early experiences
mediate motor, cognitive and socioeconomic development
Prado EL, et al. Nutrition Reviews. 2014;72(4):267-284.
Physical
growth and
health
Nutritional
status
Physical
activity
Motor, cognitive, and
socio-emotional
development
Caregiver behavior,
parent-child
interaction
Brain development
and function
Level of child
interaction with the
environment

Relationship
• Feeding is a reciprocal process
that depends on the abilities
and characteristics of both
caregiver and infant/child

Maternal-Infant Feeding Diad
• Indicates hunger (I)
• Presents milk (M)
• Consumes milk by
suckling (I)
• Indicates satiety, stops
suckling (I)
• Ends feeding (M)

Iron status is central for determining immune responses in young children
Iron Status Impacts Both Immunity and Cognition
1. Das I, et al. J Nat Sci Biol Med. 2014;5(1):158-163.
2. Marin I et al. Learn Mem. 2013 9;20(10):601-6.
Iron is important for immune cell proliferation and
generation of specific immune responses to infection1
Disruption of the immune system functioning leads to
impairments in cognition and neurogenesis2

Relationship
• The feeding relationship is
both dependent on and
supportive of infants
development and
temperament.

Time course of different processes in brain development involved in
learning and memory over the first year of life*
Radlowski EC, et al. Front Hum Neurosci. 2013;7:585.
Improving Iron status is Crucial for Mental health
*Colour intensity of the bars increases as each process peaks during a specific period of time
Dendritogenesis
Synaptogenesis
Neurogenesis
Myelination
Neurotransmitter Synthesis
Birth
6 mo
1 year
3rd trimester
Perinatal period

Iron Status Determines Learning and Memory
Fretham SJB, et al. Adv Nutr. 2011; 2(2): 112–121..
Direct Effects
Neuronal metabolism
Gene expression
Birth 1 year 8-14 years 20+ yearsConception
Human
Rapid Hippocampal
Development
Adolescence AdulthoodWeaning
Late Gestation Neonatal
Persistent Deficits
Structure
Electrophysiology
Learning and memory
Acute Deficits
Structure
Electrophysiology
Behaviour
Extra Hippocampal
Thyroid hormone
Myelination
Dopamine
Iron deficiencyHippocampus
Indirect Effects
Mitochondrial health

Iron & Cognition

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