First Aid for the Pediatrics Clerkship, 3 Ed.

Nutrition

 

NEWBORN NUTRITION

Newborn Feeding Tips

Image For term newborns, caloric requirement is 100–120 kcal/kg/day (as compared to 1-year-old, 75 kcal/kg/day).

Image Newborns grow at a rate of about 30 g/day.

Image Newborns usually begin feeding within the first 6 hours of life.

Image Newborns should be breast- or formula-fed every 3–4 hours thereafter.

Image Supply = demand—the more often the baby breast-feeds, the more milk will be produced.

Image After a period of 4–6 months of exclusive breast-feeding the mother should begin to introduce solid foods into the child’s diet.

Image If the child has stopped losing weight by 5–7 days and begins to gain weight by 12–14 days, then feeding is adequate.


Image

Term infants, due to loss of extracellular water and suboptimal caloric intake, may lose up to 10% of their birth weight in the first few days of life but regain their birth weight by the end of the second week.


Image Hunger is not the only reason infants cry. They don’t need to be fed every time they cry.

Image Human milk is ideal for a term infant in first year of life.

Image Whole cow’s milk is not suitable for infants because the higher intake of sodium, potassium, and protein Image renal solute load.

Image Cow’s milk can be introduced after the first birthday.

Image Optimal protein requirement of term infant is 2.2 g/kg body weight per day.


Image

Don’t put baby to sleep with a bottle; it can Image dental caries.


Colostrum

Image The first milk produced after birth.

Image Usually a deep lemon color.


Image

Breast milk predominant protein is whey (whey-tocasein ratio: 70:30).


Image Helps to clear bilirubin from the gut, produced from the high red blood cell turnover during blood volume contraction in the first weeks of life, which helps prevent jaundice.

Image High in protein, minerals, immunologic factors, and antimicrobial peptides such as lactoferrin and lactoperoxidase; low in carbohydrates and fat.


Image

Immunoglobulin A (IgA) accounts for 80% of the protein in colostrum.


Benefits of Breast-Feeding

Image Infant:

Image Image incidence of infection (ie, otitis media, pneumonia, meningitis, bacteremia, diarrhea, urinary tract infection [UTI], botulism, necrotizing enterocolitis).

Image Higher levels of immunologic factors—immunoglobulins, complement, interferon, lactoferrin, lysozyme.

Image Image exposure to enteropathogens.

Image Other postulated benefits include higher IQ, better vision, Image risk of sudden infant death syndrome (SIDS), less fussy eaters.

Image Image incidence of chronic disease (type 1 diabetes, lymphoma, Crohn’s/ulcerative colitis [UC], allergies).

Image Maternal:

Image Image maternal oxytocin levels.

Image Image postpartum bleeding.

Image More rapid involution of uterus.

Image Less menstrual blood loss.


Image

Whole cow’s milk is not recommended before 1 year of age, because an infant’s gastrointestinal (GI) tract is not developed enough to digest (poor absorption), predisposing to allergy, Image GI blood loss and iron deficiency.


Image Delayed ovulation.

Image Improved bone mineralization.

Image Image risk of ovarian and breast cancer.

Image Psychological benefits: Image maternal-child bonding.

Image Other: Saves money for family and society, no risk of mixing errors, correct temperature, convenient, no preparation.


Image

Cow’s milk predominant protein is casein (78%).


Common Problems with Breast-Feeding

Image Soreness of nipples: Not due to prolonged feeding––due to improper positioning and poor removal.

Image Engorgement: Unpleasant/painful swelling of the breasts when feeding cycle is Image suddenly (relieved by Image feeding on affected breast).

Image Maternal fatigue, stress, and anxiety. Affects hormones needed for lactation.

Image Fear of inadequate milk production, Image formula milk supplementation.


Image

Breast-fed infant requires the following supplements:

Image Vitamin K 1 mg IM at birth

Image Vitamin D 400 IU/day

Image Fluoride (after 6 months)

Image Iron from 4 to 12 months


Image As the infant begins to feed less often, less milk is naturally produced. This often causes mother to misconceive that she is not producing enough milk to nourish the baby. Because of this, mother will frequently begin supplementing her milk with bottle milk, beginning a cycle of longer intervals between feeding, which causes less and less milk to actually be produced.

Image Jaundice (see Table 5-1 and Gestation and Birth chapter).

Image Possible vitamin deficiencies—A, D, K, B12, thiamine, riboflavin.

Image Infants who are exclusively breast-fed should receive vitamin drops after age 4 months.


Image

Tell the breast-feeding mother: If the baby doesn’t let go, break the suction by inserting finger into corner of mouth; don’t pull.


Contraindications to Breast-Feeding

Image Breast cancer.

Image Cancer chemotherapy.

Image Some medications (such as antimetabolites, chloramphenicol methimazole, tetracycline).

Image Street drugs.

Image Herpetic breast lesions.


Image

Breast-Feeding jaundice occurs in the First week. Breast Milk jaundice occurs Many weeks later.


TABLE 5-1. Breast-Feeding versus Breast Milk Jaundice

Image


Image

Oral contraceptive is not a contraindication for breastfeeding.


Image Untreated, active tuberculosis.

Image Cytomegalovirus (CMV) infection.

Image Human immunodeficiency virus (HIV) infection.

Image In developing countries where food is scarce and HIV is endemic, the World Health Organization recommends breast-feeding by HIV-infected moms because the benefits outweigh the risks.

Image Galactosemia: Infants with galactosemia should not ingest lactose-containing milk.


Image

Not every woman will feel “milk letdown” despite proper breast-feeding.


Signs of Insufficient Feeding of Infant

Image Fewer than six wet diapers per day after age 1 week (before that, count one wet diaper per age in days for first week of life).

Image Continual hunger, crying.

Image Continually sleepy, lethargic baby.

Image Fewer than seven feeds per day.

Image Long intervals between feedings.


Image

The common cold and flu are not contraindications to breast-feeding.


Image Sleeping through the night without feeding.

Image Loss of > 10% of weight.

Image Image jaundice.


Image

Most common cause of FTT is inadequate caloric intake.


Reasons for Failure to Grow and Gain Weight

Image

An 18-month-old African immigrant male is brought in by his parents for a health evaluation. The family members are refugees. As you examine the child, you find that he is in the bottom 2% in both height and weight and is thin looking. The parents deny any childhood illnesses and state that the child has never been severely ill. Blood tests including complete blood count, chemistry, and liver function tests are within normal limits, and albumin is 2.3. What is the diagnosis? Failure to thrive (FTT). It is a condition when physical growth of a child is below the 3rd or 5th percentile. Nonorganic or psychosocial FTT is more common. The laboratory evaluation is usually normal and should be obtained judiciously. Obtaining a detailed history is the most important part of evaluation, which helps to determine whether the cause is organic or nonorganic.


Image

Mastitis: Tender erythematous swelling of portion of breast usually associated with fever. Most common organism is Staphylococcus, transmitted from oropharynx of asymptomatic infant. Infant should continue to feed on affected breast.


Image Improper formula preparation.

Image Use of skim and 2% milk before age 2.

Image Prolonged used of diluted formula.

Image Prolonged used of BRAT (bananas, rice, applesauce, toast) diet after illness.

Image Excessive juice or water.

Image Inappropriate feeding schedule.


Image

Undernutrition has the greatest effect on brain development from 1 to 3 months of age.


Formula

Image Types (see Table 5-2).

Image Inappropriate formulas (see Table 5-3).

Image Hydrolysate formula:

Image Formula with peptides: Nutramigen, Progestimil, Alimentum.

Image Formulas with free amino acids: Neocate, Elecare.

TABLE 5-2. Formulas

Image

Image


Image

Anemia in infant receiving goat milk = megaloblastic anemia.



Image

Feed at earliest sign of hunger; stop at earliest sign of satiety.



Image

Predominant fat in preterm infant formula is medium-chain triglycerides.



Image

Formula for an infant who is allergic to both cow milk and soy protein: Hydrolysate formula.


Solid Foods

Image Solid food should be introduced between 4 and 6 months; introducing solids before this time does not contribute to a healthier child, nor does it help the infant to sleep better.

Image New foods should be introduced individually and about a week apart; this is done to identify any allergies and intolerance the child may have. There are many suggested orders in which to introduce new food. A common one is vegetable first, green to orange, and then fruits, to introduce foods from most bland to sweetest.


Image

Do not give an infant under 6 months of age water or juice (water fills them up; juice contains empty calories, and excess sugar can cause diarrhea).


Readiness for Solid Foods

Image Hand-to-mouth coordination.

Image Image tongue protrusion reflex.

Image Sits with support.


Image

Do not use 2% milk before 2 years of age or skim milk before 5 years.


TABLE 5-3. Inappropriate Formulas

Image


Image

Typical formulas contain 20 kcal/ounce.


Image Improved head control.

Image Drooling.

Image Opens mouth to spoon.


Image

Avoid foods that are choking risks, including small fruits, raw vegetables, nuts, candy, and gum.


Caloric Requirements

Estimated average requirement: Basal metabolic rate × physical activity level (see Table 5-4).

TABLE 5-4. Daily Caloric Requirements

Image

FLUID MANAGEMENT

Physiologic Compartments

TOTAL BODY WATER (TBW)

TBW makes up 50–75% of the total body mass depending on age, sex, and fat content.


Image

Neonates have a greater percentage of TBW per weight than do adults (about 70–75%).


DISTRIBUTION

Image Intracellular fluid accounts for two thirds of TBW and 50% of total body mass.

Image Extracellular fluid accounts for one third of TBW and 25% of total body mass.


Image

You know a patient is dehydrated when he or she is PARCHED:

Pee, Pressure (blood)

Anterior fontanel

Refill, capillary

Crying

Heart rate

Elasticity of skin

Dryness of mucous membranes


EXTRACELLULAR FLUID (ECF)

ECF is composed of plasma (intravascular volume) and interstitial fluid (ISF).

DEHYDRATION

Image Definition: Body fluid depletion (see Table 5-5).

Image Causes can be divided into two categories:

Image Image intake.

Image Image loss (e.g., vomiting, diarrhea).

Image Image hypovolemia, gradually affecting each organ system.


Image

Percentage of dehydration can be estimated using (pre-illness weight – illness weight/pre-illness weight) × 100%.


TABLE 5-5. Signs and Symptoms of Dehydration

Image

Fluid Therapy

GOALS

Rapidly expand the ECF volume and restore tissue perfusion, replenish fluid and electrolyte deficits, meet the patient’s nutritional needs, and replace ongoing losses.


Image

For convenience, use the Holliday-Segar method to determine maintenance intravenous (IVF) requirements:

Image Give 100 mL/kg of water for the first 10 kg.

Image For a child over 10 kg but under 20 kg, give 1000 mL + 50 mL/kg for each kilogram over 10 kg.

1 kg = 2.2 pounds


METHODS

Image Fluid requirements can be determined from caloric expenditure.

Image For each 100 kcal metabolized in 24 hours, the average patient will require 100 mL of water, 2 to 4 mEq Na+, and 2 to 3 mEq K+.

Image This method overestimates fluid requirements in neonates under 3 kg.

Image For a child over 20 kg, give 1500 mL + 20 mL/kg for each kilogram over 20 kg.

MAINTENANCE

Image Replacement of normal body fluid loss.

Image Causes of normal fluid loss include:

Image Insensible fluid loss (ie, lungs and skin).

Image Urinary loss.

Image Water requirements (mL/100 calories metabolized/day): Insensible—skin, 30; lungs, 15; stool, 5; urine, 50.

DEFICIT

Image Replacement of abnormal fluid and electrolyte loss (ie, from vomiting, diarrhea, etc).

Image Example: For a 25-kg patient, 100 (for first 10 kg) × 10 + 50 (for second 10 kg) × 10 + 20 (for remainder) × 10 = 1600 mL/day or 65 mL/hr when divided by 24 hours.


Image

Calculations for fluid therapy are just estimates—you must monitor the success of fluid replacement by measuring ins and outs, body weight, and clinical picture (see Table 5-6).


Deficit Therapy

HYPONATREMIA

In hypotonic (hyponatremic) dehydration, serum Na+ < 130 mEq/L.

EPIDEMIOLOGY

Image Most common electrolyte abnormality.

Image More common in infants fed on tap water.


Image

4-2-1 IVF RULE: To determine rate in milliliters per hour, use 4 (for first 10 kg) × 10 kg + 2 (for second 10 kg) × 10 kg + 1 (for remainder) × remaining kg = 65 mL/hr.


TABLE 5-6. Calculating Maintenance Fluids per Day

Image

ETIOLOGY

Image Hypervolemic hyponatremia—fluid retention:

Image Congestive heart failure (CHF).

Image Cirrhosis.

Image Nephrotic syndrome.

Image Acute or chronic renal failure.

Image Hypovolemic hyponatremia—Image sodium loss:

Image Due to renal loss:

Image Diuretic excess, osmotic diuresis, salt-wasting diuresis.

Image Adrenal insufficiency, pseudohypoaldosteronism.

Image Proximal renal tubular acidosis.

Image Metabolic alkalosis.


Image

Hyponatremia can be factitious in the presence of high plasma lipids or proteins; consider the presence of another osmotically active solute in the ECF such as glucose or mannitol when hypotonicity is absent.


Image Due to extra-renal loss:

Image Gastrointestinal (GI)—vomiting, diarrhea, tubes, fistula.

Image Sweat.

Image Third-spacing—pancreatitis, burns, muscle trauma, peritonitis, effusions, ascites.

Image Euvolemic hyponatremia:

Image Syndrome of inappropriate antidiuretic hormone secretion (SIADH):

Image Hospitalized children are at Image risk for nonphysiologic secretion of ADH.

Image Tumors.

Image Chest disorders.

Image Central nervous system (CNS) disorders—infection, trauma, shunt failure.

Image Drugs—vincristine, vinblastine, diuretics, carbamazepine, amitriptyline, morphine, isoproterenol, nicotine, adenine arabinoside, colchicine, barbiturates.

Image Glucocorticoid deficiency.


Image

SIADH:

Image Euvolemia

Image Low urine output

Image High urinary sodium loss

Image Treat with fluid restriction


Image Hypothyroidism.

Image Water intoxication due to intravenous (IV) therapy, tap water enema, or psychogenic (excess water drinking).

Image Polydipsia.


Image

The rise in serum Na+ in the correction of chronic hyponatremia should not exceed 2 mEq/L/hr or cerebral pontine myelinosis may occur secondary to fluid shifts from the intracellular fluid.


SIGNS AND SYMPTOMS

Image Symptoms may occur at serum concentrations of ≤ 125 mEq/L.

Image Cerebral edema—more pronounced in acute.

Image Early: Anorexia, nausea, headache.

Image Mental status changes.

Image Later: Beware of brain herniation—posturing, autonomic dysfunction, respiratory depression, seizures, and coma.

Image Central pontine myelinolysis can occur if hyponatremia is corrected too quickly.

DIAGNOSIS

Image Volume status.

Image Acute versus chronic.

Image Serum and urine osmolality and sodium concentration, blood urea nitrogen (BUN), creatinine, other labs (glucose, aldosterone, thyroid-stimulating hormone [TSH], etc).


Image

The fluid deficit plus maintenance calculations generally approximate 5% dextrose with 0.45% saline; 6 mL/kg of 3% NaCl will raise the serum Na+ by 5 mEq/L.


TREATMENT

Image Na+ deficit: (Na+ desired – Na+ observed) × body weight (kg) × 0.6.

Image One half of the deficit is given in the first 8 hours of therapy, and the rest is given over the next 16 hours.

Image Deficit and maintenance fluids are given together.

Image If serum Na+ is < 120 mEq/L and CNS symptoms are present, a 3% NaCl solution may be given IV over 1 hour to raise the serum Na+ over 120 mEq/L.


Image

Look for a low urine specific gravity (< 1.010) in diabetes insipidus. These patients appear euvolemic because most of the free water loss is from intracellular and interstitial spaces, not intravascular.


HYPERNATREMIA

In hypertonic (hypernatremic) dehydration, serum Na+ > 150 mEq/L.

ETIOLOGY

Image Image water or Image sodium intake.

Image Image sodium or Image water output.

Image Diabetes insipidus (either nephrogenic or central) can cause hypernatremic dehydration secondary to urinary free water losses.

Image Hypovolemic hypernatremia:

Image Extrarenal or renal fluid losses.

Image Adipsic hypernatremia is secondary to Image thirst—behavioral or damage to the hypothalamic thirst centers.

Image Hypervolemic hypernatremia:

Image Hypertonic saline infusion.

Image Sodium bicarbonate administration.

Image Accidental salt ingestion.

Image Mineralocorticoid excess (Cushing syndrome).

Image Euvolemic hypernatremia:

Image Extrarenal losses—Image insensible loss.

Image Renal free water losses—central diabetes insipidus (DI), nephrogenic DI.


Image

A hypervolemic hypernatremic condition can be caused by the administration of improperly mixed formula, or this may present as a primary hyperaldosteronism. Always demonstrate the proper mixing of formula to parents who use powdered preparations.


SIGNS AND SYMPTOMS

Image Anorexia, nausea, irritability.

Image Mental status changes.

Image Muscle twitching, ataxia.


Image

If the serum Na+ falls rapidly, cerebral edema, seizures, and cerebral injury may occur secondary to fluid shifts from the ECF into the CNS.


TREATMENT

Image The treatment of elevated serum Na+ must be done gradually at a rate of Image around 10–15 mEq/L/day.

Image Usually, a 5% dextrose with 0.2% saline solution is used to replace the calculated fluid deficit over 48 hours after initial restoration of adequate tissue perfusion using isotonic solution.

Image If the serum Na+ deficit is not correcting, the free water deficit may be given as 4 mL/kg of free water for each milliequivalent of serum Na+ over 145, given as 5% dextrose water over 48 hours.

Image Too rapid correction of hypernatremia can result in cerebral edema.

HYPOKALEMIA

Can be considered at K+ < 3.5 mEq/L, but is extreme when K+ < 2.5 mEq/L.

ETIOLOGY

Excess renin, excess mineralocorticoid, Cushing syndrome, renal tubular acidosis (RTA), Fanconi syndrome, Bartter syndrome, villous adenoma of the colon, diuretic use/abuse, GI losses, skin losses, diabetic ketoacidosis (DKA).


Image

Hypokalemia can precipitate digitalis toxicity.


SIGNS AND SYMPTOMS

Image peristalsis or ileus, hyporeflexia, paralysis, rhabdomyolysis, and arrhythmias including premature ventricular contractions (PVCs), atrial nodal or ventricular tachycardia, and ventricular fibrillation.

DIAGNOSIS

Image Serum value.

Image Electrocardiogram (ECG) may demonstrate flattened T waves, shortened PR interval, and U waves.


Image

For every 0.1-unit reduction in serum pH, there is an Image in serum K+ of about 0.2–0.4 mEq/L.


TREATMENT

Image Consider cardiac monitor.

Image If potassium is dangerously low (< 2.5 mEq/L) and patient is symptomatic, IV potassium must be given.

Image Do not exceed the rate of 0.5 mEq/kg/hr.

Image Oral potassium may be given to replenish stores over a longer period of time. Common forms of potassium include the chloride, phosphate, citrate, and gluconate salts.

HYPERKALEMIA

Image Mild to moderate: K+ = 6.0–7.0.

Image Severe: K+ > 7.0.

ETIOLOGY

Renal failure, hypoaldosteronism, aldosterone insensitivity, K+-sparing diuretics, cell breakdown, metabolic acidosis, transfusion with aged blood.

SIGNS AND SYMPTOMS

Muscle weakness, paresthesias, tetany, ascending paralysis, and arrhythmias including sinus bradycardia, sinus arrest, atrioventricular block, nodal or idioventricular rhythms, and ventricular tachycardia and fibrillation.

DIAGNOSIS

Image Serum value.

Image ECG may demonstrate peaked T waves and wide QRS.

TREATMENT

Image If hyperkalemia is severe or symptomatic, first priority is to stabilize the cardiac membrane. Administer calcium chloride or gluconate (10%) solution under close cardiac monitoring.

Image Sodium bicarbonate, albuterol nebulizer, or glucose plus insulin can be given to shift K+ to the intracellular compartment.

Image Kayexalate resin can be given to bind K+ in the gut (works the slowest).

Image Furosemide can be given to enhance urinary K+ excretion.

Image In extreme cases, hemo- or peritoneal dialysis may be necessary.

VITAMIN AND MINERAL SUPPLEMENTS

Fluoride

Image Supplement after age 6 months if the water is not fluorinated sufficiently (particularly well water).

Image If < 3.3 ppm, supplement with 0.25 mg per day.

Image Supplementation is recommended for the exclusively breast-fed infants.

Image Deficiency: Dental caries.

Image Excess: Fluorosis—mottling, staining, or hypoplasia of the enamel.

Image Children under 2 years should not use fluoridated toothpaste, and then only a small pea-sized amount up to age 6 years.


Image

Because of the Image risk for fluorosis, don’t give fluoride supplements before age 6 months!


Vitamin D

Image Vitamin D is critical for skeletal development and cellular function because of its effect on calcium homeostasis (by promoting intestinal calcium absorption).

Image Breast milk typically contains about 25 IU/L of vitamin D, which is insufficient for rickets prevention.


Image

Most bottled water is not fluorinated.


Image Deficiency can occur if breast-feeding infant’s mother has insufficient intake, infant’s sun exposure is inadequate, or the infant is fed on whole cow’s milk.

Image Supplementation is with 400 IU/day.

Image Deficiency: Impaired mineralization of bone tissue (osteomalacia) and of growth plates (rickets).

Image Vitamin D deficiency can Image hypocalcemia.

Iron

Image

A 4-year-old female was brought in by EMS with a complaint from the mother that the child had a sudden onset of diarrhea and vomiting. The mother reports blood in the vomitus. On examination, the child is very irritable. She is breathing very rapidly, and her heart rate is 167 beats/min, with a blood pressure of 96/57 mm Hg. The mother states that she is a healthy child with no recent illnesses and is up to date on all her vaccinations. There has been no recent travel, and the child’s 3-year-old brother is not ill. There has been no change in the child’s diet. The mother states that she is very conscientious of the diets in the house, as she is trying to get pregnant again and is taking prenatal vitamins. What is the diagnosis? Iron overdose

Iron poisoning is one of the most fatal in children. Iron preparations are readily available due to their widely prescribed use in prenatal care. It is particularly attractive to young children because these brightly colored tablets appear similar to candy. In addition, often some iron preparations are coated with sucrose to make them palatable. Iron poisoning should be considered in a child with acute onset of vomiting and hypoperfusion. Serum iron levels should be obtained and are helpful in predicting the clinical course of the patient.

Image Newborn iron stores are sufficient for 6 months in a term infant.

Image Therefore, breast-fed infants need iron supplementation 1 mg/kg/day (ie, iron-fortified cereals and baby foods), beginning at 4 to 6 months.

Image Preterm breast-fed infants should receive 2 mg/kg/day starting at 2 months of age.

Image Deficiency: Anemia (hypochromic microcytic) and growth failure.

Image Only iron-fortified formula should be used for weaning or for supplementing breast milk in children younger than 12 months.


Image

Dark-skinned children are more likely to have inadequate sun exposure.


Vitamin K

Image Human breast milk is deficient in vitamin K.

Image Infant has a limited body store of vitamin K.

Image Therefore, it is necessary to administer a 1-mg vitamin K IM injection at birth. Recommended for every newborn, not just breast-fed.

Image Deficiency: Thought to contribute to hemorrhagic disease of the newborn.

Image Vitamin K is necessary for the synthesis of clotting factors II, VII, IX, and X.

Image Fat soluble: Requires bile salts for absorption.


Image

Breast milk has less iron than cow’s milk, but the iron in breast milk is more bioavailable.


Zinc

Image Deficiency-associated intestinal malabsorption, nutritional intake limited to breast milk.

Image Deficiency used to be associated with total parenteral nutrition (TPN); now formulas have zinc in them.

Image Deficiency manifests as acrodermatitis, alopecia, and growth failure.

Vitamin A

Image

A 14-month-old infant presents with anorexia, pruritus, and failure to gain weight; he has a bulging anterior fontanel and tender swelling over both tibias. The mother buys all food at a natural foods store. Think: Hypervitaminosis A.

Central nervous system, liver, bone, and skin and mucous membranes are the common sites. Acute vitamin A toxicity is not common. Initial presentation is primarily neurologic. Symptoms include irritability, tiredness, and somnolence. A bulging fontanel due to increased intracranial pressure may be present in infants. Pain and tenderness, particularly in the long bones, is often present.

Image Hypervitaminosis A.

Image Congenital absence of enzymes needed to convert provitamin A carotenoids to vitamin A.

Image Acute:

Image Pseudotumor cerebri: Bulging fontanel, drowsiness, cranial nerve palsies.

Image Nausea, vomiting.

Image Chronic:

Image Poor weight gain.

Image Irritability.

Image Tender swelling of bones—hyperostosis of long bones, craniotabes; Image mineralization of skull.

Image Pruritus, fissures, desquamation.

Other Supplements

Image If mother is a strict vegetarian, supplement thiamine and vitamin B12.

Image Thiamine deficiency causes beriberi (weakness, irritability, nausea, vomiting, pruritus, tremor, possible congestive heart failure).

Image Human milk will have adequate vitamin C only if mother’s intake is sufficient.

Image Commercial formula is often modified from cow’s milk and fortified with vitamins and minerals so that no additional supplements are needed for the full-term infant.


Image

Vitamin A deficiency is the number 1 worldwide most common cause of blindness in young children.


OBESITY

Image

A 16-year-old female presents to her primary care physician for a routine health visit. Upon questioning she states that she is very concerned about becoming overweight and that she goes to the gym often but wants nutritional advice. On examination, she is very thin and emaciated with very little sub-cutaneous fat, and you notice a thin layer of hair on her arms. She states that she is not sexually active and her last menstrual period was 4 months ago. What is the diagnosis? Anorexia nervosa

DEFINITION

Image Overweight is defined as a body mass index (BMI)-for-age ≤ 95th percentile on the Centers for Disease Control and Prevention (CDC) growth charts.

Image BMI is calculated by dividing weight (in kilograms) by height (in meters squared).

Image Adults:

Image Normal BMI: 18.5–24.9 kg/m2.

Image Overweight: 25.0–29.9 kg/m2.

Image Obesity: 30.0–39.9 kg/m2.

Image Extreme obesity: > 40 kg/m2.

Image Obesity: BMI of ≤ 30.

Image Children: “At risk for overweight”: BMI 90th–95th percentile for age and sex.

RISK FACTORS

Image Excessive intake of high-energy foods (“empty” calories).

Image Inadequate exercise in relation to age and activity, sedentary lifestyle.

Image Low metabolic rate relative to body composition and mass.

Image Genetics: Strong relationship between BMI of children and their biologic parents:

Image If one parent is obese, risk of obesity as an adult is 40%.

Image If two parents are obese, risk of obesity as an adult is 80%.

Image Certain genetic disorders (Alström syndrome, Carpenter syndrome, Cushing syndrome, Fröhlich syndrome, hyperinsulinism, Laurence-Moon-Bardet-Biedl syndrome, muscular dystrophy, myelodysplasia, Prader-Willi syndrome, pseudohypoparathyroidism, Turner syndrome).


Image

There is a direct relationship between degree of obesity and severity of medical complications.


EPIDEMIOLOGY

Most often presents at ages 1 year, 4–5 years, and adolescence.

COMPLICATIONS

Image Negative social attitudes: Embarrassment, harassment.

Image Respiratory: Sleep apnea.

Image Orthopedic: Slipped capital femoral epiphysis (SCFE).

Image Metabolic: Type 2 diabetes mellitus.

Image Cardiovascular: Hypertension, hyperlipidemia.

PREVENTION

Image Early awareness and starting good eating and exercise habits early may hinder the development of overeating and obesity.

Image Parent education is paramount in providing guidance in appropriate nutrition and feeding habits to promote healthy lifestyles for children.

Image Certain cultures are more predisposed to overfeed children when children are upset.

Image Newborns need all the nourishment they can get. They need to be fed on a continuous schedule and on demand.

Image Within the first year, offer food only when the child is hungry.

Image Have predictable eating schedules and offer child-sized portions using child-sized plates.

Image Avoid using food as reward or punishment.


Image

Obesity makes SHADE:

SCFE

Hypertension

Apnea (sleep)

Diabetes

Embarrassment


DIAGNOSIS

BMI is the most useful index for screening for obesity. It correlates well with subcutaneous fat, total body fat, blood pressure, blood lipid levels, and lipo-protein concentrations in adolescents.

TREATMENT

Image Adherence to well-organized program that involves both a balanced diet and exercise.

Image Behavioral modification.

Image Involvement of family in therapy.

Image Surgery and pharmacotherapy are relatively contraindicated in children.

Image Very-low-calorie diets are detrimental to growth and development—all nutritional needs should be met.

Image Avoid rapid Image in weight.

Image Goal of effective weight reduction is not so much to lose pounds but to maintain weight through growth spurt.

Image If BMI is > 97th percentile for age and sex, weight reduction may be recommended even prior to pubertal growth spurt.

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