Pediatric Nutrition in Practice

64 Solomons

of a nutrient (e.g. the provitamin A β-carotene)
already in the plant (such as in orange-f leshed
sweet potatoes) or introduce the same nutrient
where it never existed before (as in rice or cas-
sava).

Vitamins and Trace Elements Added to Foods
Extrinsic addition of micronutrients usually oc-
curs in processing or, occasionally, in the home
just prior to consumption. It includes three do-
mains: (1) enrichment (returning the nutrients
lost in processing); (2) public health-directed for-
tification (adding a nutrient or nutrients to a
widely consumed item such as salt, sugar, oil or
flour to counter a population-level deficit), and
(3) market-driven fortification (adding nutrients
to commercial products to enhance their appeal,
such as adding vitamin C to soda beverages) [4].
Fortification is a legitimate and effective pub-
lic health measure [5]. The major focus in the
publication arena had traditionally been iodine
in salt, but this has recently shifted to iron, spe-
cifically in wheat f lours and corn meals (Flour
Fortification Initiative), and other nutrients such
as retinol in cooking oils and condiments. A cre-
ative avenue for young children with nutrition-
ally precarious diets has been home fortification

in which multimicronutrient-fortified powders

(sprinkles) or spreads are combined with tradi-

tional foods to support nutrient intake. The Cen-

tral American republics have a several-decade

history of vitamin A fortification of sugar, but in-

creased sugar consumption is now leading to ex-

cessive consumption of the vitamin.

Micronutrient Supplements

The advances in pharmaceutical chemistry from

the second half of the 20th century allowed high

concentrations of vitamins and trace elements to

be formulated as capsules, tablets and syrups. In a

public health context, various forms of micronu-

trient supplementation are used – generally when

40% of the child population shows evidence of

nutrient deficiency. This is exemplified by the pe-

riodic distribution of high-dose vitamin A cap-

sules [6] and intensive courses of daily dosing of

iron and folic acid [7].

Beyond the prevention of micronutrient defi-

ciencies, some parents may be motivated to sup-

plement themselves and their children with the

motivation to decrease the risk of occurrence of

chronic diseases such as cancer, cardiovascular

diseases and cognitive decline; an analysis of the

current scientific evidence does not support such

an effect [8]. In fact, adverse outcomes from

chronic multimicronutrient supplementation

have been documented.

Factors Affecting Vitamin and Trace Element

Nutrition

Primary vitamin and trace element undernutri-

tion is the result of the oral intake of nutrients

from any combination of the aforementioned

sources not meeting the recommended amounts.

This is seen not only with poverty, famine and di-

saster but also widely in cases where the nutrient

density of the diet does not sustain nutrient re-

quirements when energy needs are fulfilled. This

is an especial concern with regard to complemen-

Ta b l e 2. Sources of micronutrients for human consump-
tion

Intrinsic micronutrients
Nutrients contained within the tissue matrix and fluid of
edible items from the animal and plant kingdoms

Extrinsic (added) micronutrients
Nutrients are added to foods as enrichment, in mass
fortification by public health mandate and/or with
discretionary fortification, as in commercial foods or
with nutrient mixes added to complementary foods
in the home

Supplemental micronutrients
Nutrients taken in pharmaceutical preparations
(chewable candies, tablets, elixirs) in individual or
combined forms

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 62–67

DOI: 10.1159/000367871