Both encouraging feeding style and high energy density may increase energy intakes from fermented millet gruels eaten by infants and toddlers in Ouagadougou

Highlights

• Improved fermented millet gruel increased energy intakes in infants and toddlers.

• In preschool children, the improved gruel did not increase energy intakes.

• Encouraging feeding significantly increased infants and toddlers' gruel intakes.

• Benefits of encouraging feeding and improved gruel were cumulative in toddlers.

Abstract

Traditional fermented millet gruel is frequently eaten by children in Burkina Faso as a complementary food or for breakfast. The effects of gruel energy density and feeding style on intakes (amounts and energy) were assessed in children in Ouagadougou. Twenty-three young children (11 infants and 12 toddlers) were given two meals of gruel per day for two periods of 11 consecutive days, first, the traditional fermented gruel (TFG), and second, an improved high energy density fermented gruel (IFG). On the first 10 days of each period, the children were fed as usual, while on the 11th day, the mothers were asked to use encouraging feeding. Intakes of TFG and IFG were also measured once a day for nine days in 25 preschoolers (2-5 years-old). After adjustment for the subject effect, IFG intakes did not significantly differ from TFG intakes in the groups of infants and toddlers, meaning there was a significant increase in energy intakes, which almost doubled. Encouraging feeding increased TFG intakes in both age groups, but IFG intakes only increased in toddlers, whose energy intake tripled compared to that from TFG with the usual feeding style. In preschoolers, mean IFG intakes were lower than TFG intakes and there were no increase in mean energy intakes. Improving fermented gruel and training the mothers to encourage their young children during feeding are two possible strategies to improve food intakes, and hence to better satisfy the children's nutritional needs.

Introduction

According to WHO recommendations, from six months old, intakes of breast milk are no longer sufficient to cover young children's nutrient needs and other foods should thus be introduced (WHO, 2001). As they are consumed as a complement to breast milk, these foods are called complementary foods and can be of different kinds. In many countries of the Global South, the most frequent complementary foods are cereal-based gruels, particularly for infants aged 6–12 months. In Africa, these gruels are prepared by mixing flour and water and a range of other ingredients. They may or may not undergo lactic acid fermentation, and are then cooked by boiling (Blandino et al., 2003, Guyot, 2010). In Burkina Faso, fermented pearl millet [Pennisetum glaucum] gruels are widely eaten by people of all ages and are also frequently used as complementary food. Forty-five percent of the 6-23 month-old children in Ouagadougou eat them daily, but their nutritional value does not fill the gap between nutrient intakes from breast milk and recommended nutrient intakes (Mouquet-Rivier et al., 2008). Research conducted as part of the European CEREFER project (2002) led to changes in processing, which improved the macronutrient balance thanks to co-fermentation of millet with groundnuts, and increased the energy density through partial starch hydrolysis thanks to the addition of malt (Tou et al., 2007). Adding malt makes it possible to increase the concentration of the gruel while keeping the right consistency. Compared to other ways of increasing energy density such as adding oil or sugar, adding malt has the advantage of simultaneously increasing the concentration of all the nutrients in the gruel in the same proportions. So any increase in energy intake implies a similar increase in the intake of all the nutrients present in the gruel. All these changes obviously have significant effects on the organoleptic properties of the gruel. Sensory tests with mothers showed that the improved gruel was acceptable (unpublished data), but it was still necessary to (i) check its acceptability in real conditions, i.e. when eaten by children during a normal meal and (ii) compare the energy intake from the improved gruel with that of traditional gruel.

Improving the nutritional properties of the gruel is not the only way to improve nutrient and energy intakes from complementary foods. It is widely acknowledged that feeding style also plays an important role (Pelto, Levitt, & Thairu, 2003). Indeed, it has been shown that active feeding can compensate for lack of interest in food (Engle & Zeitlin, 1996). However, in many contexts, the “laissez-faire” style of feeding, with rare encouragement to eat, predominates (Bentley, Caulfield, Torun, Schroeder, & Hurtado, 1992). In the guidelines for complementary feeding of breastfed children (PAHO, 2003), the practice of responsive feeding, in which the mother -or caregiver-interacts with the child during feeding, is strongly recommended. But studies which quantify the potential effect of encouragement during feeding on intakes are scarce (PAHO and WHO, 2003, Bentley et al., 2011). Previous studies which measured food intakes in young children in Bangladesh (Islam et al., 2008), in Viet Nam (Van Hoan, Mouquet-Rivier, Eymard-Duvernay, & Trèche, 2010) and in Burkina Faso (Traoré et al., 2005, Cames et al., 2011) reported mean food intakes in the range of 5–20 g/kg of body weight (BW)/meal, i.e. far below the assumed functional gastric capacity of 30 g/kg BW/meal, which is the value most frequently used to establish recommendations for complementary feeding (WHO, 1998). This suggests that in these contexts, the feeding style may not be optimal, i.e. may not favour maximum intakes. The present study was conducted in the framework of the Nutrifaso Programme, which has been underway since 2005 and whose objective is to sustainably prevent the appearance of malnutrition among vulnerable populations through education on good dietary and hygiene habits and health care as well as the provision of locally-produced suitable foods. In this study, two feeding styles were tested to increase the chances of the improved fermented millet gruel having a positive effect on young children's intakes: the mother's usual feeding style, and a style we call “encouraging feeding”, which consisted in continuing to offer the gruel to the child twice after the mother decided to end the meal. To this end, a trial was held to determine the effects of both the type of fermented gruel (traditional vs. improved) and the feeding style (usual vs. encouraging) on food and energy intakes in infants and toddlers who regularly consume traditional fermented gruels in Ouagadougou. In addition, the energy intakes and acceptability of the improved fermented gruel were also assessed in preschool children as they are regular consumers of the traditional fermented millet gruel.