Pediatric Nutrition and Nutritional disorders

Pediatric Nutrition and Nutritional disorders

Normal Growth pattern

• Head circumference:
• Average at birth = 35 cm (33-37)
• ♦ If> 37= macrocephaly
• ♦ If<33 = microcephaly
• Rate of growth:
• 1. first year ↑ 12cm: 1st 3 months= 2cm/m (6cm), 2nd 9
months =2/3 cm/m (6cm)
• 2. second year only ↑ 2 cm
• 3. 3-18 years ↑ 8 cm ( 0.5cm/year)
• So:
• ♦ HC at I year old = 35+12=47cm
• ♦ HC at 2 years old= 47+ 2 =51 cm
• ♦ HC at 18 years old= 51+8=59 cm

Weight

• Average at birth = 3250 g (2.5-4 Kg)
• ♦ SGA: small for gestational age = ↓ 2.5 Kg
• ♦ LGA: large for gestational age =↑ 4Kg
• Growth rate:
1. 1st year ↑ 6kg ( triple weight) : 1st 4 months=750g/m, 2nd 4
months=500g/m, 3rd 4 months=250g/m = 9250g
2. 2-7 years ↑ 2kg/yr = 20Kg at 7 yrs
3. 8-13 years = age *7-5
• Note: 2
• Double weight at 4-5 months
• 750*4+450=3450
• Triple weight at 1 year
• Quadruple birth weight at 2 yrs

LENGTH

• Average at birth= 50cm (47-55cm)
• • Growth rate:
1. 1st year ↑ 25cm (2cm/m) = 75 cm
2. 2nd year ↑ 12cm (1cm/m)= 87cm
3. 3rd year ↑ 6cm (0.5cm/m) = 93cm
4. 4th year = 1 meter
5. 5-18years = 100+(age-4)*5

Assessment of growth parameters

Pediatric nutritional requirement

• Fluids and electrolytes:
• Up to 10kg: 100ml/kg/day
• 11-20 kg: 100ml/kg/day +50ml/kg/d for each kg above 10 kg
• Above 20kg: 25ml/kg/d for each kg above 20kg.
• Calorie requirement:
• Neonates need approximately 110-120 kcal/kg/d
• Toddlers: 90kcal/kg/d
• After 3 year calorie intake varies with gender,age,weight and activity.

Macronutrients

• PROTEIN
• Protein should make up approximately 10% to 35% of a
child’s diet.
• 1.5/kg/d for infants up to 6 months of age
• 0.85/kg/d in adolescents
• FATS:
• Children <2yrs should get approximately 25% to 40% of their calories from fat.
• Older children should get 10% to 35% of their calories from fat.
• CARBOHYDRATE
• Carbohydrates make up approximately 45% to 65% of total caloric intake.
Adequate nutrition is essential for good health at all ages

Diet of the Normal Infant

• The first 6 months, is a period of exceptionally rapid growth and high nutrient requirements relative to body weight.
• There is risk of rapid deterioration in growth and nutritional status, with potential for adverse consequences on neurocognitive development.
• Most infants can start breast-feeding shortly after birth, almost always within 4–6hr.
• The time required for an infant's stomach to empty varies from 1–4hr or more during a single day. The infant's desire for food will vary at different times of the day
• Infants will have established a suitable & reasonablym regular schedule by 1 mo of age.

Diet pattern for normal infants

• Breast-fed infants prefer shorter feeding intervals than formula-fed infants.
• Most infants will be taking 80–90mL per feeding by the end of the 1st wk of life.
• Feeding considered to have progressed satisfactorily if the infant is no longer losing weight by the end of the 1st wk of life & is gaining weight by the end of the 2nd wk.
• most infants will awaken for a middle-of-the-night feeding until 3–6 wk of age, some desire it well beyond 3–6 wk of age.
• Between 4–8 mo of age, many infants will lose interest in the late evening feeding; and by 9–12 mo of age, most will be satisfied with 3 meals/day plus snacks.

BREASTFEEDING

• Human milk is the ideal and uniquely superior food for infants for the first year of life and as the sole source of nutrition for the first 6 months.

• ADVANTAGES OF BREAST-FEEDING:

• 1. advantages to mothers : decreased risk for postpartum hemorrhage, longer period of amenorrhea, reduced risk of ovarian and premenopausal breast cancers, and reduced risk of osteoporosis
• 2. Advantages to society : reduced healthcare costs owing to lower incidence of illness in breastfed infants and reduced employee absenteeism for infant illness care Advantages of breast feeding to the infant
• 1. Available at the proper temperature and requires no preparation time.
• 2. Fresh and free of bacteria ↓GI disturbances.
• 3. The protective effects of breast milk against pathogens leads to less morbidity.
• 4. Fewer feeding difficulties incident to allergy and/or intolerance to bovine milk: diarrhea, intestinal bleeding, occult melena, “spitting up,” colic, and atopic eczema.
• 5. Lower frequency of allergic and chronic diseases in later life than formula-fed infants.
• 6. Contains bacterial & viral antibodies, high secretory IgA that prevents microorganisms from adhering to the intestinal mucosa.
• 8. ↓Incidence or severity of diarrhea, respiratory illnesses, otitis media, bacteremia, bacterial meningitis, NEC.
• 9. Macrophages in human milk synthesize complement, lysozyme, and lactoferrin: lactoferrin, an iron-binding whey protein that is onethird saturated with iron and has an inhibitory effect on the growth of Escherichia coli in the intestine.
Beneficial properties of human milk compared to infant formula Human milk have a Protective effect in following conditions

Comparison of Breast Milk to infant formula

• 1. low but highly bioavailable protein content
• 2. generous quantity of essential fatty acids
• 3. presence of long-chain unsaturated fatty acids (docosa-hexaenoic)
• 4. low sodium and solute load
• 5. Low but highly bioavailable concentrations of calcium, iron, and zinc, which provide adequate quantities for 6 months.
• 6. breast milk does not need to be warmed, does not require a clean water supply, and is generally free of microorganisms.

Comparison of Breast Milk to Cow Milk

Supplement recommendation for breastfeed infant
• Supplements were needed for breastfeed infants:
1. 1mg IV of vitamin K at birth: as content of human milk is low and contribute to hemorrhagic disease of the newborn
2. 10μg/d of vitamin D: If low maternal vitamin D intake & the infant's exposure to sunlight is limited (e.g., dark-skinned infants).
3. iron -fortified foods or ferrous iron preparation: By 4–6 mo of age.
4. 10μg/d fluoride for the first 6 mo of life If the water supply is not adequately fluoridated (=0.3ppm).

Contraindication to breast feeding

• maternal contraindications to breast-feeding.
• 1. Mothers with septicemia, active tuberculosis, typhoid fever, breast cancer, or malaria should not breast-feed.
• 2. avoid infant nursing & contact on that breast in Herpetic lesions on breast
• 3. Maternal HIV infection is a contraindication for breastfeeding in developed countries.
• 4. Fresh donor milk for feeding is contraindicated if the milk is known to be CMV positive in preterm.
• 5. Substance abuse and severe neuroses or psychoses are contraindications
• Infantile contraindications:
• 1. Metabolic diseases: galactosemia, maple serup urine disease, organic academia.
• 2. Anatomical reasons: cleft lip or cleft palate, extract the breast milk and put it in bottles with special goat nipple.

Contraindication to breast feeding

MALNUTRITION

• The World Health Organization defines malnutrition as "the cellular imbalance
between supply of nutrients and energy and the body's demand for them to ensure
growth, maintenance, and specific functions."
• It is directly responsible for 300,000 deaths per year in children <5 years in developing countries and
• contributes indirectly to more than half of all deaths in children worldwide

CLASSIFICATION

• Undernutrition
• Lack of nutrients
• Calories
• Protein
• Micronutrients
• Low income countries

• Overnutrition
• Obesity
• Too many calories
• High and middle income
countries

INDICATORS OF MALNUTRITION

Indicator	Interpretation
Stunting	Low height for age	Chronic malnutrition
Wasting	Low weight for height	Acute malnutrition
Under weight	Low weight for age	Combine acute and chronic malnutrition

PEDIATRIC UNDERNUTRITION

• Worldwide, protein-energy malnutrition (PEM) is a leading cause of death among children younger than 5 years old.
• Could be:
• A. Primary PEM : social or economic factors that
result in a lack of food.
• B. Secondary PEM
• 1. increased caloric requirements (infection, trauma, cancer)
• 2. increased caloric loss (malabsorption)
• 3. reduced caloric intake (anorexia, cancer, oral intake restriction, social factors)

CLASSIFICATION

• Chronic malnutrition:
• is identified by low height for age, also known as stunting. Chronically malnourished children are shorter than other children their age and may fail to meet their long-term growth potential.
• Acute malnutrition:
• is characterized by low weight for height and low MUAC with or without symmetric edema.
• Severe acute malnutrition is defined as severe wasting, nutritional edema, or both.

Measurement of mid-upper arm circumference.

Interpretation of mid-upper arm circumference

• MUAC less than 110mm (11.0cm), RED COLOUR, indicates Severe Acute Malnutrition (SAM). The child should be immediately referred for treatment.
• MUAC of between 110mm (11.0cm) and 125mm (12.5cm), RED COLOUR (3-colour Tape) or ORANGE COLOUR (4-colour Tape), indicates Moderate Acute Malnutrition (MAM). The child should be immediately referred for supplementation.
• MUAC of between 125mm (12.5cm) and 135mm (13.5cm), YELLOW COLOUR, indicates that the child is at risk for acute malnutrition and should be counseled and followed-up .
• MUAC over 135mm (13.5cm), GREEN COLOUR, indicates that the child is well nourished.

CLASSIFICATION METHODS

Summary

WHO criteria of defining moderate and severe malnutrition

SEVERE ACUTE MALNUTRITION
• The term proteinenergy malnutrition, (PEM) applies to a group of related disorders that include marasmus, kwashiorkor and intermediate states of marasmus kwashiorkor.

MARASMUS
• Non edematous malnutrition: is a condition primarily caused by a deficiency in calories and energy.
• It is characterized by failure to weight gain &irritability followed by weight loss & listlessness until emaciation result

CLINICAL MANIFESTATIONS

• The principal clinical manifestation is emaciation with:
• A. body weight < 60% of the median for age or < 70% of the ideal weight for height
• B. Depleted body fat stores.

• Others:

• 1. Loss of muscle mass and subcutaneous fat.
• 2. The head appears large, but is proportional to the body length.
• 3. Edema is absent.
• 4. The skin is dry and thin
• 5. The hair is thin, sparse, and easily pulled out.
• 6. Apathetic and weak.
• 7. Bradycardia and hypothermia signify severe and life-threatening malnutrition.
• 8. Atrophy of the filiform papillae of the tongue is common
• 9. monilial stomatitis is frequent

KWASHIORKOR

• Hypoalbuminemia, Edematous malnutrition:
• presents with pitting edema that starts in the lower extremities and ascends with increasing severity
• classically described as being caused by inadequate protein intake in the presence of fair good caloric intake.
• Other factors, such as acute infection, toxins, and possibly specific micronutrient or amino acid imbalances, are likely to contribute to the etiology.

Clinical features of kwashiorkor

• The major clinical manifestation of kwashiorkor is that the body weight of the child ranges from 60% to 80% of the expected weight for age
• • Physical examination:
• 1. apathy and disinterest in eating are typical of kwashiorkor (relative)
• 2. maintenance of subcutaneous adipose tissue
• 3. marked atrophy of muscle mass
• 4. Edema varies from a minor pitting of the dorsum of the foot to generalized edema with involvement of the eyelids and scrotum.

Clinical features of kwashiorkor
• 5. The hair is sparse, is easily plucked, appears dull brown, red, or yellow-white.
• 6. Nutritional repletion restores hair color, leaving a band of hair with altered pigmentation followed by a band with normal pigmentation (flag sign).
• 7. Skin changes :
• 1. hyperpigmented hyperkeratosis -trunk and extremities
• 2. erythematous macular rash (pellagroid) – trunk and extremities.
• 3. superficial desquamation over pressure surfaces ("flaky paint" rash). Most severe form of kwashiorkor

Difference between marasmus and kwashiorkor

Kwashiorkor and marasmus.

Risk factors
• The following are significant risk factors for MAM and SAM:
• Inadequate dietary intake
• Inappropriate feeding
• Fetal growth restriction
• Inadequate sanitation
• Lack of parental education
• Family size
• Incomplete vaccination
• Poverty
• Economic, political, and environmental instability and emergency situations.

Pathogenesis

Diagnosis

• The diagnosis of severe acute malnutrition rests mainly on meticulous clinical examination for the symptoms and signs of the syndrome plus anthropometric assessments using different methods.
• Additionally one may need laboratory investigation for the assessment of complications and other health problems associated with malnutrition.

Laboratory Studies
• The WHO recommends the following laboratory tests:
• Blood glucose
• Examination of blood smears by microscopy or direct detection testing
• Hemoglobin
• Urine examination and culture
• Stool examination by microscopy for ova and parasites
• Serum albumin
• HIV test (This test must be accompanied by counseling of the child's parents, and strict confidentiality should be maintained.)
• Electrolytes

Laboratory features of severe malnutrition

Complications

WHO classification depending upon treatment protocol IMCI guidelines of management in children from 6-39 months
Phases in management of acute severely malnourished children.
Provide special feeds for the following:

Treatment of the complications

Hypoglycemia	Blood glucose level<54mg/dl or 3mmol/l Give 50ml of 10% glucose orally or by NG tube Feed with F-75 every 2 hr
Hypothermia	Rectal temperature <35.5C or 95.5F Cloth the child with warm cloths Provide heat Feed it immediately
Infections	If no clinical sign of infection, the WHO recommends 5 days of oral cotrimoxazole therapy If clinical sign present parenteral ampicillin and gentamicin

Dehydration
• Dehydration in children with marasmus is difficult to evaluate, is over diagnosed , oral rehydration therapy is preferred.
• In cases of shock, intravenous (IV) rehydration is recommended using
• a Ringer-lactate solution with 5% dextrose or a mixture of 0.9% sodium chloride with 5% dextrose.
• Enteral hydration using ReSoMal should be started as early as possible, preferably at the same time as the IV solution.
• The following rules should be implemented in the initial phase of rehydration:
• (1) use an nasogastric (NG) tube;
• (2) continue breastfeeding, except in case of shock or coma; and
• (3) start other food after 3-4 hours of rehydration.

Stabilization phase
• Breast milk and F-75 milk formula (75kcal and 0.9g protein per 100mL) are recommended by the WHO for feeding.
• Exclusive breastfeeding is often unsuccessful for infant with severe malnutrition ; therefore, supplementation with F-75 should be attempted.
• Deaths related to an excessive renal solute load during malnutrition recovery can be avoided by using F-75 formula.
• Between 80 and 100kcal/kg of F-75 should be given daily during the stabilization phase by way of small feedings every 2 to 3 hours

Composition of F75 and F100 diets
Rehabilitation phase (weeks 2-6)
• In this phase of treatment, nutritional intake can reach 200 kcal/kg/d.
• The goal is to reach a continuous catch-up growth in weight and height in order to restore a healthy body weight.
• To encourage the child to eat as much as possible
• To restart breastfeeding as soon as possible
• To stimulate the emotional and physical development
• To actively prepare the child and mother to return to home and prevent recurrence of malnutrition
• During the rehabilitation phase, the F100 formula, with a higher protein content or RUTF is recommended.
• The main risk of this phase of the rehabilitation is that the nutrients provided are not sufficient to sustain the weight gain, which can reach as much as 15 g/kg/d

Micronutrient supplements guidelines
• Micronutrient deficiencies are also common among children with severe malnutrition.
• Vitamin A deficiency should be assumed to be present, and high-dose vitamin A should be provided on day 1 of treatment.
• For infants < 6 months :50,000U of vit A
• 6-12 months : 100,000U
• >12 months : 200,000U
• When clinical signs of vitamin A deficiency are present, an additional large dose of vitamin A should be given on day 2 of rehabilitation and a third dose about 2 weeks later.
• micronutrient supplementation in the form of a vitamin mix containing riboflavin; pyridoxine; thiamine; and vitamins C, D, E, and K should be provided daily.
• Folate should also be supplemented giving 5mg on day 1 and then 1mg/d throughout rehabilitation and follow-up.
• Iron can have toxic effects during acute severe malnutrition and should not be given during the first week of treatment.

Summary of the management of SAM

Refeeding syndrome
• Complications associated with refeeding include:
• Hypomagnesemia
• Hyperglycemia
• Hypokalemia
• Hypophosphatemia- hallmark
• Thiamine deficiency

Clinical presentation of refeeding syndrome

Prevention and treatment of refeeding syndrome
Preventive measures for malnutrition
• Promotion of breastfeeding
• Appropriate complementary feeding
• vitamin A supplementation
• Antenatal care provides opportunities for nutritional counseling and healthy mother
• Proper case management of childhood illnesss are most effective at preventing malnutrition or its effects
• Prevention of diarrheal diseases
• Immunization to prevent infections

Obesity
• Many obese children become obese adults.
• • The risk of remaining obese increases with age and the degree of obesity also is influenced by family history..
• • If one parent is obese, the odds ratio for the child to be obese in adulthood is 3, but this increases to 10 if both parents are obese.
• • Obesity runs in families
• • The diagnosis of obesity depends on the measurement of excess body fat.
• • BMI is a convenient screening tool that correlates fairly strongly with body fatness in children and adults.
• • For children < 2 years old, weight for length greater than 95th percentile may indicate overweight or obesity and warrants further assessment.

Body Mass Index (BMI) Interpretation Complications of Obesity

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