Pedia - Nutrition

8/12/2019 Pedia - Nutrition

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Eva I. Bautista, MD, DPPS

Nutrition


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Adequate Nutrition:

maintains current weight

supports normal growth and development


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Infancy

rapid

critical for neuro-cognitive development

high metabolic rate

high nutrient requirement


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Nutrition and growth in infancy

predict adult stature / health outcomes

nutrient deficiencies can impart lasting effects

on growth and development


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Inappropriate feeding practices:

diabetes

hypertension obesity

metabolic syndrome


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Breastfeeding

Exclusive breastfeeding for at least 6 months

Follow up within 24-48 hours after discharge


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Breastfeeding concerns

nipple pain

engorgement

mastitis

milk leakage

inadequate milk intake

jaundice

breast milk collection

growth of the infant


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Nipple pain

poor infant positioning

nipple candidiasis


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Engorgement

2ndstage of lactogenesis

firm, overfilled and painful breasts Due to incomplete removal of milk

Treatment: frequent breastfeedingmanual milk expression


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Mastitis

in 2-3% of lactating women

usually unilateral occurs after the 2ndpost-delivery week

breast pain, myalgia, fever, nausea, vomiting,

warmth, tenderness, edema, erythema


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Mastitis

Causes: S. Aureus, E. coli, Strep,

H. influenzae, Klebsiella, Bacteroides

Treatment: antibiotics and analgesics

breastfeeding (?)

emptying of the affected breast

Complication: breast abscess


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Milk Leakage

common

involuntary causes: breastfeeding on the opposite side

reflex in response to infants cry

resolves spontaneously


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Inadequate milk intake

Causes: insufficient milk production

failure of established breast-feedinghealth condition of the infant( preterm)

improper technique

Must breast-feed at least 8x /day


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Inadequate milk intake

fretful, dehydrated

delayed stooling decreased urine output

weight loss >7% of birth weight

increased hunger


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Breast-feeding Jaundice

insufficient fluid intake

healthy baby with jaundice

hyperbilirubinemia

declines after 2ndweek


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Causes of Breast feeding Jaundice

Breastmilk content:

inhibitors of glucuronyl transferase

enhanced absorption of bilirubin from the gut


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Breast feeding jaundice

If severe or persistent

galactosemia

hypothyroidism

urinary tract infection

hemolysis

Treatment: Change from breast milk to

formula for 24 to 48 hours and/or

Phototherapy with breast feeding

Should continue breast milk collection


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Breast milk Collection

mothers work / illness

hygiene breast pumps / manual expression

ref48 hours

freezer- 6 months thawed milk- 24 hours


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Breast-fed infants

their growth patternthe norm

less risk for excess weight gain


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Beneficial properties of human milk

Secretory IgA

lactoferrin

cytokines

nucleotides


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Protective effects of human milk:

Acute

diarrhea

UTI

Septicemmia

Chronic

diabetes

leukemias

allergy


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Protective effects of human milk:

obesity and overweight

hospitalizations

infant mortality


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Contraindications to Breast-Feeding

HIV

Tuberculosis

Varicella-Zoster Infection

Herpes Simplex Infection

CMV infection

Hepatitis B

Cigarette smoking

Chemotherapy/Radiopharmaceuticals


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Formula feeding

20 kcal/30 ml

sterility

variable scoop sizes

water used ?

hygiene allergy to cows milk protein


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Feeding

25-30 g/day weight gain

140-200 ml/kg/day


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Cows milk protein based formulas

higher protein

predominant whey protein ( globulin)


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Soy formulas

Cows milk protein-free

Lactose-free

Indications:

galactosemia

hereditary lactase deficiency

vegetarian diet

secondary lactose intolerance


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Protein hydrolysate formula

Partially hydrolyzed

Not for infants with cows milk protein allergy

for high risk of atopic disease


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Extensively hydrolyzed formulas

cows milk protein intolerance

soy protein intolerance lactose free

medium chain triglycerides

for those with malabsorption


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Complementary feeding

at 6 months

cup, not bottle

introduce 1 food at a time

iron-containing foods

higher energy density

continue breastfeeding

up to 24 oz /day of cows milk

up to 6 oz of fruit juices


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Complementary feeding

introduce 1 food at a time, no new food for 3-5 days

variety of foods, 8-10 attempts

choking hazards:hot dogs

nuts

grapes popcorn avoid adding sugar/salt


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Water intake

weight/length/head circumference

temperature


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Feeding toddlers and Preschool-age

children

Slower growth

Increased motor activity

Decreased appetite

Explores the environment


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6 mo - birthweight x 2

2 y/obirthweight x 4

4 y/obirth length x 2


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Feeding toddlers and Preschool-age

children

Limited food intake

Like a particular food for a time period


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How to deal with parental concern?

Growth chart

Guidance

Foster healthful eating habits

Offer foods that are age-appropriate

Dont always give in to every childs request


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Feeding skills

6-9 mo feeds in upright positionthin, pureed foods, finger foods

9-12 mo cup drinking

lumpy, mashed food

12-18 mo self feeding

holds cup, grasps spoon

18-24 mo chews broad range food

24-26 mo cup drinking without spill

use fingers to fill spoon

use fork


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Feeding toddlers

Encourage positive eating behaviors

Ignore negative ones

Reluctance to accept new foods?

Eat 5-7 times a day


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School-Age Children and Adolescents

5 food groups: grains

fruits

vegetables

milk

meat and beans

plus oils Eat variety of food


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School-age and Adolescents

Sweetened beverages

Snack foods

High fat meat

High fat dairy products

Skipping meals

Larger serving sizes

Fad diet


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Nutrition issues

Food as reward

food withdrawal as punishment

Food advertisement


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Vegetarianism

Can satisfy the nutritional goals

Lower risks: cancer, ischemic heart disease

Lower BMI / cholesterol / BP


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Nutrients of concern: Vegetarian diet

Iron beans, cashews, raisins

Vit B12 dairy products and eggs

Fatty acids

Calcium leafy greens

Zinc red meat


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Organic foods

More expensive

Limited scientific basis

Lower / no detectable pesticides - urine


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Undernutrition

Household level food security

Access to health and sanitation services

- immunization

Child-caring practices

- weaning


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Undernutrition

Inadequate knowledge: benefits of breastfeeding

Pregnancy

First 2 years of life

Folate deficiency

Iron-deficiency anemia


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Malnutrition

Undernutrition

underweight

stunting

wasting

nutrient deficiency

overweight


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Malnutrition

Classification Definition Grading Criteria

Gomez Weight below %

Median WFA

Mild / 1

Moderate/2

Severe / 3

75-90% WFA

60-74% WFA


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Height for Age (HFA)

Assess nutritional status

A measure of skeletal growth Stunting

A measure of chronic malnutrition


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Weight for height (WFH)

Wasting

A measure of Acute malnutrition

If not feasible, use mid-upper arm

circumference (MUAC)


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Weight for age

Combines stature with current health

conditions

Less clinical significance


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130 lb, 4 ft 10 inches

BMI ? = weight (kg)

___________

height (m )


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130 lb, 4 ft 10 inches

BMI = 27


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140 lb, 5ft 3 in

BMI = ?


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140 lb, 5 ft 3 in

BMI = 24.8


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Outcomes of poor nutrition

Prematurity

IUGR

Low birth weight

Premature death- most immediate

consequence

Increased risk of death

Cognitive impairment


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Stunting, severe wasting and IUGR

35% of all child mortality globally

2.2 million deaths < 5 y/o


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8 Millenium Development Goals

Agreed upon by international devtcommunities

1st- to eradicate extreme poverty and hunger

To halve, between 1990- 2015the proportion of people who suffer from

hunger

the proportion of people whose incomeis less than $ 1/day


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Key Interventions

Exclusive breastfeeding

Adequate and timely complementary feeding

key hygiene behavior

Micronutrient interventions

Deworming and oral rehydration

Fortifying foods with micronutrients

Malaria treatment / insecticide-treatedbednets


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Other interventions

Birth-spacing

immunizations


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HIV- positive mothers

Can she breastfeed?


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HIV transmission

Risk of HIV transmission

15-25% by a non-breastfeeding mother

20-45% by a breastfeeding mother

HIV positive mothers and


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HIV-positive mothers and

breastfeeding

Lesser risk if exclusively breastfeeding

Higher risk if longer duration of breastfeeding

Majority of transmission occurs 6 months

after delivery

HIV positive mothers and non


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HIV-positive mothers and non-

breastfeeding

Costly milk substitutes

Diarrheal diseases

Higher infant/child mortality


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Marasmus

Severe protein calorie malnutrition

nonedematous malnutrition

Failure to gain weight and irritability

weight loss

emaciation


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Kwashiorkor

Lethargy / irritability

Loss of muscle tissue

Increased susceptibility to infections

Vomiting / diarrhea

Dermatitis

Thin, sparse hair / streaky red or gray hair


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Activity Initial Treatment Rehabilitation Follow- up


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Treatment of Severe MalnutritionDays 1-2 3-7 weeks 2-6 weeks 7-26Treat or prevent

hypoglycemia ---------

hypothermia ---------

dehydration ---------

infection -------------------

Correct

electrolyte imbalance ---------------------- ----------------------

micronutrient def ------------------------

----------without

----------------------

Iron-----------------

Begin feeding -------------------

Increase feeding to

recover lost weight

------------------------- ----------------------

Stimulate emotional

sensorial devt ---------------------- ------------------------- ----------------------

Prepare for Discharge ----------------------


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Obesity

Increased adiposity

Imbalance of caloric intake and energy

expenditure

Childhood complications

Increased morbidity and mortality

Increased prevalence


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Obesity

BMI 30

> 2 y/o BMI 95thpercentile


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Obesity

Global public health problem

30 % of adults (35% are overweight) in the US

31% of >2 y/oobese or overweight

16% of 6- 19 years


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Risk factors for Obesity

Parental obesity

Prenatal factors

weight gain during pregnancy

high birth weight

gestational diabetes

l l h


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Etiology: Environmental changes

Larger portion sizes

1/3 of US children eat fast food daily

Sweetened beverages

fructose-laden products

Decreased physical activity

l


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Nutritional Requirements

Recommended Dietary Allowance (RDA):

daily dietary nutrient intake level= the

nutritional requirements of 97-98% healthy

persons (life stage and gender group)


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Estimated Energy Requirement (EER)

In children, includes the needs associated withthe deposition of tissues at rates consistent

with good health

(kcal/day)

= TEE (total energy expenditure) + ED (energy

deposition)

( )


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Age ED

(Energy deposition)

TEE

(Total Energy Expenditure)

0-3 mo

4-6 mo

7-12 mo

13-59 mo

175

56

22

20

EER= TEE + ED

= kcal/day

(89 weight [kg] 100)



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Boys

3-8 y

9-18 y

Girls

3-8 y

9-18 y

EER = 88.5 (61.9 age [yr] + PA [(26.7 weight [kg] + (903 height [m])] +20

+25

EER=135.3-(30.8 x age [yr] + PA[(10 x weight [kg] + (934 x height [m]) + 20

+

25

PA- physical activity

PHYSICAL ACTIVITY COEFFICIENTS:


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PHYSICAL ACTIVITY COEFFICIENTS:

(for use in EER equations)

SEDENTARY

Typical daily living

activities*

Boys 1

Girls 1

LOW ACTIVE


activities plus 30-

60 min of daily

moderate activity

1.13

1.16

ACTIVE


activities plus 60

min of daily

moderate activity

1.26

1.31

VERY ACVTIVE


activities plus 30-

60 min of daily

moderate activity

plus 60 min ofvigorous activity or

120 min of

moderate activity

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ACCEPTABLE MACRONUTRIENT DISTRIBUTIONRANGES
http://www.expertconsultbook.com/expertconsult/b/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00041-5--tn0010&appID=NGEhttp://www.expertconsultbook.com/expertconsult/b/linkTo?type=bookPage&isbn=978-1-4377-0755-7&eid=4-u1.0-B978-1-4377-0755-7..00041-5--tn0010&appID=NGE


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RANGES

AMDR (% OF ENERGY)

Children 1-3 yr Children 4-18 yr

Fat 30-40 25-35

Carbohydrate 45-65 45-65

Protein 5-20 10-30

CARBOHYDRATE


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CARBOHYDRATE

primary energy source for the brain

a source of kcal to maintain body weight

the upper limit of intake

1. less risk of chronic disease

2. to provide adequate intake of other nutrients

CARBOHYDRATE


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CARBOHYDRATE

Major types: starches and sugar

Starch: grains, vegetables (corn, pasta, rice)

Natural sugars: fruits and juices

Added sugars: soft drinks, candy, desserts

FIBER


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FIBER

Improves laxation

reduces risk of coronary heart disease

assists in maintaining normal blood glucose

levels

FIBER


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FIBER

grains :oats, wheat, unmilled rice

functional fiber: butter, vegetable oils, whole milk

visible fat: meat and poultry products,

invisible fat: fish, shellfish

plant products: seeds and nuts

T t l f t


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Total fat

Energy source when found in foods

a source of PUFAs

facilitates absorption of fat-soluble vitamins

T t l f t


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Total fat

Butter, margarine, vegetable oils, whole milk,

visible fat: meat and poultry products,

invisible fat: fish, shellfish

plant products: seeds and nuts

PUFAs


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PUFAs

Essential component of structural membranelipids, involved with cell signaling, precursor of

eicosanoids

Required for normal skin function Involved with neurologic development and

growth

Precursor of eicosanoids


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Saturated and trans Fatty Acids


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Saturated and transFatty Acids

No dietary requirement

There is an incremental increase in plasma

total and LDL cholesterol concentrations with

increased intake of saturated or transfatty

acids

the intakes of each should be minimized whileconsuming a nutritionally adequate diet

PROTEIN


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PROTEIN

Major structural component of all cells in thebody

enzymes in membranes

transport carriers

hormones

AMINO ACIDS


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AMINO ACIDS

building blocks of protein

9 indispensable amino acids must be provided

in the diet

the body can make the other amino acids

AMINO ACIDS IN THE HUMAN DIET


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AMINO ACIDS IN THE HUMAN DIET

Indispensable

HistidineIsoleucine

Leucine

Lysine

Methionine

Phenylalanine

ThreonineTryptophan

Valine

Dispensable

AlanineAspartic acid

Asparagine

Glutamic

acid

Serine

Conditionally

Indispensable

ArginineCysteine

Glutamine

Glycine

Proline

Tyrosine

Precursors of Conditionally

Indispensable

Glutamine/ glutamate, aspartate

Methionine,serineGlutamic acid/ammonia

Serine,choline

Glutamate

phenylalanine

DIETARY REFERENCE INTAKES FOR


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SELECT MICRONUTRIENTS AND WATER

Sodium

Maintains fluid volume outside of cells and

thus normal cell function

Processed foods with added sodium chloride(salt), benzoate, phosphate; salted meats,

bread, nuts, cold cuts; margarine; butter; salt

added to foods in cooking or at the tableSalt is 40% sodium by weight


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Chloride

With sodium, maintains fluid volume outside

of cells and thus normal cell function

Processed foods with added sodium chloride(salt), benzoate, phosphate; salted meats,

nuts, cold cuts; margarine; butter; salt added

to foods in cooking or at the tableSalt is 60% chloride by weight

Potassium


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Potassium

Maintains fluid volume inside/outside of cellsand thus normal cell function; acts to blunt

the rise of blood pressure in response to

excess sodium intake, and decrease markers ofbone turnover and recurrence of kidney

stones

Fruits and vegetables, dried peas, dairyproducts, meats, nuts


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Vitamin Daka calciferol

1 g calciferol = 40 IU vitamin D

DRI values are based on absence of adequateexposure to sunlight

Fish liver oils, flesh of fatty fish, liver and fat

from seals and polar bears, eggs from hensthat have been fed vitamin D, fortified milk

products, fortified cereals

Iron


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Iron

Critical component of enzymes, cytochromes,myoglobin and hemoglobin

Heme sources: meat, poultry, fish

Non-heme: dairy, eggs, plant-based foods,breads, cereals, breakfast foods

Zinc


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Zinc

Essential for proper growth and development,and an important catalyst for 100 specific

enzymes

Meats, shellfish, legumes, fortified cereals,whole grains

Water


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Water

Maintains homeostasis in the bodyAllows transport of nutrients to cells and

removal and excretion of waste products of

metabolism All beverages, including water

Moisture in foods

High-moisture foods include watermelon,meats, soups

Water requirement


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Water requirement

Age6 mo

7-12 mo

1-3 yr

4-8 yr

9-13 yr

14-18 yr 19 yr

Ml/day700

800

1,300

1,700

2,400 boys / 2,100 girls

3,300 boys / 2300 girls3,700 boys / 2700 girls

Kwashiorkor


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Kwashiorkor


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Noma


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Noma


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