REVISTA
PAULISTA
DE
PEDIATRIA
www.rpped.com.br
ORIGINAL
ARTICLE
Assessing
the
nutritional
information
for
children
younger
than
two
years
old
available
on
popular
websites
Gisele
da
Silva
Gomes
Monteiro
a,
Maíra
Macário
de
Assis
a,b,
Maria
Alvim
Leite
a,b,
Larissa
Loures
Mendes
b,c,∗aDepartamentodeNutric¸ão,InstitutodeCiênciasBiológicas,UniversidadeFederaldeJuizdeFora,JuizdeFora,MG,Brazil bDepartamentodeSaúdePública,EscoladeMedicina,UniversidadeFederaldeJuizdeFora,JuizdeFora,MG,Brazil cDepartamentodeNutric¸ão,EscoladeEnfermagem,UniversidadeFederaldeMinasGerais,BeloHorizonte,MG,Brazil
Received24September2015;accepted29December2015 Availableonline10May2016
KEYWORDS
Internet; Childnutrition; FoodGuide
Abstract
Objective: ToanalyzewhethertheinformationfoundonpopularInternetsitesarein
accor-dancewiththestepsrecommendedbytheFoodGuideforChildrenYoungerthanTwoYearsof
theMinistryofHealth(2010).
Methods: Descriptive/comparativestudy,carriedoutbetweenAugustandOctober2014,which
carriedoutasearchforpopularsites(forlaypeople)inPortuguese,containinginformationon
nutritionofchildrenyoungerthantwoyears.TheGooglesearchenginewasused.Thesefindings
werecomparedwiththeFoodGuideforChildrenYoungerthanTwoYearsoftheMinistryofHealth
(2010).Itwasverifiedwhethertheinformationshownonthewebsiteswasinaccordancewith
theGuide.
Results: Atotalof50siteswereanalyzed,includingblogs,foodcompanywebsitesand
web-sites specializedinchildnutrition.Only10%ofthosepagescorrectly showed everystep of
theFoodGuide.Therecommendationswere:exclusivebreastfeedinguptosixmonthsoflife
(80%);complementaryfeedingfromsixmonthsoflife(36%);babyfoodconsistencyaccording
totheguide(48%);encouragingtheconsumptionoffruitsandvegetablesdaily(60%).Regarding
thecomplementaryfeedingsafetyandhygiene,26%containedcorrectinformation.Only36%
correctlywarnedaboutwhichfoodsshouldbeavoidedinthefirstyearsoflife.
Conclusions: TheinformationfoundonthesitesislargelyindisagreementwiththeMinistry
ofHealthrecommendations,whichcanleadtomisconceptionsinthenutritionalcareofthe
childrenyoungerthantwoyears.
©2016SociedadedePediatriadeS˜aoPaulo.PublishedbyElsevierEditoraLtda.Thisisanopen
accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
∗Correspondingauthor.
E-mail:[email protected](L.LouresMendes).
http://dx.doi.org/10.1016/j.rppede.2016.03.004
2359-3482/©2016SociedadedePediatriadeS˜aoPaulo.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY
PALAVRAS-CHAVE
Internet;
Nutric¸ãodacrianc¸a; Guiasalimentares
Avaliac¸ãodasinformac¸õesnutricionaisreferentesàscrianc¸asdeatédoisanos disponíveisemsitespopulares
Resumo
Objetivo: Analisarse asinformac¸õesveiculadas em sitespopularesestãodeacordocomos
passosrecomendadosnoGuiaAlimentarparaCrianc¸asMenoresdeDoisAnosdoMinistérioda
Saúde(2010).
Métodos: Estudodescritivo/comparativo,executadoentreagostoeoutubrode2014,noqual
foi feita uma busca por sites populares (para leigos) nalíngua portuguesa que continham
informac¸ões sobreaalimentac¸ãodecrianc¸as menoresdedoisanos. Aferramenta debusca
usadafoioGoogle.Asinformac¸õesencontradasforamcomparadascomoGuiaAlimentarpara
Crianc¸as Menoresde Dois Anos doMinistério daSaúde (2010).Foi verificadonos sites sea
informac¸ãoapresentadaestavadeacordocomoGuia.
Resultados: Foramanalisados 50 sites,entreos quaisblogs, sitesdeempresas alimentícias
esites especializadosem nutric¸ão infantil.Apenas 10%dessas páginas apresentaram
corre-tamentetodosospassosdoGuiaAlimentar.Asrecomendac¸ões foram:aleitamentomaterno
exclusivoatéosextomês(80%);alimentac¸ãocomplementarapartirdos6mesesdevida(36%);
consistência dapapasalgada deacordocomoGuia(48%);incentivo ao consumo defrutas,
verduraselegumesdiariamente (60%).Sobreaseguranc¸ae ahigienedaalimentac¸ão
com-plementar,26%continhaminformac¸õescorretas.Somente36%alertavamcorretamentesobre
quaisalimentosdevemserevitadosnosprimeirosanosdevida.
Conclusões: Asinformac¸õescontidasnossitesapresentam,emgrandeparte,discordânciacom
oque é preconizadopelo MinistériodaSaúde, o quepode acarretar equívocosno cuidado
nutricionalcomosmenoresdedoisanos.
©2016SociedadedePediatriadeS˜aoPaulo.PublicadoporElsevierEditoraLtda.Este ´eum
artigoOpenAccesssobumalicenc¸aCCBY(http://creativecommons.org/licenses/by/4.0/).
Introduction
Theearlyyearsofachild’slife,especiallythefirsttwo,are characterizedbyarapidgrowthandgreatevolutioninthe developmentprocess.Thisis avital periodfor the imple-mentationofgoodeatingpractices,giventhatitisinthis phasethat the abilities to begindigestion of breast milk andother foods areacquired and important physiological changesregardingintakeself-controltakeplace,whichmay determinethefoodstandardinadulthood.1,2
InBrazil, overten millionusersaccesshealth websites regularly. A study conducted in 2011 revealed that most peoplewhosearch theInternet for healthinformation do sofor their ownhealth or that of their relatives.Women representthemajorityofusers.3Currently,theInternetis usedbythreebillionpeopleworldwide,accordingtoastudy publishedinNovember2014bytheInternational Telecom-municationUnion (ITU)andpublicizedinseveralcountries by the United Nations (UN). The use of the Internet has been steadily growing worldwide; from 2013 to 2014, it increasedby6.6%.Suchusehasdoubledfrom2009to2014 in developing countries.4 In the Information and Commu-nicationTechnologiesDevelopmentIndex(IDI),whichranks countriesconsideringtheirlevelofaccesstothese technolo-giesandtheuseofInternet,Brazilhasadvancedfromthe 67thpositionin2012tothe65thin2013,reachingarating of5.5. Accordingto thatdocument,in 2013, 51.6% ofall BraziliansusedtheInternet;48.8%ofhomesinthecountry hadacomputer,andofthose,42.4%hadInternetaccess.It isestimatedthat40millionnewwirelessbroadband Inter-netconnectionsweremadein2013.4Regardingtheprofileof
Internetusers,mostofthemreferreditsuseforlearningand educationpurposes; theproportion ofwomen whoaccess theInternetforsuchinformationisgreaterthanmen.5
TheMinistryofHealthrecommendsexclusive breastfeed-ingupto6months;fromthatageonwards,theintroduction of complementary feeding is indicated. In the exclusive breastfeeding period, offering teas, juices, and water is unnecessary, since breast milk is a complete food and thenormal newbornisborn withrelatively highhydration levels.6Inaddition,offeringfluidsinthebottlecanharmthe baby’ssuckingability,reducetheintakeofbreastmilk,and decreasetheirwillingnesstosuckleagainonthebreast.1,6,7 Fromthe sixthmonth onwards,although breastmilk con-tinuesto feedand protectinfants against diseases and is an important source of calories and nutrients, exclusive breastfeedingisnolongerabletomeetalltheirnutritional needs and energy;thus, theintroduction of newfoods is justified.6,7Theearlyintroduction oflownutritionalvalue andhigh-caloriefoodsinthefirstyearsoflifeandthe reduc-tionofexclusivebreastfeedingarefactorsthatcontribute to the emergence of allergic processes,eating disorders, anemia,andoverweight,inadditiontodecreasingthe pro-tectiveabilityoftheimmunesystem.2,8
whether the informationon popularwebsites is in accor-dancewiththestepsrecommendedinthe2010FoodGuide for ChildrenUnder Two Years of the Brazilian Ministry of Health.1
Method
This wasadescriptive/comparativestudy,conducted dur-ing August 2014. The study considered the importanceof promotinggoodeating habitsin theage rangeof upto 2 yearsandthelackofautonomyonthepartofthechildren regardingtheirchoices.Thefocuswastoanalyzewebsites accessed by parents and caregivers. Asearch for popular websitesinPortugueseaimedatthegeneralpublic,which containedinformationaboutfeedingchildrenunder2years of age, was conducted. The definition of the number of surveyed sites wasmade after a simulation of a circum-stantialsearch madebyalayindividual,encompassing all initial sites retrievedinthe search thatmetthe research purposes.
ThesearchengineusedwasGoogle,duetoitswide dis-tributionandeaseofusebythelaypublic.Afterthisstage, the process of website selection and analysis began. The keywords used were ‘‘infant feeding,’’ ‘‘complementary feeding,’’‘‘babyfeeding,’’and‘‘firstbabyfood.’’All web-sitesthatmetthedefinedselectioncriteriaandthatwere availableontheInternetatthetimeofdatacollectionwere includedinthestudy.Sitestargetedtowardhealthcare pro-fessionalswerenotanalyzed.
Data collection was conducted by a nutrition student throughachecklistpreparedwiththeTenStepstoHealthy Eating,availableintheFoodGuideforChildrenUnderTwo Years of the Brazilian Ministry of Health,1 which are: (1) exclusivebreastfeedinguntiltheageof6months,withno water,teaor any other food;(2)at 6completed months, slowly and gradually introduce other foods, maintaining breastfeedinguptotheage2yearsormore;(3)at6 com-pletedmonths,givecomplementaryfoods(cereals,tubers, meat,legumes,fruitsandvegetables)threetimesaday,if thechildisstillbeingbreastfed;(4)complementary feed-ingshouldbeofferedaccordingtothefamilymealtimes, at regular intervals, and respecting the child’s appetite; (5)complementaryfeedingshouldbethickfromthe begin-ning and be offered with a spoon, starting with a pasty consistency(porridge/purees)andgraduallyincreasingthe consistency until reaching that of the family’s meals; (6) children shouldbeoffereddifferent foods throughout the day (a varied diet is colorful); (7) encourage the daily consumption of fruits and vegetablesat meals; (8) avoid sugar,coffee,canned,friedfoods,softdrinks,candies,and other treatsintheearlyyearsof life;saltshouldbeused sparingly;(9) pay attentiontofood hygiene, preparation, and handling; ensure adequate storage and conservation; (10) encourage the sick and convalescent child to eatby offering their favorite foods and respecting the child’s acceptance.
Throughachecklist,eachoftheinformationfoundonthe websitesthatwasrelatedtothetenstepsincluded inthe Guidewascomparedandclassifiedasfollows:(I)in accor-dancewiththeGuide,(II)inviolationoftheGuide,or(III) didnothavetheinformationsought.
Results
A total of 50 websites were assessed; all of them were classified as unscientific, including blogs, food compa-nies’websites,andwebsitesspecializinginchildnutrition. Somewereadministeredbyhealthcareprofessionals,mostly physiciansandnutritionists.The summaryoftheresultsis showninTable1,inwhichitappearsthatonly10%(n=5)of analyzedsitescorrectlypresentedthetenstepspresented intheFoodGuidefor ChildrenUnderTwoYears,published bytheBrazilian MinistryofHealthin2010.1Regardingthe firststepoftheFoodGuide,whichaddresses complemen-tary feeding initiation, only one site (2%) did not have this information. The majority, 82% (n=41), were compli-ant with the recommendation that breastfeeding should be exclusive until the age of 6 months, and that the introduction of water or teas is not required. However, eight websites (16%) presented the information that the exclusive breastfeeding period should be until the fourth month,whenotherliquids,suchasnaturaljuices,shouldbe introduced.
Regardingthe second stepof theGuide, which recom-mendscomplementaryfeedingstartingfromthesixthmonth onwards,36%(n=18)ofthesitespresentedthecorrect infor-mation,while24%(n=12)presenteditincorrectly,and40% (n=20)omittedit.
After analyzing the third step, it was found that 64% (n=32)ofthewebsitesproperlyinformedthat complemen-taryfoods shouldbe offeredafterthe sixthmonth, three times a day, for children who are exclusively breastfed. Another 26% (n=13) said only one daily baby food would be required to supplement the feeding at this stage, or that only fruit should only be offered, while the Guide recommends the introduction of cereals, tubers, meats, vegetables,fruits,andvegetables.Theremaining10%(n=5) didnotfeaturethisinformation.
Onthefourthstep,mostofthewebsites(60%;n=30)did notmention this information, while only 30% (n=15) pre-senteditcorrectlyand10%(n=5),incorrectly.
The fifth step indicates that complementary feeding should be initiated in the form of porridge and purees, andshouldbeservedwithaspoon.Itisnecessarythatthe increaseinconsistencyoccursgradually,untilreachingthat ofthefamilymeal. The resultfound onpopularsites was that26%(n=13)stillindicatedthatthemealshouldbesifted orliquefiedtopreventchoking.
Regardingthe sixthstep,inthe present study,most of them(66%;n=33)werefaithfultotheinformationcontained intheGuideand30%(n=15)didnothavethisguidance.Only 4%(n=2)ofthesitespresentedincorrectinformationabout this step,as theyencouraged the supply of processed or sugaryfoods.
Oneofthem,presentedintheseventhstepoftheFood Guide,concerns the encouragement of daily consumption offruitsandvegetablesatmeals,forwhich60%ofthesites providedthecorrectinformation.
pre-Table1 Informationcollectedonpopularwebsites,
com-paredwith the Food Guide for Children Under Two Years
(MinistryofHealth,2010);Brazil,2015.
Recommendation n %
Step1---Exclusivebreastfeedinguntilthesixthmonth
Agreement 40 80
Disagreement 9 18
Noinformation 1 2
Step2--- Complementaryfeedingfromthesixthmonth onwards
Agreement 18 36
Disagreement 12 24
Noinformation 20 40
Step3---Foodoffer
Agreement 32 64
Disagreement 13 26
Noinformation 5 10
Step4---Mealtimesaccordingtothatofthefamily
Agreement 15 30
Disagreement 5 10
Noinformation 30 60
Step5---Consistency
Agreement 24 48
Disagreement 13 26
Noinformation 13 26
Step6---Variedfood
Agreement 33 66
Disagreement 2 4
Noinformation 15 30
Step7---Dailyofferoffruitsandvegetables
Agreement 30 60
Disagreement 2 4
Noinformation 18 36
Step8---Avoidofferingprocessedfoods
Agreement 18 36
Disagreement 2 4
Noinformation 30 60
Step9---Importanceofhygieneduringpreparation
Agreement 13 26
Disagreement 0 0
Noinformation 37 74
Step10---Encouragethesickchildtoeat
Agreement 6 12
Disagreement 0 0
Noinformation 44 88
sented itcorrectly, 4%(n=2)presented it incorrectly,and most(60%;n=30)didnotgivethisinformation.
The vast majority of sites (74%; n=37) did not fea-ture information about complementary food safety and hygiene, while 26% (n=13) containedcorrect information, which corroborated the ninth step: attention to food hygiene,preparation,andhandling;ensureproperstorage andconservation.
Only12%(n=6)ofthewebsitesaddressedthetenthstep, whichistoencouragesickandconvalescentchildrentoeat byofferingtheirusualfoodandfavoritefoods,respecting theiracceptance.Mostwebsites88%(n=44)didnotpresent thisrecommendation.
Discussion
Regardingtostepone,whichreinforcestheexclusive breast-feedinguntilsixmonthsofage,itisimportanttohighlight that a study that assessed the growth of children receiv-ing exclusive breastfeeding until 6 months demonstrated that thesechildren reached thesixthmonth witha mean weight higher than the 50th percentile of the National Center for Health Statistics (NCHS) weight curve.10 This reinforces thatbreast milk notonly ensures the develop-ment ofnumerous psychological andimmunologicalskills, but alsois acomplete foodfrom anutritional standpoint and, whenprovided tothechild exclusively untilthe age of 6 months,promotes healthy and propergrowth at this stage, meetingall the nutritionalneeds andreducing the incidence of morbidity and mortality, among many other benefits.10---12
On thesecond step,exclusive breastfeeding is ableto nourishthechildonlyuntilthesixthmonth;afterthisage,it isnecessarytointroducenewfoods.Atthisstage,thechild isalreadyphysicallyandpsychologicallypreparedtoreceive complementary foods. Early or late introduction of com-plementaryfoods cancause seriousdamagetothechild’s healthanddevelopment.Ifstartedearly,itreduces exclu-sivebreastfeedingtimeandmaydecreasetheabsorptionof importantnutrientspresent inbreastmilk;ifstartedlate, itcanleadtodeficiencyinmicronutrientsthatareessential tochilddevelopment.7,13
Aboutthirdstep,complementaryfoodshouldberichin micronutrientsandenergy,have aproperconsistency,and beuncontaminated,toensureahealthygrowthofthechild. Iron,forexample,isanessentialmicronutrientforgrowth andinfantdevelopment.Theintroductionoffoodscan inter-ferewiththeabsorptionoftheironpresentinbreastmilk,so itisveryimportantthatcomplementaryfoodsareiron-rich, suchasmeatoroffal,andaresourcesofvitaminC,which contributestotheabsorptionofnon-hemeironpresent in foodssuchasdarkgreenvegetables.1,7,13
Thetimewhencomplementaryfeedingisintroducedin thechild’sroutineisveryimportantforabetteracceptance duringthistransitionphase,aswellasisaddressedonthe fourth step.1 This stepclarifies thatcomplementaryfoods shouldbeservedaccordingtothefamilymealtime,at reg-ularintervals, andrespecting thechild’s appetite.This is oneofthestepsthatweremodifiedin2010,sincethe previ-ousFoodGuide,from2002,stipulatedthatcomplementary feeding shouldbeofferedwithout rigid schedules, always respectingthechild’swill.
value, thus hindering oral dynamics, growth, and proper development.1,14---16
In a study that evaluated scientific and popular sites, Werneck16 foundthat theinformationpresentin thesixth step,which indicatesthatthechildshouldbeoffered dif-ferent foods each day, was correctly presented in 41.7% of the sites, while 58.3% did notprovide any information aboutfooddiversity.Differentfromthepresentstudy,which hadmoreencouragingresults,andmostevaluatedwebsites (66%)weretruetotheGuide’srecommendation(step6).
Regardingthestep7,theacceptanceoffruitsand veg-etables by children cause great anxiety in parents. The rejectionofthesefoodsiscommon,becauseinadditionto thefactthatfoodneofobiaisaphysiologicalcharacteristic, childrenusually havea preferencefor sweet taste. There are,however,severalwaystoestablishhealthyeatinghabits early.16,17
Despitetheimportanceoftheeighthstep,which recom-mendsavoidingtheofferofsomefoodssuchassugar,coffee, canned,friedfoods,softdrinks,candiesandotherprocessed foods tochildren under twoyears,most of the websites (60%)omittedthisinformation.Suchfoods,besidesreducing children’sappetite,competewithnutritious food,making childrenrejectthelatter.Theintroductionofenergy-dense foodswithlow nutritionalvaluefromthebeginningof life and the early withdrawal of breastfeeding contribute to impaired growthanddevelopment,andlead todecreased immune protection, triggering of allergic processes, and nutritionaldisorders.1,8,10,18,19
Abouttheninthstep,attentiontohygieneinthe prepa-rationofmealsisveryimportanttopreventinfectionsand food poisoning through contaminated food. In this stage of life, children arestilldeveloping their immune system andneedgreaterattentionandcare.Inpreparedfood,the proliferation of organismscan occur ifthe food is leftat roomtemperature or ifthefridgeis notkeptat a proper temperature(below5◦C).Therecommendationisthatfood
should be prepared in sufficient quantity for the timeof consumption.1,6,7
On thetenthandfinalstep,itis ofutmostimportance thatthesickchildisfedproperlyforaquickrecovery, pre-ventingdelaysingrowthandweightloss,whichatthisstage canbecomeirreversible,andreinforcingtheroleofparents andcaregiversinthestimulusoffeeding.1,20
Itisworthemphasizingthatthisstudyhassome limita-tions,suchasthefactthatsocialnetworkssuchasFacebook and Instagram, which have shown an increase use in the countryin recent years,werenot included. Furthermore, thequalityofthewebsites,includingspecificcriteriasuchas legibility,completeness,design,andaccuracy,among oth-ers,wasnotbroadlyassessed.21Nevertheless,inthecontext outlinedinthepresentstudy,itisimportanttomentionthe roleofhealthcareprofessionalsatalllevelsofattentionin providingreliableandupdatedinformation,inlinewiththe recommendationsof officialhealthagencies,todemystify potentialmisinformationdisseminatedontheInternet.
The informationcontainedinthewebsiteswas,for the mostpart,in disagreementwithwhatis recommendedby theBrazilianMinistryofHealth(2010).Theinformationthat was most in contradiction with the recommendation was thatrelatingtocomplementaryfeeding,bothinthe diver-sityofthefoodsupplyandinitsconsistency.Still,itshould
benotedthataconsiderablenumberoftheanalyzedsites reported the importance of exclusive breastfeeding until thesixthmonth.Itwasobservedthat,althoughcontenton foodandnutritionhavegainedspaceontheInternetdueto theincreaseddemandofthepopulationforhealth-related topics,many sites present incorrect information, without theoreticalfoundation.
Therefore,greater publicityof theappropriate recom-mendations and the inspection of content on websites focused on child feeding are necessary. Reliable sources directed both to the lay population and healthcare pro-fessionalcan contributeto diseaseprevention and health promotion.
Funding
Thisstudydidnotreceivefunding.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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