Nutrition

1. Nutrition Ricardo A. Caicedo, M.D. Pediatric Gastroenterology & Nutrition

2. NUTRITION GROWTH DEVELOPMENT CHILD HEALTH

3. Objectives • Normal nutrition • Expected growth • Energy requirements • Infant diet • Undernutrition • Failure to thrive • Overnutrition • Obesity

4. Normal Growth INFANCY • Postnatal wt loss expected • 5% of birth wt (BW) • Wt loss > 10% of BW requires evaluation • By 2 weeks: regains BW • 4-6 months: doubles BW • 1 year: triples BW 2 years until puberty • Weight gain: 2-3 kg/yr • Height increase: 5-8 cm/yr

5. Ideal Body Weight (IBW) • Wt (kg) at the 50%ile for the actual ht or length for age • 50th %ile weight-for-length

6. Energy Requirements Requirements for normal growth (kcal/kg/day) Birth 3m 6m 1yr 4yr Adolescence 120 115 100 95 90 75 60 50 40 • Energy (kcal/kg/day) needed for catch-up growth: • 5(grams below IBW) / days for correction of deficit • FATS • Energy: 9 kcal/g triglycerides • Infancy: 30-50% of total kcal; after 2 y: < 30% • Carbohydrates • Energy: 4 kcal/g • After 2 y: > 60% of total kcal, with < 10% from simple sugars • Protein • Increased requirements in prematurity, infants, high catabolic states (sepsis, trauma, surgery)

7. Infant Feeding

8. Advantages Faster gastric emptying Host Defense: IgG Secretory IgA Lysozyme and lactoferrin Decreased atopic conditions Maternal/Infant bonding ECONOMICS Disadvantages Breast engorgement Soreness of nipples TIME Back to work. . . Breastfeeding

9. Breastfeeding • CONTRAINDICATIONS • Maternal TB • Maternal HIV (developed nations) • HSV breast lesions • Maternal illicit drug abuse • Radiation exposure (including diagnostic) • Galactosemia • Medications • Chemotherapy • Diazepam • Lithium • Tetracycline • Alcohol and tobacco use should be avoided/minimized

10. Newborn Diet History • Breastfeeding • How often do you breastfeed? • Does the baby latch on, suck, and swallow? • How do you stimulate the baby? • Formula • How do you prepare the formula? • How much does the baby take per feeding? • How often does the baby feed? • How many total bottles do you prepare for the baby in a day? • Both: • Is the baby spitting up? • How many wet diapers and bowel movements does the baby have each day?

11. Infant Diet History • Does the baby take other liquids? • Not needed before 4-6 m • Limit juice to 4-6 oz/day • Have you started solid foods? • Introduce rice cereal at 4-6 m • When baby can take from a spoon • How many times a day does the baby have solids? • Start with once, increase gradually to 3-4 • How do you introduce new solids? • One new food at a time, with at least 3 day intervals • Cereals, pureed veg. first, then fruits except citrus • Strained meats at 9-12 m • After 12 m: citrus, egg, fish, whole cow’s milk (until age 2y, then low-fat milk)

12. Infant Formulas SEMI-ELEMENTAL Hydrolyzed casein SOY protein-based Lactose-free STANDARD Cow’s milk protein-based ELEMENTAL Amino acids PRETERM DISCHARGE 22 kcal/oz

13. Supplements • Infants • Vitamin K: All infants receive at birth • Vitamin D: Breastfed infants or infants who take <500 ml/day of vit. D fortified formula • Iron: Breastfed infants • Fe absorption is good from human milk, but concentration low. • Fluoride: May be dependent on water supply

14. Supplements • CF, liver disease, malabsorptive disorder • Fat soluble vitamins: A, D, E, K • Vegetarian with inadequate dairy intake • Vitamin B12, D • Eating disorders • Inadequate dairy intake or sunlight UV exposure • Vitamin D • Adolescents: Calcium, Iron • Undernutrition

15. UNDERNUTRITION • Failure to thrive (FTT) • “Failure to gain wt in accordance with standardized growth charts” • Deceleration of growth velocity • Crossing two major percentile tracks on growth curves • Wt below 3rd %ile for age on > 1 occasion • Wt below 80% of ideal body wt for age • EXCEPTIONS • Familial or genetic short stature • Constitutional growth delay (“late bloomer”) • SGA or preterm infants • A sign, NOT a diagnosis

16. Infant chronic medical conditions prematurity developmental delay congenital anomalies intrauterine toxin exposure Family poverty social isolation unusual health and nutrition beliefs disordered feeding techniques violence or abuse parental substance abuse or other psychopathology Risk Factors for Undernutrition

17. FTT Patterns CALORIC Deprivation Poor weight gain Endocrine disorder Wt & ht deficiency Normal HC GENETIC disorder All 3 parameters affected since birth

19. INADEQUATE SUPPLY • Decreased CALORIC intake • ORGANIC causes • Impaired swallowing • Congenital anomaly • Neurologic impairment • Anorexia = impaired appetite • Chronic systemic disease • Cardiac, renal, IBD, cancer, AIDS • PSYCHOSOCIAL causes • Neglect/abuse • Inappropriate feeding technique, preparation, food for age • Limited economic resources

20. Critical illness Sepsis Trauma Burns Chronic systemic disease Cancer Congenital heart disease Hyperthyroidism Diabetes Renal tubular acidosis Inborn errors of metabolism Galactosemia Urea cycle defects Glycogen storage disease INCREASED REQUIREMENTS IMPAIRED UTILIZATION

21. EXCESSIVE LOSSES • VOMITING • Gastroesophageal reflux disease • Anatomic obstruction • Pyloric stenosis • Malrotation • MALABSORPTION • Congenital GI tract anomaly • Pancreatic insufficiency • CF • Inflammatory bowel disease • Celiac disease • Cholestatic liver disease

22. HISTORY Chronology Caloric intake Feeding practices 3-day diet hx Medical Developmental Psychosocial GROWTH CHART Attained parameters Growth VELOCITY Weight for height ratio EXAM General appearance Subcutaneous fat Skinfold measurements Interaction w/caregiver Observation of feeding Complete physical LAB STUDIES CBC Electrolytes/Cr urinalysis Albumin/prealbumin Evaluation

23. Management • OUTPATIENT • Increase caloric density • Decrease water volume in formula • Add carbohydrate or fat • Peanut butter, milk products, margarine • Establish routine • Meals and snacks at set times • Frequent weight checks • INPATIENT • Hospitalize if outpt management fails or high-risk situation • Involve dietitian and social worker • Document daily caloric intake, output, and weight trend • Evaluate ability to swallow and absorb • Imaging • Feeding therapy (speech path.) • Stool tests • Endoscopy • Supplemental feedings • Nasogastric/naso-enteral • Gastrostomy tube • Parenteral nutrition

24. OBESITY • An epidemic in pediatrics • Past 20 y: doubled in kids; tripled in teens • Increase in obesity in adults since 1980 = prevalence of obesity in adolescents • 1999-2002: age 6-19 - 31% at risk for overweight; 16% overweight • Severe obesity (BMI > 35) • More common in children than combined: CF, type 1 diabetes, HIV, and cancer

25. Body mass index (BMI) = weight/height2 = kg/m2

26. Complications • Cardiovascular disease risk factors • 50% have 1, 20% have 2 • Hyperlipidemia • HTN: 22% • Type 2 diabetes • < 25% of obese children at risk • If develops before age 14 y, can lose 17-27 y life expectancy • Sleep disorders: 37% • Asthma • Gastrointestinal disorders • GERD • Chronic abdominal pain • Gallstone disease • Non-alcoholic fatty liver disease • Joint disease • Psychosocial disorders • Low self-esteem • Depression (10%)

27. Management • Graduated • Realistic goals • Motivation • Patient contract • Family participation • Frequent sessions • Long duration • Explicit diet and exercise plan • Weight maintenance • More challenging than initial weight loss • Indications for referral • Co-morbidity • Severe obesity may warrant medication or even bariatric surgery

28. NUTRITION GROWTH DEVELOPMENT CHILD HEALTH