Pediatric Nutrition

Darwin Deen, MD, MSRPSM

July 27,2001

Overview• Newborn

feeding• Formulas• Requirements• Infant Feeding• Beikost• Nutrient

sources

• Toddler Diet• School-aged

children• Special Topics:

– Obesity– Eating disorders– Food

Intolerance– Healthy Eating

• Resources

Developmental Stages

• Infants: newborn, 1, 2, 4, 6, 9, 12 months

• Toddlers: 15, 18, 24, 36, and 48 months

• Children: 5, 6, 8, 10 y.o.• Adolescents: 11-21 yrs.

Newborns• Breastfeeding for 6-12 months• Iron-supplemented formula as an

alternative.• Low iron formulas do not reduce

GI symptoms.• Soy-based formulas for

intolerance symptoms but not for allergy.

Breast vs. FormulasBreast Cow

ForSoy For

Cal/L 680 680 1000

Pro,g 10.5 14-16 *17-20

Case% 30 0-80

Whey%

70 18-100

Fat, g 39 35-37 36-37

CHO, g

72 72-74 68-70

Requirements

• Calories• Protein• Iron• Calcium• Zinc

Requirements• Calories:

– Infants: 105 kcal/kg/d– Toddlers: 90-100 kcal/kg/d– Children: 80-90 kcal/kg/d– Adolescence: 2100-2200 cal/d

for females and 2700-2800 cal/d for males

Infants• Introduce solids at 4-6 months

when neuromuscular development is adequate: head control, ability to sit up, extrusion reflex has disappeared, infant swallows solids.

• Early introduction of solids increases risk of food intolerance & overfeeding.

• Start with a cereal (rice or barley) & add new foods one at a time.

Infants*• 1-4 months-breast or formula only• 4-6 months-cereals added• 6-7 months-vegetables added• 8-9 months-start finger foods

(banana) & chopped (junior foods)• 9 months- add meat and juices

from a cup• 10 months- egg yolk (cooked) &

bite-sized cooked food• 12 months- whole egg, cows milk,

table foods

Infants• Alternative strategy:• Cereals at 6 months, fruits at 7,

veges at 8, meats at 9.• Start with 1-2 teaspoons increase

gradually to 9 teaspoons (1 jar).• At 9 months: 6-12 t cereal, ½ oz.

Meat, 9-18 T fruit & vege, breast PRN or 26-31 oz formula.

Nutrients in Baby Foods

• Cereals are fortified with iron.• Juices are fortified with Vit C.• Fruits and vegetables supply

vitamins & minerals.• Meats supply protein and iron.• Deserts supply only sugar and

starches.• Avoid dinners, deserts, and

pudding.

Macronutrients in Foods

% Calories

From

Protein Fat CHO

Human Milk 6 56 38

Formula 9 48 43

Cow’s --WholeMilk --Skim

2240

483

3057

Baby Food 8 12 80

Food Sources of Nutrients

• Iron: red meats, legumes, green leafy veges, fortified cereals, dried fruit, peanut butter

• Calcium: dairy, greens, broccoli, legumes, tofu, almonds, sesame seeds

• Zinc: meats, seafood, eggs, milk• Vit A: dark yellow & green veges• Folate: dark green leafy veges and

fruit• Vit B6: whole grain cereals, seeds,

nuts, legumes, potatoes

Home-made• Thoroughly wash fresh or thaw

frozen fruits or vegetables. Trim meats well.

• Use canned goods without added salt or sugar & rinse.

• Steam or boil until tender. Stew meats.

• Puree in blender or grinder. Add water to adjust consistency.

• Will keep refrigerated for 48 hrs or can be frozen in ice cube tray.

Toddlers• Between 1 and 3 appetite

declines along with growth rates. Parents require reassurance.

• Suggestions: provide small portions of “finger foods” to consume frequently.

• Avoid appetite stimulants.

Toddler DietFood Group Portion Size

Milk- 3 servings 4-6 oz.

Meat/Alternative- 2 servings

1-2 oz.

Grains- 4 servings

Bread ½-1 slicePasta & Cereal ¼-½ cup

Fruits/Vegetables- 4 servings

Veg 2-4 TFruit 2T or ½ piece

School Age Children• Advise 2-3 glasses of low fat or

skim milk per day.• Encourage physical activity and

limit TV hours.• Don’t use food as a reward.• Encourage nutritious snacks.• Encourage healthy family

eating patterns.

Adolescents• Body Image issues• Encourage physical activity• Discourage dieting• Watch intake of soda and junk• Reinforce healthy attitudes

toward food and nutrition• See Adolescent Nutrition

presentation

Special Topics• Obesity• Eating Disorders• Vegetarianism• Food Intolerance/Allergy• Healthy Eating Habits• Drinks/Snacks

Obesity• Weight for Height or BMI > 85%ile is

overweight and > 95%ile is obese.• Increasing prevalence in children

and adolescence.• Associated with parental obesity

and inactivity (hours of TV).• Prevention is easier than treatment.• Encourage activity and healthy

eating.

Eating Disorders• Common onset in adolescence• Be alert for body image

disturbances• Screen for medical complications• Treat with nutritional and

psychiatric interventions• See Eating Disorders presentation

Vegetarianism• Protein: combine protein

sources to maximize biological value.

• eggs, grains, seeds, nut butters, hummus, tofu, soy milk, tempeh, dairy products, legumes, bean soups & chili, vege burgers, vegetables.

Vegetarianism• Non-dairy Calcium sources:

– Green leafy veges: bok choy, kale, broccoli, mustard, turnip, beet, and collard greens

– Tofu– Dry beans– Sesame seeds or tahini– Figs, almonds, molasses– Fortified orange juice or soy milk

Food Intolerance/Allergy

• Allergy: immunologic reaction to food

• Intolerance: non-immunologic• Clinically respiratory,

gastrointestinal, dermatologic or systemic symptoms

• Challenge testing

Food Allergy

• More common in families with atopy history.

• Allergy symptoms: respiratory distress, vomiting, diarrhea.

• Foods to avoid: cow’s milk, eggs, nuts, fish, wheat.

Food Allergy Symptoms

• GI: abdominal pain, bloating, diarrhea, malabsorption, nausea, vomiting, constipation

• Respiratory: asthma, chronic cough, runny nose, wheezing

• Dermatologic: eczema, atopy, urticaria, angioedema, itching, rash

• Systemic: anaphylaxis, headache, behavioral changes

Common allergens• Milk• Wheat• Soy• Nuts (ground

or tree)

• Shellfish• Beef• Watermelon• Corn• egg

Food Intolerance

• Skin rashes• GI symptoms: vomiting,

diarrhea, constipation• Upper respiratory

symptoms: cough, runny nose

Healthy Eating Habits• Provide 3 meals and 2 snacks daily.• Choose foods from each food group

and proportions according to the pyramid.

• Choose whole grains when possible.• Avoid fatty or sugary items except in

small portions after a meal.

Healthy Snacks

• 100% juice not sugar water.• Avoid too much soda, candy,

cake, non-juice soft drinks.• Low fat Milk and cheese,

yogurt, fruit, vegetables, muffins.

• PB&J on whole wheat bread.

Healthy Carbohydrates

• Whole grain breads• Whole grain cereals• Tortillas (esp. corn)• Rice cakes• Pita bread• Pop Corn• Pretzels

Healthy Fruits• Whatever the child likes, including:

– Apples– Bananas– Pears– Berries– Oranges– Melon– Grapes– Canned fruits

Healthy Vegetables• Cooked or raw:

– Carrots, green peppers, cucumbers, radishes, cauliflower, tomatoes (grape or cherry)

• Cooked:– Broccoli, green beans, peas, etc.

Healthy Protein Sources

• Low fat milk• Turkey or chicken• Yogurt• Cottage or other low fat cheese• Nuts• Tuna• Eggs

Fruit Juice• AAP recent position paper on

juices: Americans spend $5 billion per year on fruit juices. Most are little more than sugar water (11-16% CHO). 6 oz. Juice = 1 fruit serving. Use cup not a bottle to avoid tooth decay. No more than 4-6 oz per day for infants and 8-12 oz per day for older children. Do not use as re-hydration formula. (Pedialyte is 2-3% CHO & much higher in Na & K). http://www.pediatrics.org/

Drinks/Snacks• Apples wedges with peanut butter• PB&J sandwiches (substitute apple

butter• Raw veges with yogurt-based dip• Cottage cheese with canned fruit • rice cakes with PB or low fat cheese• Grilled cheese sandwich or Tortilla

with melted cheese

Composition of Beverages*

Fluid CHO PR

O

Fat Cal Na K mOs

m

Gatorade 14 0 0 56 11

0

25 280

Pedialyte 6 0 0 24 22

4

17

9

270

Cola 25 0 0 96 9 0 650Man Ped Nutr P.146

Composition of Beverages*

Fluid CHO PRO

Fat Cal Na K mOsm

Orange Juice 27 1.7 .1 112 2 474

1600

Apple Juice 29 .2 .3 116 7 296

1300

Skim Milk 12 8.4 .4 86 126

406

275

Whole Milk 11 8.0 8.2 150 120

370

650

Iron deficiency• Very common in children. Risks

include: poverty, minority groups, immigrants, premis and LBW, maternal diabetes.

• Associated with learning problems (even without anemia).

• Reduced risk by using only high iron formulas and by adding meat and fruit to the diet.

• No need for Vit C supplement unless you are adding iron supplement.

Current Controversies

• Addition of long-chain fatty acids to infant formula

• Why delay solids?• Sugar and dental caries

Web resources in Pediatric Nutrition:

• Virginia Cooperative Extension: ABCs of Feeding preschoolers– http://www.ext.vt.edu/pubs/preschoolnutr/348-

009/348-009.html

•  USDA Food Guide Pyramid for Young Children

– http://www.usda.gov/cnpp/KidsPyra/index.htm • About.com information on healthy eating for children

– http://nutrition.about.com/library/blchildfoodguide.htm

• General Children’s Health Info• http://www.kidshealth.org/

More Web Resources:• Nutrition In Pediatric HIV Infection

– http://www.hivpositive.com/f-Nutrition/f-3-PediatricNeut/n-Zafonte.html

• Harvard Medical School’s Consumer Health Information– http://www.intelihealth.com/IH/ihtIH/

EMIHC000/20722/20722.html?k=tnavx3324x20722• American Dietetic Association Pediatric Practice Group

– http://www.eatright.org/dpg/dpg22.html• International Food Information Council

– http://ific.org/• Children’s Hospital of Iowa

– http://www.vh.org/Patients/IHB/Peds/Diet/PedsDiet.html

References• Kleinman RE. Pediatric Nutrition Handbook 4th

Ed.: American Academy of Pediatrics, 1998• Tamborlane WV: The Yale Guide to Children’s

Nutrition. New Haven 1997• Picciano MF et. Al: Nutritional Guidance is

needed during the dietary transition in early childhood. Pediatrics 2000;106:109-114.

• Bogen DL Baker SS: Screening for iron deficiency anemia by dietary history in a high-risk population. Pediatrics 2000;105:1254-59.

• Deckelbaum RJ: Fat intake in children: is there a need for revised recommendations? J Pediatr 2000;136:7-9

• Hall RF Carroll RE: Infant Feeding. Peds Rev 2000;21(6):191-9.

References• Trusswell AS: ABC of Nutrition 3rd Ed. BMJ Books,

London, 1999• Kreiter SR, et.al.: Nutritional Rickets in African

American breastfed infants. J Pediatrics 2000;137:153-7.

• Klish WJ, Baker SS: Soy Protein-based infant formulas. Pediatrics 1999;104:119-23.

• Renfrew MJ, et. al.: Interventions for influencing sleep patterns in exclusively breastfed infants. Cochrane Database Syst Rev. 2000; 2: CD000113.

• Walker WA, Watkins JB: Nutrition in Pediatrics: Basic Science and Clinical Applications. 2nd Ed. BC Decker Inc 1997, Hamilton

• Hendricks KM, Duggan C, Walker, WA: Manual of Pediatric Nutrition 3rd Ed. BC Decker, 2000, Hamilton.