Newborn Feeding Tips
For term newborns, caloric requirement is 100–120 kcal/kg/day (as compared to 1-year-old, 75 kcal/kg/day).
Newborns grow at a rate of about 30 g/day.
Newborns usually begin feeding within the first 6 hours of life.
Newborns should be breast- or formula-fed every 3–4 hours thereafter.
Supply = demand—the more often the baby breast-feeds, the more milk will be produced.
After a period of 4–6 months of exclusive breast-feeding the mother should begin to introduce solid foods into the child’s diet.
If the child has stopped losing weight by 5–7 days and begins to gain weight by 12–14 days, then feeding is adequate.
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.
Hunger is not the only reason infants cry. They don’t need to be fed every time they cry.
Human milk is ideal for a term infant in first year of life.
Whole cow’s milk is not suitable for infants because the higher intake of sodium, potassium, and protein renal solute load.
Cow’s milk can be introduced after the first birthday.
Optimal protein requirement of term infant is 2.2 g/kg body weight per day.
Don’t put baby to sleep with a bottle; it can dental caries.
The first milk produced after birth.
Usually a deep lemon color.
Breast milk predominant protein is whey (whey-tocasein ratio: 70:30).
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.
High in protein, minerals, immunologic factors, and antimicrobial peptides such as lactoferrin and lactoperoxidase; low in carbohydrates and fat.
Immunoglobulin A (IgA) accounts for 80% of the protein in colostrum.
Benefits of Breast-Feeding
incidence of infection (ie, otitis media, pneumonia, meningitis, bacteremia, diarrhea, urinary tract infection [UTI], botulism, necrotizing enterocolitis).
Higher levels of immunologic factors—immunoglobulins, complement, interferon, lactoferrin, lysozyme.
exposure to enteropathogens.
Other postulated benefits include higher IQ, better vision, risk of sudden infant death syndrome (SIDS), less fussy eaters.
incidence of chronic disease (type 1 diabetes, lymphoma, Crohn’s/ulcerative colitis [UC], allergies).
maternal oxytocin levels.
More rapid involution of uterus.
Less menstrual blood loss.
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, GI blood loss and iron deficiency.
Improved bone mineralization.
risk of ovarian and breast cancer.
Psychological benefits: maternal-child bonding.
Other: Saves money for family and society, no risk of mixing errors, correct temperature, convenient, no preparation.
Cow’s milk predominant protein is casein (78%).
Common Problems with Breast-Feeding
Soreness of nipples: Not due to prolonged feeding––due to improper positioning and poor removal.
Engorgement: Unpleasant/painful swelling of the breasts when feeding cycle is suddenly (relieved by feeding on affected breast).
Maternal fatigue, stress, and anxiety. Affects hormones needed for lactation.
Fear of inadequate milk production, formula milk supplementation.
Breast-fed infant requires the following supplements:
Vitamin K 1 mg IM at birth
Vitamin D 400 IU/day
Fluoride (after 6 months)
Iron from 4 to 12 months
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.
Jaundice (see Table 5-1 and Gestation and Birth chapter).
Possible vitamin deficiencies—A, D, K, B12, thiamine, riboflavin.
Infants who are exclusively breast-fed should receive vitamin drops after age 4 months.
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
Some medications (such as antimetabolites, chloramphenicol methimazole, tetracycline).
Herpetic breast lesions.
Breast-Feeding jaundice occurs in the First week. Breast Milk jaundice occurs Many weeks later.
TABLE 5-1. Breast-Feeding versus Breast Milk Jaundice
Oral contraceptive is not a contraindication for breastfeeding.
Untreated, active tuberculosis.
Cytomegalovirus (CMV) infection.
Human immunodeficiency virus (HIV) infection.
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.
Galactosemia: Infants with galactosemia should not ingest lactose-containing milk.
Not every woman will feel “milk letdown” despite proper breast-feeding.
Signs of Insufficient Feeding of Infant
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).
Continual hunger, crying.
Continually sleepy, lethargic baby.
Fewer than seven feeds per day.
Long intervals between feedings.
The common cold and flu are not contraindications to breast-feeding.
Sleeping through the night without feeding.
Loss of > 10% of weight.
Most common cause of FTT is inadequate caloric intake.
Reasons for Failure to Grow and Gain Weight
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.
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.
Improper formula preparation.
Use of skim and 2% milk before age 2.
Prolonged used of diluted formula.
Prolonged used of BRAT (bananas, rice, applesauce, toast) diet after illness.
Excessive juice or water.
Inappropriate feeding schedule.
Undernutrition has the greatest effect on brain development from 1 to 3 months of age.
Types (see Table 5-2).
Inappropriate formulas (see Table 5-3).
Formula with peptides: Nutramigen, Progestimil, Alimentum.
Formulas with free amino acids: Neocate, Elecare.
TABLE 5-2. Formulas
Anemia in infant receiving goat milk = megaloblastic anemia.
Feed at earliest sign of hunger; stop at earliest sign of satiety.
Predominant fat in preterm infant formula is medium-chain triglycerides.
Formula for an infant who is allergic to both cow milk and soy protein: Hydrolysate formula.
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.
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.
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
tongue protrusion reflex.
Sits with support.
Do not use 2% milk before 2 years of age or skim milk before 5 years.
TABLE 5-3. Inappropriate Formulas
Typical formulas contain 20 kcal/ounce.
Improved head control.
Opens mouth to spoon.
Avoid foods that are choking risks, including small fruits, raw vegetables, nuts, candy, and gum.
Estimated average requirement: Basal metabolic rate × physical activity level (see Table 5-4).
TABLE 5-4. Daily Caloric Requirements
TOTAL BODY WATER (TBW)
TBW makes up 50–75% of the total body mass depending on age, sex, and fat content.
Neonates have a greater percentage of TBW per weight than do adults (about 70–75%).
Intracellular fluid accounts for two thirds of TBW and 50% of total body mass.
Extracellular fluid accounts for one third of TBW and 25% of total body mass.
You know a patient is dehydrated when he or she is PARCHED:
Pee, Pressure (blood)
Elasticity of skin
Dryness of mucous membranes
EXTRACELLULAR FLUID (ECF)
ECF is composed of plasma (intravascular volume) and interstitial fluid (ISF).
Definition: Body fluid depletion (see Table 5-5).
Causes can be divided into two categories:
loss (e.g., vomiting, diarrhea).
hypovolemia, gradually affecting each organ system.
Percentage of dehydration can be estimated using (pre-illness weight – illness weight/pre-illness weight) × 100%.
TABLE 5-5. Signs and Symptoms of Dehydration
Rapidly expand the ECF volume and restore tissue perfusion, replenish fluid and electrolyte deficits, meet the patient’s nutritional needs, and replace ongoing losses.
For convenience, use the Holliday-Segar method to determine maintenance intravenous (IVF) requirements:
Give 100 mL/kg of water for the first 10 kg.
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
Fluid requirements can be determined from caloric expenditure.
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+.
This method overestimates fluid requirements in neonates under 3 kg.
For a child over 20 kg, give 1500 mL + 20 mL/kg for each kilogram over 20 kg.
Replacement of normal body fluid loss.
Causes of normal fluid loss include:
Insensible fluid loss (ie, lungs and skin).
Water requirements (mL/100 calories metabolized/day): Insensible—skin, 30; lungs, 15; stool, 5; urine, 50.
Replacement of abnormal fluid and electrolyte loss (ie, from vomiting, diarrhea, etc).
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.
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).
In hypotonic (hyponatremic) dehydration, serum Na+ < 130 mEq/L.
Most common electrolyte abnormality.
More common in infants fed on tap water.
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
Hypervolemic hyponatremia—fluid retention:
Congestive heart failure (CHF).
Acute or chronic renal failure.
Hypovolemic hyponatremia— sodium loss:
Due to renal loss:
Diuretic excess, osmotic diuresis, salt-wasting diuresis.
Adrenal insufficiency, pseudohypoaldosteronism.
Proximal renal tubular acidosis.
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.
Due to extra-renal loss:
Gastrointestinal (GI)—vomiting, diarrhea, tubes, fistula.
Third-spacing—pancreatitis, burns, muscle trauma, peritonitis, effusions, ascites.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH):
Hospitalized children are at risk for nonphysiologic secretion of ADH.
Central nervous system (CNS) disorders—infection, trauma, shunt failure.
Drugs—vincristine, vinblastine, diuretics, carbamazepine, amitriptyline, morphine, isoproterenol, nicotine, adenine arabinoside, colchicine, barbiturates.
Low urine output
High urinary sodium loss
Treat with fluid restriction
Water intoxication due to intravenous (IV) therapy, tap water enema, or psychogenic (excess water drinking).
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
Symptoms may occur at serum concentrations of ≤ 125 mEq/L.
Cerebral edema—more pronounced in acute.
Early: Anorexia, nausea, headache.
Mental status changes.
Later: Beware of brain herniation—posturing, autonomic dysfunction, respiratory depression, seizures, and coma.
Central pontine myelinolysis can occur if hyponatremia is corrected too quickly.
Acute versus chronic.
Serum and urine osmolality and sodium concentration, blood urea nitrogen (BUN), creatinine, other labs (glucose, aldosterone, thyroid-stimulating hormone [TSH], etc).
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.
Na+ deficit: (Na+ desired – Na+ observed) × body weight (kg) × 0.6.
One half of the deficit is given in the first 8 hours of therapy, and the rest is given over the next 16 hours.
Deficit and maintenance fluids are given together.
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.
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.
In hypertonic (hypernatremic) dehydration, serum Na+ > 150 mEq/L.
water or sodium intake.
sodium or water output.
Diabetes insipidus (either nephrogenic or central) can cause hypernatremic dehydration secondary to urinary free water losses.
Extrarenal or renal fluid losses.
Adipsic hypernatremia is secondary to thirst—behavioral or damage to the hypothalamic thirst centers.
Hypertonic saline infusion.
Sodium bicarbonate administration.
Accidental salt ingestion.
Mineralocorticoid excess (Cushing syndrome).
Extrarenal losses— insensible loss.
Renal free water losses—central diabetes insipidus (DI), nephrogenic DI.
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
Anorexia, nausea, irritability.
Mental status changes.
Muscle twitching, ataxia.
If the serum Na+ falls rapidly, cerebral edema, seizures, and cerebral injury may occur secondary to fluid shifts from the ECF into the CNS.
The treatment of elevated serum Na+ must be done gradually at a rate of around 10–15 mEq/L/day.
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.
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.
Too rapid correction of hypernatremia can result in cerebral edema.
Can be considered at K+ < 3.5 mEq/L, but is extreme when K+ < 2.5 mEq/L.
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).
Hypokalemia can precipitate digitalis toxicity.
SIGNS AND SYMPTOMS
peristalsis or ileus, hyporeflexia, paralysis, rhabdomyolysis, and arrhythmias including premature ventricular contractions (PVCs), atrial nodal or ventricular tachycardia, and ventricular fibrillation.
Electrocardiogram (ECG) may demonstrate flattened T waves, shortened PR interval, and U waves.
For every 0.1-unit reduction in serum pH, there is an in serum K+ of about 0.2–0.4 mEq/L.
Consider cardiac monitor.
If potassium is dangerously low (< 2.5 mEq/L) and patient is symptomatic, IV potassium must be given.
Do not exceed the rate of 0.5 mEq/kg/hr.
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.
Mild to moderate: K+ = 6.0–7.0.
Severe: K+ > 7.0.
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.
ECG may demonstrate peaked T waves and wide QRS.
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.
Sodium bicarbonate, albuterol nebulizer, or glucose plus insulin can be given to shift K+ to the intracellular compartment.
Kayexalate resin can be given to bind K+ in the gut (works the slowest).
Furosemide can be given to enhance urinary K+ excretion.
In extreme cases, hemo- or peritoneal dialysis may be necessary.
VITAMIN AND MINERAL SUPPLEMENTS
Supplement after age 6 months if the water is not fluorinated sufficiently (particularly well water).
If < 3.3 ppm, supplement with 0.25 mg per day.
Supplementation is recommended for the exclusively breast-fed infants.
Deficiency: Dental caries.
Excess: Fluorosis—mottling, staining, or hypoplasia of the enamel.
Children under 2 years should not use fluoridated toothpaste, and then only a small pea-sized amount up to age 6 years.
Because of the risk for fluorosis, don’t give fluoride supplements before age 6 months!
Vitamin D is critical for skeletal development and cellular function because of its effect on calcium homeostasis (by promoting intestinal calcium absorption).
Breast milk typically contains about 25 IU/L of vitamin D, which is insufficient for rickets prevention.
Most bottled water is not fluorinated.
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.
Supplementation is with 400 IU/day.
Deficiency: Impaired mineralization of bone tissue (osteomalacia) and of growth plates (rickets).
Vitamin D deficiency can hypocalcemia.
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.
Newborn iron stores are sufficient for 6 months in a term infant.
Therefore, breast-fed infants need iron supplementation 1 mg/kg/day (ie, iron-fortified cereals and baby foods), beginning at 4 to 6 months.
Preterm breast-fed infants should receive 2 mg/kg/day starting at 2 months of age.
Deficiency: Anemia (hypochromic microcytic) and growth failure.
Only iron-fortified formula should be used for weaning or for supplementing breast milk in children younger than 12 months.
Dark-skinned children are more likely to have inadequate sun exposure.
Human breast milk is deficient in vitamin K.
Infant has a limited body store of vitamin K.
Therefore, it is necessary to administer a 1-mg vitamin K IM injection at birth. Recommended for every newborn, not just breast-fed.
Deficiency: Thought to contribute to hemorrhagic disease of the newborn.
Vitamin K is necessary for the synthesis of clotting factors II, VII, IX, and X.
Fat soluble: Requires bile salts for absorption.
Breast milk has less iron than cow’s milk, but the iron in breast milk is more bioavailable.
Deficiency-associated intestinal malabsorption, nutritional intake limited to breast milk.
Deficiency used to be associated with total parenteral nutrition (TPN); now formulas have zinc in them.
Deficiency manifests as acrodermatitis, alopecia, and growth failure.
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.
Congenital absence of enzymes needed to convert provitamin A carotenoids to vitamin A.
Pseudotumor cerebri: Bulging fontanel, drowsiness, cranial nerve palsies.
Poor weight gain.
Tender swelling of bones—hyperostosis of long bones, craniotabes; mineralization of skull.
Pruritus, fissures, desquamation.
If mother is a strict vegetarian, supplement thiamine and vitamin B12.
Thiamine deficiency causes beriberi (weakness, irritability, nausea, vomiting, pruritus, tremor, possible congestive heart failure).
Human milk will have adequate vitamin C only if mother’s intake is sufficient.
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.
Vitamin A deficiency is the number 1 worldwide most common cause of blindness in young children.
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
Overweight is defined as a body mass index (BMI)-for-age ≤ 95th percentile on the Centers for Disease Control and Prevention (CDC) growth charts.
BMI is calculated by dividing weight (in kilograms) by height (in meters squared).
Normal BMI: 18.5–24.9 kg/m2.
Overweight: 25.0–29.9 kg/m2.
Obesity: 30.0–39.9 kg/m2.
Extreme obesity: > 40 kg/m2.
Obesity: BMI of ≤ 30.
Children: “At risk for overweight”: BMI 90th–95th percentile for age and sex.
Excessive intake of high-energy foods (“empty” calories).
Inadequate exercise in relation to age and activity, sedentary lifestyle.
Low metabolic rate relative to body composition and mass.
Genetics: Strong relationship between BMI of children and their biologic parents:
If one parent is obese, risk of obesity as an adult is 40%.
If two parents are obese, risk of obesity as an adult is 80%.
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).
There is a direct relationship between degree of obesity and severity of medical complications.
Most often presents at ages 1 year, 4–5 years, and adolescence.
Negative social attitudes: Embarrassment, harassment.
Respiratory: Sleep apnea.
Orthopedic: Slipped capital femoral epiphysis (SCFE).
Metabolic: Type 2 diabetes mellitus.
Cardiovascular: Hypertension, hyperlipidemia.
Early awareness and starting good eating and exercise habits early may hinder the development of overeating and obesity.
Parent education is paramount in providing guidance in appropriate nutrition and feeding habits to promote healthy lifestyles for children.
Certain cultures are more predisposed to overfeed children when children are upset.
Newborns need all the nourishment they can get. They need to be fed on a continuous schedule and on demand.
Within the first year, offer food only when the child is hungry.
Have predictable eating schedules and offer child-sized portions using child-sized plates.
Avoid using food as reward or punishment.
Obesity makes SHADE:
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.
Adherence to well-organized program that involves both a balanced diet and exercise.
Involvement of family in therapy.
Surgery and pharmacotherapy are relatively contraindicated in children.
Very-low-calorie diets are detrimental to growth and development—all nutritional needs should be met.
Avoid rapid in weight.
Goal of effective weight reduction is not so much to lose pounds but to maintain weight through growth spurt.
If BMI is > 97th percentile for age and sex, weight reduction may be recommended even prior to pubertal growth spurt.