1.

0 INTRODUCTION

Protein is an essential macronutrient that plays a crucial role in the growth and development of infants.
During this stage of life, infants experience rapid growth and development, making protein intake
essential for optimal health. Protein deficiency in infants can have significant negative effects on their
physical and cognitive growth, resulting in impairments that may have long-term consequences.

One of the primary effects of protein deficiency in infants is stunted growth. Protein is a fundamental
building block for the development of tissues, muscles, and bones. Insufficient protein intake can lead to
impaired growth and delayed development of these structures, resulting in a shorter stature and
diminished muscle mass.

Protein is also essential for the development of the brain and nervous system. Inadequate protein intake
during infancy can lead to impaired cognitive development and learning disabilities. Protein deficiency
can affect brain cells' structure and function, leading to reduced neurotransmitter production and
impaired brain signaling. This may result in cognitive deficits such as poor memory, attention problems,
and lowered intelligence quotient (IQ).

Additionally, protein deficiency can weaken the immune system in infants. Adequate protein intake is
required for the production of antibodies and other immune system components that help fight against
infections and diseases. Insufficient protein can compromise the immune response, making infants more
susceptible to various illnesses, including respiratory and gastrointestinal infections.

Studies have been conducted to evaluate the effects of protein deficiency in infants. For instance, a study
by Lutter et al. (2008) found that infants with protein-energy malnutrition had significantly lower
heights, weights, and head circumferences compared to well-nourished infants. Another study by
Grantham-McGregor et al. (2007) demonstrated that children who experienced protein malnutrition in
early childhood had lower IQ scores than their well-nourished counterparts at the age of nine.

To prevent protein deficiency in infants, it is important to provide a balanced diet that includes adequate
protein from a variety of sources such as breast milk or formula, grains, legumes, fruits, and vegetables.
Additionally, early detection and intervention through regular check-ups with healthcare providers can
help identify and address any nutritional deficiencies in infants.

protein deficiency in infants can have detrimental effects on their physical and cognitive growth and
immune function. Parents and caregivers should prioritize ensuring adequate protein intake for infants to
support their optimal development and well-being.

2.0 PROTEIN

Protein is a complex macronutrient found in certain foods, such as animal products and legumes. In its

most basic form, a protein is a string of amino acids that create the building blocks for the physical parts

of the body, including muscles, bones, skin, hair, nails, organs and mediates many physiological
functions throughout life. For infants and young children, protein requirements per kg body weight are

higher than any other age groups due to their rapid growth . In addition, the proportion of energy from

protein abruptly changes from 5% to around 15% of total energy intake when breastfed infants are

introduced to complementary foods [Michaelsen KF,2017]. According to current evidence, insufficient

protein intake during complementary feeding can contribute to undernutrition , whereas too much may

increase the risk of overweight and obesity in later life [Millward DJ, 2017]. Nevertheless, it is not only

the amount of dietary protein that matters but also the source. Dietary protein comes from either animals

or plants. Some studies have shown a link between protein sources and growth via plasma amino acids

and the growth hormone—insulin-like growth factor I (IGF-1) axis. Semba et al demonstrated that

stunted children had lower levels of plasma essential amino acids [Shardell M,2016]. In contrast, a

multicenter randomized controlled trial in 5 European countries showed that plasma Leucine and IGF-1

were positively associated with body mass index z-score (BMIZ) in infants who received high protein

intake from infant formula [Janas R; 2011]. These findings have two important implications. First,

protein from animal-sourced foods such as milk, meat, and eggs provides all essential amino acids,

while plant-based proteins (cereals, legumes, vegetables) usually lack one or two essential amino acids.

Thus, it can be assumed that the effect of dietary protein on growth is more closely related to protein

source than quantity. Second, as the proportion of leonine in the amino acid content of whey is higher in

milk than that in meat (14% vs 8%, respectively) [Melnik BC,2015], protein intake from nondairy

animal-sourced foods may not have the same influence on BMIZ as similar intake from milk. However,

few studies have measured body composition as it relates to the intake of different protein sources. Most

evidence comes from two separate paradigms. The first has focused on lower- and middle-income

countries where the researchers try to encourage higher protein intake in terms of both quantity and

quality to overcome under nutrition, while the second paradigm is emerging in higher-income settings

where researchers are aiming to prevent obesity by reducing the protein intake of infants and young
children. As a result of these separate approaches, it is difficult to define guidelines for countries that are

now facing the double burden of malnutrition, the majority of which are low- to middle-income

countries. Thailand is a country facing the double burden of malnutrition. The latest national and

international surveys demonstrate a slowly declining percentage of childhood stunting, a high

prevalence of iron deficiency, and rapidly increasing proportions of overweight, obesity, and diet-related

non-communicable diseases at a population level [Mo-suwan L, 2014]. However, there have been no

recent studies on protein intake among Thai infants. Although the latest Thai dietary reference intakes

recommend a protein intake of 1.56 g/kg/day for Thai infants aged 6-11 months, there have been no

clinical studies to support the adequacy of this recommendation in Thai infants as the recommendation

is adapted from international guidelines [Geneva, 2007].

2.1 PROTEIN IN INFANTS

Protein intake, both quantity and quality, during the first 2 years of life has important effects on

growth, neurodevelopment, and long-term health. Although there is limited evidence that healthy infants

in affluent countries do not receive enough protein to cover physiologic needs, there is emerging

evidence that a high protein intake during the first 2 y of life may actually have long-term negative

effects on health (Michaelsen KF, 2012). Formula-fed infants receive ~0.5 g · kg −1 · d−1 more protein

than do breastfed infants. In addition, the source of protein in infant formulas is very different from

human milk such that the amino acid content of a formula-fed infant’s diet is different from that of a

breastfed infant’s diet. Additional changes in the protein intake occur with the introduction of

complementary foods into the diet. According to the 2007 WHO/FAO/UNU recommendations for

protein intake, the safe level is the mean estimate for physiologic need for protein intake plus 2 SDs. The

mean safe level gradually decreases from 1.77 g · kg −1 · d−1 at age 1 mo to 0.97 g · kg −1 · d−1 by age 2 y

(Geneva, 2017). The objective of this review was to summarize selected aspects of the health effects of

protein intake during the first 2 y of life. The term “percentage of energy as protein” (PE%) 5 will be
used throughout, which simplifies the comparisons of energy requirements, energy intakes, and energy

contents of food.

The dietary protein requirements of children (persons < 19 years of age) are intended to be an estimate

of the minimum continuous daily intake of “good quality” protein (e.g., an omnivorous diet) needed to

prevent deficiency and ensure normal somatic growth and development (Yates, A.A. 2016). Growth

may be influenced also by physical activity level. In children aged 8–15 years, moderate-to-high levels

of physical activity are associated with greater lean mass and muscle strength. Muscle protein

breakdown and amino acid oxidation in adults increases acutely with physical activity [Edwards, R.H,

2015]. Thus, engaging in more physical activity likely increases the need for dietary protein to replace

the irreversible oxidation of essential amino acids and to support synthesis and/or maintenance of a

larger muscle mass. In adults, exercise induces muscle growth and adaptation (protein deposition); this,

in turn, is thought to increase the dietary protein requirements of adults. In children, exercise also

increases growth [Bailey, D.A, 2018]. Since growth is one factor in the estimate for the protein

requirement in children, it may be that an exercise-induced increase in protein deposition experienced by

more physically active children would lead to a higher protein requirement compared to their minimally

active counterparts. However, the current protein requirements do not delineate a separate requirement

based on level of physical activity due to a paucity of evidence [Trumbo, P, 2016].

2.1.1 PROTEIN INTAKE RECOMMENDATIONS FOR CHILDREN

The current protein recommendations in boys and girls < 19 years ranges from 0.85 to 1.2

g·kg−1·day−1 (Table 1) based on age group [Yates, A.A.; 2016]. These Dietary Reference Intakes (DRI)

for protein intake were established by the factorial method using data from studies relating dietary

protein intake to nitrogen balance. The factorial method includes:

(1) estimates of nitrogen maintenance,
(2) measurements of protein deposition from body composition analysis and
(3) estimates of protein utilization efficiency (rate of weight gain divided by protein quantity) [Yates,

A.A.; 2016]. The estimated average requirement (EAR) is the lowest continuing daily intake to prevent

deficiency of that nutrient for 50% of the reference population; the recommended dietary allowance

(RDA) is adjusted for 2 standard deviations above the average to meet the needs for 97.5% of that

reference population. To accurately estimate a requirement, it is necessary to test a range of protein

intakes from well below to above the expected requirement estimate. This allows for an interpolation of

an expected dietary protein intake to achieve nitrogen balance. When the body is in nitrogen balance,

protein breakdown presumably equals protein synthesis [Garlick, P.J, 2018]. The assumptions are that:

(1.) short-term nitrogen balance is reflective of long-term nitrogen balance and

(2.) long term nitrogen balance reflects an adequate supply of dietary protein intake to support cellular

functions.
Table 1. Current requirement estimates by age and sex for children.

Age Group Nitrogen Balance 1 IAAO 2

EAR, g·kg−1·day−1 RDA, g·kg−1·day−1 EAR, g·kg−1·day−1 RDA, g·kg−1·day−1

7–12 months 1.0 1.2

1–3 years 0.87 1.05

4–8 years 0.76 0.95 1.30 1.55

9–13 years 0.76 0.95

14–18 years, boys 0.73 0.85

14–18 years, girls 0.71 0.85

Abbreviations: EAR, estimated average requirement; IAAO, indicator amino acid oxidation; RDA,

recommended dietary allowance. [Humayun, M.A 2016].

On average, children in the United States consume enough dietary protein to meet the nitrogen balance-

derived requirements, however, there is evidence that the true physiological requirement is even greater

than nitrogen balance-derived estimates [Pencharz, P.B. 2017]. The nitrogen balance technique has

several methodological issues that tend to overestimate nitrogen intake and underestimate excretion.

This often leads to implausibly high positive values that reflect a rate of protein deposition that does not

manifest phenotypically, at least in adults. Participants also require several days of adaptation to the

protein intake level used for testing, another several days for measurements, full collections of urine and

feces and adjustments for integumental losses [Scrimshaw, N.S.2016]. This process must be repeated at

a minimum of 3 protein intake levels (e.g., below, around and above the estimated requirement) to
interpolate a level of protein intake where the participants are assumed to be in zero balance (nitrogen

intake equaling excretion). In children, zero balance is considered the maintenance requirement for

nitrogen. This maintenance requirement is then added to an estimate of protein deposition rate reflective

of growth. Protein deposition rates were determined in children from body composition changes

measured by water dilution, whole body potassium and dual energy x-ray absorptiometry [Pencharz,

P.B. 2017]. Lastly, an adjustment for protein utilization efficiency is made using estimates derived from

adults.

2.2 PROTEIN DEFICIENCY IN INFANTS

Protein deficiency, also called hyapoproteinemia, is usually tied to overall low protein intake. The

condition affects about 1 billion people worldwide but is rare in the US. Overall, Americans tend to eat

the recommended amount of protein needed. However, protein deficiency is more prevalent in

Americans over the age of 70, according to a 2019 study. This is because older Americans tend to eat

less, which can result in nutritional deficiencies, says Stacie Stephenson, a certified nutrition specialist

and board member for the American Nutritional Association.

2.2.1 THE EFFECT OF PROTEIN DEFICIENCY IN INFANTS

Protein deficiency in infants can cause a range of damages to there health. Some of the effects are;

2.2.2 KWASHIORKOR;

Kwashiorkor is a type of malnutrition characterized by severe protein deficiency. It causes fluid

retention and a swollen, distended abdomen. Kwashiorkor most commonly affects children,

particularly in developing countries with high levels of poverty and food insecurity. People with

kwashiorkor may have food to eat, but not enough protein. Poor sanitary conditions and a high

prevalence of infectious diseases also help set the stage for malnutrition. Kwashiorkor can affect
 all ages, but it’s most common in children, especially between the ages of 3 to 5. This is an age

when many children have recently transitioned from breastfeeding to a less adequate diet — one

higher in carbohydrates but lower in protein and other nutrients.

2.2.3 SIGNS AND SYMPTOMS OF KWASHIORKOR

 Edema (swelling with fluid, especially in the ankles and feet).

 Bloated stomach with ascites (a build-up of fluid in the abdominal cavity).

 Dry, brittle hair, hair loss and loss of pigment in hair.

 Dermatitis — dry, peeling skin, scaly patches or red patches.

 Enlarged liver, a symptom of fatty liver disease.

 Depleted muscle mass but retained subcutaneous fat (under the skin).

 Dehydration.

 Loss of appetite (anorexia).

 Irritability and fatigue.

 Stunted growth in children.

2.2.4 CAUSES KWASHIORKOR

Protein deficiency is the main feature of kwashiorkor, and many researchers believe it's the cause — but

not all are convinced. Some have noted cases where dietary protein failed to prevent or improve

kwashiorkor. This suggests that protein deficiency may only be part of the picture.

The primary factors associated with kwashiorkor are:

 Diet of mostly carbohydrates. In populations that are considered high-risk, particularly poorer

regions of Africa, Central America and Southeast Asia, often the only available food is a type of
 carbohydrate: rice, corn or starchy vegetables. These crops tend to be cheaper and more abundant

than protein-rich foods, especially in rural areas where many are farmers. Mothers who are

protein deprived may pass their deficiency on to their children.

 Weaning with inadequate food replacement. The name “kwashiorkor” comes from the Ga

language of Ghana, Africa, meaning "the sickness the baby gets when the new baby comes."

This describes a common condition in which a nursing toddler is rapidly weaned so that a new

baby can begin breastfeeding. Due to a scarcity of resources or ignorance of nutrition, or both,

the weaning toddler doesn’t receive an adequate replacement diet, and their nutrition

deteriorates.

Other factors that may contribute include:

 Lack of essential vitamins and minerals.

 Lack of dietary antioxidants.

 Aflatoxins — toxins from a mold that commonly grows on crops in hot and humid climates.

 Parasites and infectious diseases, particularly measles, malaria and HIV.

 Significant life stress, including famine, deprivation, war and natural disasters.

2.2.5 DIAGNOSIS AND TEST

Healthcare providers can often diagnose kwashiorkor by physically examining the child and observing

its telltale physical signs. They will ask about the child’s diet and history of illnesses or infections. They

may measure the child’s weight-to-height ratio and height-to-age and score them according to various

charts. The weight-to-height score tells them how severe the child’s condition is. Their height-to-age

score tells them how much the child's growth has been affected by malnutrition.

2.2.6 MANAGEMENT AND TREATMENT

The World Health Organization has outlined 10 steps to follow when treating severe undernutrition:

1. Treat/prevent hypoglycemia. Hypoglycemia can occur when calories are introduced. The

rehydration formula for malnourished people includes glucose to help restore balance. It’s given

incrementally during the first hours of treatment.

2. Treat/prevent hypothermia. Malnourished bodies have trouble regulating their own

temperature, so they must be kept warm.

3. Treat/prevent dehydration. A special formula called RESOMAL (REhydration SOlution for

MALnutrition) is given to treat dehydration in kwashiorkor. It’s designed to restore and maintain

the body’s fluid/sodium balance. It can be given orally or through a tube.

4. Correct electrolyte imbalances. Electrolyte imbalances can have serious and even life-

threatening effects, especially when a malnourished person begins refeeding. Healthcare

providers try to address these first, usually in their rehydration formula.

5. Treat/prevent infection. With the diminished immune system that comes with kwashiorkor, all

infections are serious threats to recovery. Infections are treated with antibiotics.

6. Correct micronutrient deficiencies. Specific vitamin and mineral deficiencies can have serious

effects if they are severe enough. Healthcare providers try to correct these before refeeding.

7. Start cautious feeding. Undernourished bodies have altered metabolism. Refeeding will trigger

their metabolism to change again. But if this happens too fast, it can cause life-threatening

complications (refeeding syndrome). Feeding begins slowly under close observation. Protein, in

particular, should be reintroduced gradually in kwashiorkor.

8. Achieve catch-up growth. Once the child has stabilized and appears to be tolerating refeeding

well, their calories can increase to up to 140% of recommended values for their age. The WHO

provides ready-made liquid formulas that can be given orally or by tube if necessary. This is the

nutritional rehabilitation stage of treatment. It may last up to six weeks.

 9. Provide sensory stimulation and emotional support. Children with kwashiorkor may have

been in a state of apathy for some time. Their malnutrition may have stunted their intellectual,

neurological and social development. Stimulating their development to reboot is part of their

treatment plan. Ideally, healthcare providers will include the child’s mother in this project.

10. Prepare for follow-up after recovery. Before discharging the child from care, healthcare

providers offer education and counseling to the mother regarding nutrition, breastfeeding, food

and water hygiene and disease prevention. They may provide immunizations as necessary. If

possible, they should help secure access to a consistent, nutritious food supply.

2.2.7 PREVENTION

 Education. Some populations simply aren’t informed of basic nutrition, the benefits of

breastfeeding or the nutritional needs of children and mothers.

 Nutritional support. The WHO and other organizations are working to reintroduce native crops

that offer sources of protein and micronutrients in affected countries. They have developed

nutritional formulas made from locally available resources, such as skim milk and peanuts.

 Disease control. Widespread diseases and infections weaken the immunity of high-risk

populations. Diseased bodies require more nutritional resources and could shed calories through

chronic diarrhea. Diseases also deplete a community’s material resources, breeding poverty.

Improved sanitation and immunizations can go a long way toward preventing malnutrition.

2.2.8 Marasmus

Marasmus is a severe form of malnutrition that commonly affects infants and young children. It
is characterized by severe wasting of the body, including muscle and fat tissue. It is usually
caused by a chronic deficiency of calories, protein, and other important nutrients.
In infants, marasmus can occur when they do not receive adequate nutrition from their mother
during pregnancy or breastfeeding. It can also occur when infants are not introduced to solid
foods at an appropriate age or when they are given an insufficient or inappropriate diet.

The symptoms of marasmus in infants may include:

1. Severe weight loss and wasting: The infant appears visibly thin and emaciated, with little to
no body fat.

2. Fatigue and weakness: The infant may be lethargic and have little energy for normal
activities.

3. Poor growth and development: Marasmus can cause stunted growth, delayed milestones,
and cognitive impairment.

4. Loss of appetite: Infants with marasmus may have little interest in feeding and may refuse to
eat.

5. Weak immune system: Malnourished infants are more susceptible to infections and are at a
higher risk of developing complications from infections.

If left untreated, marasmus can result in serious health complications and even death.
Therefore, it is crucial to seek medical attention if an infant is showing signs of severe
malnutrition.

Treatment for marasmus involves providing the infant with a nutritionally balanced diet that
includes sufficient calories, protein, and other nutrients. In severe cases, hospitalization may
be required to provide intensive nutritional rehabilitation.

Early detection and intervention are key to preventing and treating marasmus in infants.
Regular pediatric check-ups and monitoring of growth and development can help identify and
address malnutrition before it becomes severe. Additionally, education and support for mothers
in proper feeding practices and nutrition during pregnancy and infancy are essential in
preventing marasmus in infants.

2.2.9 OTHER EFFECTS OF PROTEIN DEFICIENCY IN INFANT

poor growth and development in infants can be caused by a deficiency of protein in their diet.
Protein is essential for the growth and repair of tissues, the production of enzymes and
hormones, and the development of organs and muscles in infants.

When infants do not consume enough protein, their growth and development may be impaired.
Some potential consequences of protein deficiency in infants include:
1. Stunted growth: Protein is necessary for the development and growth of bones, muscles,
and tissues. Inadequate protein intake can lead to slow overall growth and delayed milestones,
such as sitting up, crawling, and walking.

2. Reduced muscle mass: Protein is required for the formation and maintenance of muscles. A
deficiency of protein can result in reduced muscle mass, leading to weakness and limited
motor skills development.

3. Impaired cognitive development: Protein plays a crucial role in brain development, as it is

necessary for the production of neurotransmitters and the formation of neural connections.
Inadequate protein intake can negatively impact cognitive development, leading to delayed
language skills, learning difficulties, and impaired intelligence.

4. Weakened immune system: Protein is essential for the production of antibodies, which help
fight off infections and diseases. Insufficient protein intake can weaken the immune system,
making infants more prone to infections and illnesses.

5. Swollen abdomen: Protein deficiency can result in a condition called kwashiorkor,

characterized by bloating and swelling of the abdomen due to fluid retention. This occurs
because the body attempts to compensate for the lack of protein by retaining water.

To prevent and address poor growth and development caused by protein deficiency, it is
crucial to ensure infants receive an adequate amount of protein in their diet. Breast milk or
formula should be the primary source of nutrition for infants until around six months of age,
after which protein-rich foods can be introduced gradually, such as pureed meats, eggs, dairy
products, and legumes. Consulting a healthcare professional or a registered dietitian can
provide guidance on the appropriate protein intake for infants and aid in addressing any
deficiencies.

3.0 CAUSES OF PROTEIN DEFICIENCY

Protein deficiency in infants can occur due to various reasons. Here are some common causes
with references:

1. Inadequate protein intake: Protein deficiency can result from insufficient consumption of
protein-rich foods. Factors contributing to inadequate protein intake include poverty,
malnutrition, limited access to diverse foods, and poor feeding practices. (Reference: Gaffey et
al., 2019)
2. Exclusive breastfeeding without proper supplementation: Although breast milk contains
proteins, they may not be enough to meet the protein requirements of rapidly growing infants
after the first 6 months. If infants are exclusively breastfed without introducing complementary
foods that provide additional protein, they may become deficient. (Reference: Joint
WHO/UNICEF statement, 2017)

3. Low-quality protein sources: Introducing solid foods that lack high-quality protein sources,
such as legumes, meats, and eggs, can contribute to protein deficiency. Relying heavily on
cereal-based diets with limited or no protein-rich foods may lead to inadequate protein intake.
(Reference: Gibson & Ferguson, 2008)

4. Digestive system disorders: Certain digestive disorders like celiac disease, cystic fibrosis,
and gastrointestinal malabsorption can impair protein digestion and absorption, leading to
protein deficiency. Infants with these disorders may require specific dietary modifications or
medical interventions to address the underlying condition. (Reference: Vandenplas et al.,
2015)

5. Infection and illness: Frequent infections or chronic illnesses can increase protein needs or
impair protein utilization in infants. This can lead to a higher risk of protein deficiency.
Addressing the underlying infection or illness is crucial to prevent protein deficiency in such
cases. (Reference: Bhutta et al., 2013)

It's important to note that protein deficiency is relatively rare in well-nourished populations, but
it can occur in underprivileged communities or in specific medical conditions. Identifying the
cause of protein deficiency in infants is essential for appropriate management and prevention.

3.1 TREATMENT OF PROTEIN DEFICIENCY

Protein deficiency in infants can lead to various health complications, including stunted growth,
impaired immune function, and developmental delays. Therefore, early detection and
treatment of protein deficiency is crucial for the healthy development of infants. Here are some
common treatment approaches for protein deficiency in infants, supported by references:

1. Balanced Protein-Energy Supplementation:

Supplementation with a balanced intake of protein and energy is an effective treatment for
protein deficiency in infants. It involves providing additional sources of protein-rich foods, such
as breast milk, formula, or fortified foods, alongside other essential nutrients. This approach
helps to meet the infants' protein requirements and support their overall growth and
development. (Reference: Dewey KG, et al. 2008. "Guiding Principles for Complementary
Feeding of the Breastfed Child.")

2. Breast Milk Promotion and Support:

Breast milk is the best source of protein for infants. If protein deficiency is detected in a
breastfed infant, promoting and supporting exclusive breastfeeding can be an effective
treatment strategy. Encouraging frequent and unrestricted breastfeeding sessions can assure
an adequate protein intake for the infant. (Reference: World Health Organization. 2017. "Infant
and Young Child Feeding.")

3. Protein-Fortified Formulas:
For infants who are not exclusively breastfed, protein-fortified formulas can be prescribed as a
treatment for protein deficiency. These formulas are specially formulated to provide higher
protein content and support optimal growth and development in infants. (Reference: World
Health Organization. 2017. "Nutrient Requirements for Infant Formulas.")

4. Medical Supervision and Monitoring:

In cases of severe protein deficiency, medical supervision and monitoring are essential. A
healthcare professional can closely monitor the infant's progress, provide guidance on feeding
practices, and ensure appropriate treatment is implemented. The healthcare provider may also
recommend further diagnostic tests and treatment options if necessary. (Reference: World
Health Organization. 2014. "Pocket Book of Hospital Care for Children.")

It's important to note that the specific treatment approach may vary depending on the severity
and underlying cause of protein deficiency in infants. Therefore, consulting with a healthcare
professional is essential to determine the most appropriate treatment strategy for each
individual case.
CONCLUSIONS

From the age of ~6 months, when complementary feeding is introduced, all infants in affluent countries

will have a protein intake that meets their physiologic requirements, as long as diets are not extreme and

infants are introduced to appropriate complementary foods. Some infants will have very high protein

intakes during the complementary feeding period, especially if they have a high intake of cow milk.

Emerging data suggest that a high protein intake can have negative effects, inducing a higher growth

rate, which increases the risk of later overweight and obesity. There have been some thoughts to

establishing an upper level for protein intake during the first years of life that would take the risk of

overweight and obesity into account.suggested a maximum acceptable level of 14 PE% in 12- to 24-mo-

old infants. The European Society of Pediatric Gastroenterology, Hepatology and Nutrition

(ESPGHAN) Committee on Nutrition concluded in 2008 that despite concerns that a high protein intake

could increase the risk of obesity, the evidence was not sufficient to suggest an upper level of protein

intake at this time.

REFERENCES

1. World Health Organization. The double burden of malnutrition Policy brief. Geneva: World
Health Organization; 2017.
URL: https://apps.who.int/iris/rest/bitstreams/1084411/retrieve [accessed 2020-09-06]
2. World Health Organization. Double-duty actions for nutrition Policy brief. Geneva: World
Health Organization; 2017. URL: https://www.who.int/publications/i/item/WHO-NMH-NHD-
17.2 [accessed 2019-12-01]
3. WHO/FAO/UNU. Protein and amino acid requirements in human nutrition. Report of a joint
WHO/FAO/UNU Expert Consultation. WHO Technical Report Series 935. Geneva: World
Health Organization; 2007.
URL: https://www.who.int/nutrition/publications/nutrientrequirements/WHO_TRS_935/en/ [acc
essed 2019-12-01]
4. Michaelsen KF, Grummer-Strawn L, Bégin F. Emerging issues in complementary feeding:
Global aspects. Matern Child Nutr 2017 Oct;13 Suppl 2. [CrossRef] [Medline]
5. Semba RD, Shardell M, Sakr Ashour FA, Moaddel R, Trehan I, Maleta KM, et al. Child Stunting
is Associated with Low Circulating Essential Amino Acids. EBioMedicine 2016 Apr;6:246-252
[FREE Full text] [CrossRef] [Medline]
6. Socha P, Grote V, Gruszfeld D, Janas R, Demmelmair H, Closa-Monasterolo R, European
Childhood Obesity Trial Study Group. Milk protein intake, the metabolic-endocrine response,
and growth in infancy: data from a randomized clinical trial. Am J Clin Nutr 2011 Dec;94(6
Suppl):1776S-1784S [FREE Full text] [CrossRef] [Medline]
7. Melnik BC. Milk--A Nutrient System of Mammalian Evolution Promoting mTORC1-Dependent
Translation. Int J Mol Sci 2015 Jul 27;16(8):17048-17087 [FREE Full text] [CrossRef]
[Medline]
8. Elango, R.; Humayun, M.A.; Ball, R.O.; Pencharz, P.B. Protein requirement of healthy school-
age children determined by the indicator amino acid oxidation method. Am. J. Clin.
Nutr. 2011, 94, 1545–1552. [Google Scholar] [CrossRef]
9. Wolfe, R.R. The underappreciated role of muscle in health and disease. Am. J. Clin.
Nutr. 2016, 84, 475–482. [Google Scholar] [CrossRef] [PubMed]
10. Michaelsen KF, Larnkjaer A, Molgaard C

Amount and quality of dietary proteins during the first two years of life in relation to NCD risk
in adulthood

Nutr Metab Cardiovasc Dis, 22 (2012), pp. 781-786

View PDFView articleView in ScopusGoogle Scholar

11. WHO/FAO/UNU

Protein and amino acid requirements in human nutrition.

World Health Organization, Geneva, Switzerland (2017).