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March Board Review Nutrition. Test Question Sean Payton should be suspended for the whole 2012-2013 season – A. True – B. False.

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Presentation on theme: "March Board Review Nutrition. Test Question Sean Payton should be suspended for the whole 2012-2013 season – A. True – B. False."— Presentation transcript:

1 March Board Review Nutrition

2 Test Question Sean Payton should be suspended for the whole season – A. True – B. False

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4 Current Evidence for Infants Meta-analyses or systematic reviews strongly favored breastfeeding for a reduced risk of: – Acute otitis media – *GI infections – Asthma (regardless of family history) – Type 2 DM – Leukemia – SIDS Lower risk for atopic derm in infants with family history for BF exclusively for 3 months *Reduced risk of hospitalization for LRTI in infants who were breastfed exclusively for 4 months

5 Current Evidence for Mamas Reduced risk of breast cancer in premenopausal women Association between BF and a reduced risk of ovarian cancer (more studies needed) Reduced risk of type 2 DM in women who did not have a history of gestational DM

6 Beyond the Evidence Attachment and bonding between infant and mother Psychological and developmental benefits for both Skin-to-skin contact – Positive attachment – Successful breastfeeding – Longer duration of breastfeeding – Allow in the first hour after birth

7 Question #1 As you are completing the physical exam on a newborn, the father mentions that he and his wife have allergic rhinitis and asthma. He asks whether his son is at increased risk for allergies and how to reduce his chance of developing them. Of the following, the MOST appropriate next step is to explain: –A–A. Because both parents have asthma, breastfeeding will not reduce the risk of eczema –B–B. Breastfeeding or formula choices do not matter now, because mom did not restrict her diet during pregnancy –C–C. You need to obtain a cord blood IgE level to determine the risk –D–D. Exclusive breastfeeding with the addition of hypoallergenic formula if needed is the best option to decrease and delay allergies –D–D. The parents should start a cow milk formula, and then switch to breastfeeding if he develops eczema

8 Breastfeeding to Avoid Allergy *Breastfeeding for the first 6 months with supplementation with a hypoallergenic formula will decrease the severity and delay the onset of allergic disease – 42% reduction in atopic dermatitis (with family history) – 27% reduction in risk of asthma (no family history) – 40% reduction in risk of asthma (with family history)

9 Question #2 A mother is trying to decide between breastfeeding and formula feeding and asks you for information on the composition of human milk compared with cow milk infant formula. Of the following, the MOST accurate statement is that human milk has a –A–A. Lower concentration of protein than cow milk formula –B–B. Higher concentration of vitamin D than cow milk formula –C–C. Higher concentration of vitamin K than cow milk formula –D–D. Same amount of cells, enzymes, and antibodies as cow milk formula –E–E. Lower concentration of docosahexaenoic acid (DHA) than cow milk formula

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11 *Protein Human MilkCow Milk Total protein1.8 g/dL2.8 g/dL Casein30%82% Whey70%18%

12 Colostrum “The first immunization” – *High concentrations of antibodies and infection- protective elements – *Provides local GI immunity against organisms entering the body via GI tract High in total protein, low in carbohydrate, and lower in fat than mature milk After processing, cow milk and infant formula contain no cells, no enzymes, and no antibodies or other active protective agents – Do not support the maintenance of physiologic gut flora

13 Vitamins Vitamin C is significantly higher in human milk Vitamin D – Diminished from skin exposure to sun – Women pass less to the fetus, so newborns lack sufficient stores – Breastfed infants are given 400 U daily from birth – Formula contains 400 U in 26 to 32 oz Vitamin K – *Low content in human can contribute to hemorrhagic disease of newborn – All newborns receive 1mg IM at birth regardless of proposed feeding method

14 Question #3 There are numerous bioactive factors in human milk that boost the immune system. Immunoglobulins are the most recognized and studied. Which of the following is found in the highest concentrations in human milk? –A–A. IgG –B–B. IgA –C–C. IgM –D–D. IgE

15 Immunology Human milk bolsters the infant’s immature immune response and mucosal immunity Bioactive factors – *Igs are predominantly secretory IgA Smaller amounts of IgM and IgG *Act at mucosal level in infant’s mouth, nasopharynx, and GI tract Actual antibodies against specific microbial agents depend on mom’s exposure and response to particular agents – Other proteins include: lactoferrin, lysozyme, alpha- lactalbumin, casein – Lactose, oligosaccharides, glycoconjugates, lipids, nucleotides, cytokines, hormones, and growth factors

16 Question #4 You are addressing a group of expectant mothers about the benefits of breastfeeding. One woman asks if it is ok to breastfeed if she has had CMV in the past. You explain that there are only a few infections that are contraindications to breastfeeding. Of the following, breastfeeding is MOST likely to be contraindicated if a mother: –A–A. Has genital herpes without breast lesions –B–B. Is a CMV carrier –C–C. Tests positive for West Nile Virus –D–D. Is being treated with antibiotics for a Staph mastitis –E–E. Has active, untreated pulmonary TB

17 Infectious Disease *Viral infections – HTLV-1 or -2 - contraindication to breastfeeding – HIV - advised not to breastfeed Unless in area with increased infectious disease, nutritional deficiencies, morbidity, mortality, etc. – Latent or recent CMV - not a contraindication to BF Unless preterm, low-birthweight

18 Infectious Disease (cont’d) *Viral infections (cont’d) – WNV is transmitted through human milk, but not clinically significant, so no contraindication to BF – HSV, Varicella-zoster, vaccinia, or variola require temporary avoidance of BF and milk from a breast with identified lesion – Hepatitis Hepatitis B surface antigen positive – can BF after routine prophylaxis (Hep B vaccine and HBIG) Hepatitis C antibody positive – can BF safely (unless also HIV +)

19 Infectious Disease (cont’d) *Bacterial Infections – TB mastitis BF can continue once mother on appropriate anti-TB therapy and infant is on isoniazid – Staph or group A Strep Temporary suspension of BF during first 24 hours of abx therapy for the mom – Group B Strep Temporary suspension of BF during first 24 hours of abx therapy for the mom Transmission via BF is uncommon compared to close direct contact

20 *Disorders of Breast Previous breast surgery – No contraindication – May cause ineffective lactation Inverted or flat nipples – Use nipple shields and lactation consultation Breast cancer – No contraindication as long as not on antineoplastic medications Candida breast infection – Continue to BF – Treat both mother and infant

21 Question #5 A soon-to-be mother in your practice asks you to look at the list of medications that she is on at home to make sure that they are safe to take while breastfeeding. Of the following, in which situation is it SAFEST to recommend breastfeeding? – A. A mother on tetracycline for a skin infection – B. A cocaine addict who has failed to comply with her methadone maintenance program – C. A diabetic mother on insulin therapy – D. A mom with leukemia on methotrexate – E. A mother with hyperthyroidism receiving radioactive iodine treatment

22 Maternal Medications Drugs that are routinely administered to infants are safe to prescribe breastfeeding mother Large molecules such as insulin, heparin, and many Igs do not pass into milk *Maternal ingestion of drugs with sedative properties can potentially cause sedation in breastfed infants

23 *Maternal Medications Drugs of abuse or street drugs are considered contraindicated – Women who have been stable on a methadone maintenance program should be permitted to breastfeed Immunosuppressant drugs are contraindicated (ex: methotrexate) Radioactive compounds – Use ½ life to calculate clearance time and determine how long a mother needs to pump and dump

24 *Maternal Medications

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28 INFANT FORMULAS

29 Cow Milk-based Formulas for Term Infants “Standard” infant formulas Available in: – Ready-to-use liquids 20 cal/oz – Powder or liquid concentrates Can yield caloric densities b/t cal/oz

30 Content of Cow Milk-based Formulas for Term Infants Protein – Whey vs. casein The numbers: – Human milk: whey-to-casein ratio 70:30 – Bovine milk: whey-to-casein ratio 18:82 The difference: – Casein forms large curds on exposure to gastric acid – Whey is resistant to precipitation and undergoes more rapid gastric emptying Formula: – 50% higher total protein content to match the quality of human milk – Contains supplemental taurine – Casein-predominant (20:80), whey-predominant (60:40), and 100% whey formulas have all been shown to support normal growth patterns in term and preterm infants

31 Content of Cow Milk-based Formulas for Term Infants Carbohydrate – Lactose In both cow milk-based formulas and human milk Fat – Human milk Rich in palmitic, oleic, linoleic, and linolenic fatty acids Docohexaenoic acid (DHA) and arachidonic acid (ARA) are LCPUFA present in human milk – Found to accumulate rapidly in the fetal retina and brain during the last trimester  2 years of age

32 Content of Cow Milk-based Formulas for Term Infants Fat (con’t) – Formula Contains specific blends of vegetable oils designed to mimic the ratios of saturated, monounsaturated and polyunsaturated fatty acids in human milk Now supplemented with DHA and ARA – Based on recent studies that have shown that higher doses of DHA and equal amounts of ARA yielded improved visual and neurodevelopmental outcomes – No negative effects observed

33 Question #6 The mother of a 5-month-old boy has come to your office seeking nutritional advice. She exclusively breastfed the infant for the first 4 months, then weaned the baby to a standard, cow milk protein- based infant formula. One week after weaning, she noted that the baby "strained with stool." Because of her concerns regarding the development of constipation, the mother switched him to a low iron formula (containing 2 mg/L iron). Of the following, the MOST important dietary recommendation for this infant is to –A–A. Add pureed vegetables to the diet –B–B. Change back to a cow milk protein-based formula containing 12 mg/L iron –C–C. Change to a soy protein-based formula –D–D. Continue the present regimen and supplement with 4 oz/day diluted apple juice –E–E. Substitute oatmeal for rice cereal in the diet

34 Content of Cow Milk-based Formulas for Term Infants Vitamins and minerals – Iron Absorbed at a higher rate from human milk (20-50%) compared with cow’s milk (4-7%) In order to compensate for lower bioavailability, all fortified formulas contain double to triple the amount of iron Formula-fed infants should be on iron-fortified formula

35 Content of Cow Milk-based Formulas for Term Infants Nucleotides – Composed of one RNA nucleoside, one 5-carbon sugar moiety, and one or more phosphate groups – Supplementation shown to (?): Enhance growth in SGA infants Enhance IgA and IgM concentrations in preterm infants Decrease incidence of diarrheal disease Enhance Ab response to certain vaccines

36 Content of Cow Milk-based Formulas for Term Infants Prebiotics, probiotics and synbiotics – Basic principles BF infant intestinal flora – Bifidobacterium, Lactobacillus Formula-fed infant intestinal flora – Complex; also includes Bacteroides, Enterobacteriaceae, Clostridium and Streptococcus

37 Content of Cow Milk-based Formulas for Term Infants – Pre/pro/synbiotics attempt to reproduce the intestinal flora of a BF infant – Specifics: Prebiotics: stimulate growth and function of specific species of bacteria Probiotics: live microorganisms that survive digestion and colonize the colon  more beneficial colonic microbiota Synbiotics: combination of pre and probiotics – Proposed benefits (probiotics) Decreased incidence of clinical eczema in high-risk infants Decreased incidence of NEC and all-cause mortality in VLBW infants Decreased respiratory and intestinal infections

38 Preterm Infant Formulas Higher caloric density – 24 cal/oz Increased protein content (whey-predominant) Fat and CHO compositions designed to overcome nutrient losses from low concentrations of lipase, bile salt and intestinal lactase – Medium-chain triglyceride (MCT) oil provides b/t % of total fat – 60:40 or 50:50 mixture of glucose polymers and lactose

39 Preterm Infant Formulas Higher amounts of vitamins and minerals – Calcium – Phosphorous – Vitamins A&D Intake of some nutrients may be excessive if preterm formulas are consumed in quantities >12 oz/d – Preterm formulas should always be d/ced before hospital discharge

40 Preterm Transitional Formulas 22 cal/oz Have intermediate nutrient concentrations Transition usually occurs at g or 34 weeks – Continued until 6-9 months of age 2007 Cochrane meta-analysis found no evidence that these formulas lead to improvement in growth or neurodevelopmental outcomes

41 Human milk Fortifiers EBM alone inadequate to meet the nutritional needs of preterm infants (especially VLBW infants) Contain protein, fat, CHO and 23 vitamins and minerals – Matches growth and metabolic effects of premature infant formulas Ongoing use may eventually lead to excessive intake of certain nutrients (with potential for toxicity)

42 Question #7 A young mother has brought her newborn to your clinic for his first visit. She has heard that soy formulas are better than milk-based formulas. For which of the following conditions is soy formula indicated? –A–A. Allergic enteropathy –B–B. Colic –C–C. Galactosemia –D–D. GER –E–E. Prematurity

43 Soy Formula What’s the difference? – Protein: higher concentrations to improve biologic value, supplemental aa – CHO: glucose polymers, maltodextrin (NO LACTOSE) – Fat: similar to cow milk-based formula – Vitamins and minerals: 20% higher concentrations (Ca, Phos, Zinc, Fe) due to decreased bioavailability

44 Soy Formula Safe for term infants – NOT Preterm infants Cannot meet increased requirement for Ca and Phos  osteopenia Increased aluminum concentrations  decreased Ca absorption  further effects on bone mineralization *Indications* – Congenital lactase deficiency – Galactosemia – (IgE-mediated allergy to cow’s milk) 8-14% with cross-reaction

45 Question #8 Atopic dermatitis may be delayed or prevented in high risk (non-BF) infants with the use of which type of formula? –A–A. Soy –B–B. Extensively hydrolyzed –C–C. Premature –D–D. Pre-thickened –E–E. Follow-up

46 Soy Formula NOT indications – Infantile colic – Cow milk protein allergy 30-64% have a cross-reaction to soy protein – Prevention of atopic disease – Transient lactase deficiency

47 Hydrolyzed and Amino Acid-based Formula What’s the difference? – Protein: hydrolyzed casein or free amino acids – CHO: glucose polymers (lactose-free) – Fat: variable, similar to cow milk-based formula; some products contain MCT* Examples – Extensively hydrolyzed (EHFs): Nutramigen, Pregestimil*, Alimentum* – Amino acid-based: Nutramigen AA, Neocate*, Elecare*

48 Question #9 A mother brings in her 2 mo infant due to some blood streaks noted in her stool. She takes Enfamil Lipil 4oz q3- 4h, and there has been no recent change in formula. In addition, she has been more irritable than usual and spitting up more frequently. Her stools are normal (other than the blood that was noted), occurring 1-3 times per day. On PE, you notice her weight has dropped from the 50 th percentile at her 1 mo visit to just above the 10 th percentile at this visit. There are no anal fissures. Stool is FOBT positive, but the infant otherwise appears well. Of the following, what are you most likely going to suggest to this mother? –A–A. Change to soy formula –B–B. Increase Enfamil feeds to 6 oz q4h to promote weight gain –C–C. Change to an extensively hydrolyzed formula –D–D. Change to whole milk –E–E. Thicken feeds with 1-3 tsp of rice cereal

49 Hydrolyzed and Amino Acid-based Formula Indications – Infants with proven CMPA that are not BF should be fed EHFs AA formulas should be reserved for those who do not respond to EHFs – Infants at high risk for developing atopic disease (have one first-degree relative with atopy) who are not BF exclusively for 4-6 mos or are formula- fed Atopic dermatitis may be delayed or prevented with the use of EHFs

50 Finally… Pre-thickened formulas not superior to formula thickened later with rice cereal Follow-up formulas (for term infants) have no clear advantage over infant formulas designed to meet all nutritional needs throughout the first postnatal year

51 Content Specs Not Covered Age at which cow’s milk should be introduced into the diet… – 12 mos Deficiency that infants fed goat milk exclusively are prone to… – Folate Signs and symptoms of CMPA… – (non-IgE) Vomiting, diarrhea, blood-tinged stools, irritability – (IgE mediated) Sx of allergic reaction Difference b/t CMPA and lactose intolerance… – Amount of product required for a reaction, lactose intolerance less common in younger children (especially infants), severity of symptoms (sometimes:))

52 PROTEIN-ENERGY MALNUTRITION (PEM)

53 Question #10 You are called at by an ER physician about admitting an 8 month old male for suspected abuse and neglect. You ask your colleague to report growth parameters and physical exam findings. The boy is <3 rd percentile for length, weight, head circumference, and weight for height. He has an emaciated appearance with dry skin, little subcutaneous fat, no ascites or hepatosplenomegaly, and no edema. On further history, he has severe constipation and developmental delay. Of the following, the MOST likely diagnosis is: –A–A. Kwashiorkor –B–B. Marasmus –C–C. Combined-type protein-energy malnutrition –D–D. Iron deficiency anemia –E–E. Complications of a vegan diet

54 Kwashiorkor A form of PEM characterized by insufficient protein intake and reasonable carbohydrate intake – Hypoalbuminemia (universal) – *Edema – Dermatosis – Growth retardation – Occurs after age 1 when weaned from breastfeeding to diet rich in carbohydrates but poor in proteins Results from: malabsorption syndromes, neglect, or extreme dietary restrictions

55 Kwashiorkor *Clinical features – Irritability – Mild growth failure – Developmental delay – Edema of extremities (hallmark) – Distended abdomen with hepatomegaly – Neurologic, hematologic, and immunologic dysfunction – Normal or near normal weight and height for age

56 Kwashiorkor

57 Marasmus *Characterized by severe caloric restriction Clinical features – Decreased weight for height – Little subcutaneous fat – Dry skin – Severe constipation – Emaciated appearance without edema – Occurs before age 1

58 Combined Type PEM Combined Kwashiorkor and Marasmus Deficiencies of many essential nutrients – Vitamin B6 and B12 – Niacin – Riboflavin – Thiamine – Zinc – Fatty acids

59 Management 1) Correct fluid and electrolyte imbalances, replace deficient vitamins and nutrients, and treat any infections – Fluid and sodium increased cautiously to prevent cardiac overload 2) Initiate nutrition – Can be delayed 24 to 48 hours – Start with a low amount and advance slowly

60 Question #11 Your patient in the previous question is admitted to the hospital for child neglect and severe malnutrition consistent with marasmus. You stabilize the patient by correcting electrolyte abnormalities with IVFs and plan to initiate nutrition. You are worried about refeeding syndrome and plan to continue to check electrolytes as you slowly start feeds. Of the following, which is the primary electrolyte disturbance seen in refeeding syndrome? –A–A. Hyperphosphatemia, hyperkalemia, hypermagnesemia –B–B. Hyperphosphatemia, hyperkalemia, hypercalcemia –C–C. Hyperphosphatemia, hyperkalemia, hypochloremia –D–D. Hypophosphatemia, hypokalemia, hypermagnesemia –E–E. Hypophosphatemia, hypokalemia, hypomagnesemia

61 Refeeding Syndrome Results from abnormal fluid and electrolyte shifts in a body that is already fluid- and electrolyte depleted *Primary electrolyte disturbances – Hypophosphatemia – Hypokalemia – Hypomagnesemia

62 Refeeding Syndrome (cont’d) *Clinical manifestations – Neurologic impairment – Cardiac arrhythmias – Impaired cardiac and respiratory function – Death Monitor electrolytes and watch for signs of and symptoms during initiation of feedings

63 CHILDHOOD OBESITY

64 Some Scary Statistics Prevalence of overweight/ obese children >33% – Prevalence in children 6-19 yo tripled from – Prevalence in children 2-5 yo rose from 5% to 12.4% Type II DM being diagnosed in morbidly obese 9 yos Bariatric surgery has been performed in children as young as 12 yo!

65 Question #12 You are seeing a 14 yo F in your clinic for a well-child check. When you plot her BMI, you find that it is in the 90 th percentile for age. This means (by definition) that she is: –A–A. Obese –B–B. Normal –C–C. Overweight –D–D. Underweight –E–E. Tall

66 Definitions Obesity occurs when energy intake exceeds expenditure BMI=kg/m 2 – Overweight: BMI 85%-95% – Obese: BMI>95%

67 Factors Contributing to Increased Childhood Obesity Prenatal influences – Prenatal nutritional deprivation – Gestational DM – High birthweight Having an obese parent Genetic factors Environmental factors

68 Question #13 Little Johnny’s mother comes to you with concerns about his weight. His BMI is currently in the 85 th percentile for age (8 yo), and Mom is worried that he will grow up to be obese. She wonders what she can do at home to help prevent more weight gain. All of the following are appropriate environmental modifications to promote a healthy lifestyle, EXCEPT: –A–A. Eating family dinners at the table away from the television –B–B. Limiting screen time to 4 hours per day –C–C. Avoiding prepackaged foods at the grocery store –D–D. Removing televisions from the bedroom –E–E. Choosing outdoor/active weekend activities for the family

69 Factors Contributing to Increased Childhood Obesity Environmental factors – Demise of the family dinner – Prepackaged food with high ratios of saturated fat and high-fructose corn syrup – Less accessible and lower intake of fruits and vegetables in the average urban family – Lack of safe areas to play – Sedentary lifestyles – Diminished school PE requirements – Media – Feeding trends

70 Protective Factors Breastfeeding Being a part of families who have active lifestyles Minimal TV usage Having non-obese parents

71 The Bottom Line… Being an obese infant/child  being an obese adolescent  being an obese adult

72 Question #14 All of the following are medical complications of pediatric obesity, EXCEPT: –A–A. Hypertension –B–B. High HDL –C–C. Type II DM –D–D. Coronary artery disease –E–E. High LDL

73 Complications of Obesity

74 Laboratory Evaluation

75 Treatment: The Pediatrician’s Role First Step: regularly track BMI and recognize when overweight or obesity status occurs Second Step: react to an increasing BMI with an approach that promotes positive family change without decreasing the parents’ or patient’s self-esteem So what EXACTLY does that include??

76 Treatment: The Pediatrician’s Role Interventions – Frequent office visits Overweight  quarterly visits Obese  monthly visits – Motivational interviewing to promote change Interventions tend not to work unless both the patient and the parent are ready for change – Family involvement Cut out their own weight-related talk – “Talk less and do more”

77 Treatment: The Pediatrician’s Role Interventions – Family involvement (con’t) Removing TV sets from bedrooms Limiting television and video game usage Discourage eating in front of the TV or computer to stop the child from eating more than anticipated – Medications Metformin Orlistat Sibutramine (in adolescents> 16yo)

78 Treatment: The Pediatrician’s Role Interventions – Diet modifications Weight Watchers Protein-sparing modified fast – Bariatric surgery Suitable surgical candidates must: – Have achieved abstract thought or the ability to forsee consequences – Have the ability to follow through with needed medical F/U – Be forewarned that they may need plastic surgery later for excess skin reduction (which may not be covered by ins)

79 The Cleveland Clinic Pediatric Obesity Initiative Behavioral approaches – /day fruits and veges 2 hours or less of screen time 1 hour or more of exercise 0 sugar-sweetened beverages – “5 to GO!”

80 The Cleveland Clinic Pediatric Obesity Initiative Behavioral approaches – Stoplight diet Red light foods (cakes, fried chicken)= STAY AWAY! Yellow light foods (ground beef, dark chocolate, olive oil)= proceed with caution Green light foods (salmon, brown rice, low-fat yogert)= GO! School involvement – Replacement of soda pop in vending machines with water, milk, and 100% juice – Improvement in school lunch menus

81 The Cleveland Clinic Pediatric Obesity Initiative Community involvement – The Cleveland Clinic No trans fats No nondiet soda pop Only healthy options in vending machines and food services Benefits for employees: – Free fitness facilities » $100 for going 10 times for 10 months – Free Curves or Weight Watchers memberships – Coverage of benefits for offspring – GO! foods at eye level at local grocery stores (and sold at sporting events!)

82 The Cleveland Clinic Pediatric Obesity Initiative Community Involvement – Safe playgrounds, green spaces, bike paths, and “walking school buses.”

83 Question #15 Which of the following is the strongest predictor of being able to successfully reduce BMI? –A–A. Early detection of obesity –B–B. Weight at diagnosis –C–C. BP at diagnosis –D–D. Number of PCP visits after diagnosis –E–E. Family hx negative for obesity

84 Take Home Message… Early detection of childhood obesity predicts better outcomes long term – In a British study, the strongest predictor for successfully reducing BMI was younger age at the time of diagnosis So……

85 GENERAL Normal Nutritional Requirements

86 Early Feeding of Solid Foods *Early (before 6 months of age) feeding of complementary foods such as cereals to breastfed infants is an increased likelihood of gastrointestinal infection The direct relationship between early complementary feedings and the incidence of diarrheal illness is based on several case- control studies

87 *Age-related Changes in Digestion Until pancreatic maturity is achieved (around 4 months of age) dietary starches may be hydrolyzed incompletely – undigested carbohydrate pass into the colon, where bacterial fermentation results in gas production Lactase concentrations reach mature values in the small intestine by the 36th week of gestation in all healthy infants – Congenital or early-onset primary lactose intolerance is an extremely rare condition that is associated with severe diarrhea

88 *Adolescent Nutritional Deficiencies Low consumption – Fruit and vegetables – Whole grains – Calcium – Low-fat dairy foods High consumption – Sweetened beverages – Fast food

89 *Dietary Practices Vegetarian – Monitor Vitamin B12, Folate, and Omega-3 Fatty Acid intake Vegan – Same as vegetarian – Use soy formula in needed – Begin zinc supplements when starting solids Goat’s Milk – Causes folate deficiency (megaloblastic anemia)

90 MINERALS Normal Nutritional Requirements

91 Iron *Full-term neonates have adequate iron stores – Exclusively breastfed term infants receive a supplement of elemental iron at 1 mg/kg per day, starting at 4 months of age – The preterm infant has lower iron content and requires initiation of iron supplementation between 2 and 4 weeks of age

92 Iron *Iron deficiency anemia is major nutritional deficiency of American youths – Typical lab findings: low MCV and MCH; a hypochromic, microcytic peripheral blood smear; and a normal or low reticulocyte count – Symptoms: tachycardia, fatigue, pallor

93 Calcium and Phosphorous *The American Academy of Pediatrics recommends that preadolescents and adolescents (9 to 18 years of age) consume 1,300 mg of both calcium and phosphorus daily – 40% of total lifetime bone mineral content is accrued during adolescence – Optimizing calcium intake is important during adolescence, and those who experience delayed puberty have an increased risk for osteoporosis and fracture

94 VITAMINS Normal Nutritional Requirements

95 Vitamin D Children and adolescents need 400 IU/day – Start at birth in breastfed infants

96 PROTEIN Normal Nutritional Requirements

97 Protein *Know the protein requirements of preterm and fullterm infants – The estimated protein requirement for a preterm infant is 3.0 to 4.0 g/kg per day compared to 1.5 to 2.0 g/kg per day for the term infant – Protein content declines in the first weeks of lactation (Human milk fortifier for preterm milk)

98 DEFICIENCY STATES AND HYPERVITAMINOSIS

99 Vitamin Deficiency States Vitamin D Deficiency – Rickets: hypocalcemia, hypophosphatemia, poor growth, tetany, muscle weakness, bone deformations Folate Deficiency – May develop in malabsorption syndromes – Results in megaloblastic anemia, irreversible neurologic damage

100 Mineral Deficiency States Zinc deficiency – short stature, hypogonadism, skin disorders including alopecia, cognitive dysfunction, impaired development, peripheral neuropathy, anorexia, diarrhea, platelet dysfunction, and altered wound healing – Acrodermatitis enteropathica erythematous-to-vesiculobullous or pustular lesions, have sharply demarcated borders perioral, perianal, and acral areas of the body

101 Mineral Deficiency States Selenium deficiency – skin and hair pigment loss, macrocytosis, and in severe cases, cardiomyopathy Copper deficiency – neutropenia, hypochromic anemia unresponsive to iron administration, bone abnormalities, and hair and skin depigmentation Menkes- steely hair Chromium deficiency – a cofactor for insulin; impaired glucose, fat, and protein metabolism and growth retardation


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