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Nutrition in Children
Florianne Feliza F. Valdes,M.D.Fellow, Philippine Pediatric Society,Inc.
Section Head,Ambulatory Pediatrics
The Medical CityAteneo School of Medicine and Public Health
October 27,2010
Nutrition
Combination of processes by which living organisms receive and utilize the materials necessary for growth, maintenance of functions, and repair of component parts
Del Mundo,et al. Textbook of Pediatrics and Child Health
Metabolism
All changes occurring in food from absorption from the GIT until end-products are eliminated by the different excretory organs
Nutritional Requirements
FNRI DOST,NRC RENI
Advisable intake-variable, observed, approximated intake by a group of healthy individuals
Minimum requirement- least amount of nutrient needed for optimum health
Recommended Energy and Nutrient IntakesPhil.,2002
Recommended Energy and Nutrient IntakesPhil.,2002
RENI
In the Philippines, the revised edition of the dietary standards changed from Recommended Dietary Allowances (RDA) to Recommended Energy and Nutrient Intake (RENI)
Levels of intake of energy and nutrients which on the basis of current scientific knowledge, are considered:
Adequate for the maintenance of health and well being of nearly all healthy persons
Adequate intake based on the experimentally observed average intake of health individuals
Essential Nutrients
Water
FoodMacronutrients
CHO, Fat, proteins
Carbohydrates – 55 – 70%
Fats and fatty Acids- 10-15%
Proteins – 30-40%
MicronutrientsVitamins
Minerals
Electrolytes
Water
Infants and children must receive adequate amounts of fluids
Healthy infants : fluid consumption – 10-15% of Body weight
Adults: - 2-4 % Absorption : intestinal tract Interstitial compartment fluid: depends
on protein and electrolyte concentrations
Water
Balance depends on Fluid intake Diet:proteins and minerals Solute load Metabolic and respiratory rates Body temp
Evaporation: 40-50%lungs and skin Renal excretion
Approx daily requirements of Filipino Infants and Children
Neonates: 120-150 mL/kg 1-12 months: 150 1-3 years: 140 4-6 years: 120 7-9 years: 100 10-12: 90 13-15: 70 16-19: 50
Macronutrients
CARBOHYDRATES Children: growth and development Energy production Storage of calories as glycogen Conversion to fat,AA synthesis Cellulose as roughage Growth Repair of tissues Production of new cells and tissues
Carbohydrates
Deficiency: Underweight Ketosis General
weakness Fainting Collapse seizures
Excess: Obesity Diarrhea Syndromes due to
inborn errors of sugar metabolism
Carbohydrates
Sources: Starch, bread, cereals,rice and products Noodles, potatoes, roots, Tubers
Sugars, fruits, jams, preserves, jellies Cakes Cookies, candies MILK
Macronutrients
PROTEINS: Building blocks 20-22 amino acids Essential amino acids necessary to avoid
neg nitrogen balance Isoleucine, leucine, lysine,methionine,
phenylalanine,threonine, tryptophan,valine, and histidine
Proteins
Functions: AA for building and repairing body tissues Heat and energy supple when there is
CHO and fat shortage Ions in nitrogen balance
Proteins
Deficiency: Neg N2 balance Weakness Prominent abdomen Edema Retarded growth Slow recuperation Underweight Reduced resistance
to infection Kwashiorkor and
marasmus
Excess: Hyperammonemia Azotemia Acidosis
Proteins
Sources: Garbanzos,tokwa Peanut butter, munnggo, other beans Cereals, nuts Milk, meat,liver, heart,
kidney,poultry,eggs, fish, shellfish
Macronutrients
Fats – without this, malnutrition is a risk Low fat milk: low Vit A , linoleic acid, < 20 % of caloric intake- diarrheas, high
renal solute load Supplies essential fatty acids Carries fat soluble vitamins Structural part of every cell Reserve energy resource
FATS
Protein sparer Fats needed for satiety and appetite stimulation! Linoleic/arachidonic acids-
for growth, skin and hair integrity, regulation of cholesterol metabolism, lipotropic activity, Prostaglandins decreased platelet adhesiveness, reproduction
Fats
Omega 3 – special group of fatty acids Low rates of cardiovascular diseases in
Greenland Eskimos Fish oil Alpha linolenic acid, DHA- retinal development and cognitive
performance DHA /EPA- promote anti inflammatory
and immune effects
FATS
Deficiency: Underweight No appetite Skin
changes( linoleic a deficiency
Hair loss
Excess: Obesity atherosclerosis
Fats
Sources: Margarine, nuts, oils, shortening Milk Cream Meat , lard
Maronutirents and Micronutients
Energy/Calories Protein Fats Water
Vitamins Minerals Electrolytes
Minerals
Absolutely necessary for maintenance of LIFE Indispensable for new tissue cells and growth Sodium Potassium Calcium Magnesium Chloride Sulfur
MINERALS
Calcium Chromium Copper Fluoride Iodine Iron Magnesium Manganese
Molybdenum Phosphorus Potassium Selenium Sodium Chloride Zinc
Vitamins
First called “accessory factors” (1906) by English biochemist Sir Frederick Gowland Hopkins
Other substances necessary for health
Historical Background
“VITAMINE” (Polish American biochemist, Casimir Funk) an amine (organic base) essential to life
1912, Hopkins and Funk vitamin hypothesis of deficiency
Thiamine
Vitamins
A class of 13 organic compounds “that are essential in small quantities for the normal metabolism of other nutrients and maintenance of physiological well being”*
Help body turn food into energy and tissues
Most prescribed and MOST requested prescription in everyday pediatrics
* Reference: Burton BT: Human Nutrition, 3rd ed, McGraw, New York, 1976: 85
Functions of Vitamins
Vitamins do not directly yield energy but are required for energy yielding processes in the body
Some are co-factors in enzyme activity.
Some are antioxidants (prevent oxygen from doing damage in the body)
One vitamin (Vit. D) is a prohormone.
Functions of Vitamins
Normal growth
Maintenance of life
Normal function of the digestive tract
Normal nutrition, especially utilization of mineral elements
Proper oxidation of carbohydrates
Tissue resistance to bacterial infections
Normal reproduction
Functions of Vitamins
Act as catalysts or coenzymes (vit C)
No direct yield of energy but are necessary for some energy-yielding processes in the body (Krebs Cycle)
May vary from species to species
Differ in chemical structure and no common chemical grouping (water and fat soluble)
Classification of Vitamins
Fat SolubleVitamin A
Vitamin D
Vitamin E
Vitamin K
Water SolubleVitamin C
B complexB complex
Folic Acid
Pantothenic Acid
Fat Soluble Vitamins
Rickets
Water Soluble Vitamins
BERIBERI
Scurvy
MINERALS
Interactions between Micronutrients
Nutritional Status of the Filipino Child
Children O - 5 years of age: 68% normal weight for age, 32% underweight, 0.4% overweight 66% normal height, 34% stunted,0.4% tall 93% normal wt for ht 6% wasted, 0.9 % overweight for height
Children 6 -10 years of age: 27% are underweight for age (2.5 Million) 37% are stunted or short in height for age (3.4 Million)
* Reference: FNRI, 2003 data
Nutritional Status of the Filipino Child (0-5 years) – FNRI 2003
Normal Weight71.7%
Underweight26.9%
Stunted29.9%
Normal Height69.5%
Nutritional Status of the Filipino Child (6-10 years) – FNRI 2003
Normal Weight71.7%
Underweight26.9%
Stunted29.9%
Normal Height69.5%
Nutritional Status of the Filipino Adolescent, FNRI, 2003
11-12 years old 49% normal weights for height 26% underweight 4% overweight
13-19 years old 68% normal weights for height 12% underweight 3 % overweight
Energy and Nutrient Requirements(RENI)
13-15 years old 16-18 years old 19-29 years old Nutrients Male Female Male Female Male Female
Energy (kcal) 2800 2250 2840 2050 2490 1860 Protein (g) 71 63 73 59 67 58 Vitamin A (g RE) 550 450 600 450 550 500 Vitamin C (mg) 65 65 75 70 75 70 Thiamin (mg) 1.2 1.0 1.4 1.1 1.2 1.1 Riboflavin (mg) 1.3 1.0 1.5 1.1 1.3 1.1 Niacin (mg NE) 16 14 16 14 16 14 Folate (g DFE) 400 400 400 400 400 400 Calcium (mg) 1000 1000 1000 1000 750 750 Iron (mg) 20 21 14 27 12 27 Iodine (g) 150 150 150 150 150 150 Magnesium (mg) 225 220 260 240 235 205 Phosphorus (mg) 1250 1250 1250 1250 700 700 Zinc (mg) 9.0 7.9 8.9 7.0 6.4 4.5 Selenium (g) 31 31 36 36 31 31 Flouride (mg) 2.5 2.5 2.9 2.5 3.0 2.5 Manganese (mg) 2.2 1.6 2.2 1.6 2.3 1.8 Vitamin D (g) 5 5 5 5 5 5 Vitamin E* (mg) 12 12 13 12 12 12 Vitamin K (g) 50 49 58 50 59 51 Vitamin B6 (mg) 1.3 1.2 1.3 1.2 1.3 1.3 Vitamin B12 (g) 2.4 2.4 2.4 2.4 2.4 2.4
Potential Nutrition related problems in Adolescents
Undernutrition-Micronutrient malnutrition and chronic energy deficiency resulting in thinness (low Body Mass Index) and /or stunting
Obesity,Metabolic syndrome Eating Disorders: anorexia nervosa,
bulimia
Nutritional Status of Adolescents,using BMI
% Prevalence Underweight Overweight Gender/Age
1993 1998 2003 1993 1998 2003 Male 11-12 13-19 All
27.1 19.1 21.6
34.0 19.3 23.0
31.0 17.0 20.5
2.6 2.5 2.6
1.8 1.0 1.2
4.9 2.9 3.4
Female 11-12 13-19 All
19.2 5.9 9.5
27.2 12.9 16.4
20.6 6.4
10.1
1.5 2.5 2.2
3.2 5.2 4.7
3.4 3.9 3.8
Both 11-12 13-19 All
23.5 12.6 15.8
30.6 16.2 19.8
25.9 12.0 15.5
2.2 2.5 2.4
2.5 3.1 2.9
4.2 3.4 3.6
Energy and Nutrient Requirements
Increased nutritional needs-growth spurt Increased physical activity-males( protein and
energy) Poor eating habits Special considerations/stresses:
Sports Menstruation Pregnancy Drug abuse Special diets-
Vegetarian Religious reasons Allergies Intolerance
Nutritional Requirements
Energy: increased in males Protein – 1 g/kg /day – males;0.8
g/kg/day females Minerals: Iron, Calcium, Zinc,Iodine Vitamins – B12, folate, D,A,C,E,
thiamine, niacin, riboflavin Calories:
Males: 2400-2800 Females: 1800-2200
Calories CHO(grams)
FAT Cholesterol(mgs)
Big-MacWhopperQuarter pounder cheese
563660740
4149
3341
86
?
French fries
KFC leg/thigh
270
643 each
31
46
15
35
13
180
PHSuper Supreme
Coca-cola 10.5 oz
2 slices –340
96
42
24
11
0
22
Nutritional Status of the Filipino Child
* Reference: FNRI, 2003 data
Estimated prevalence of anemia in 2003 66% among infants 0-6 months old
29.1% in children 1-5 years old
37 - 40% in children >5 years old
Food & Nutrient Intake among Children, 2003
Energy & Nutrients
Energy (kcal)*
Protein (g)**
Iron (mg)**
calcium, (g)**
Vitamin A (mcg, Retinol equivalent)**
Thiamin (mg)**
Riboflavin (mg)**
Niacin (mg)**
Ascorbic Acid (mg)**
Proportion of households meeting
(>) RENI
Proportion of households not
meeting (<) RENI43.1
66.3
19.4
16.0
28.9
56.9
33.7
80.6
84.0
71.1
45.1
27.3
90.9
31.8
54.9
72.7
9.1
68.2
Marasmus( infantile atrophy, Inanition,Athrepsia,Cachexia, Decomposition)
Kwashiorkor( pr malnutrition, malignant malnutrition, melnarschaden)
Nutritional Assessment of Children and Adolescents
Assessment of Nutritional Status
1. HistoryDietary history of mother and child
History of wt and ht changes
Other lifestyle issues
2. Anthropometric IndicatorsDeviations from average ht and wt
Depletion of fat depots
Decrease in muscle mass
Assessment of Nutritional Status
3. Change in psychic reaction
4. Reaction to infection
5. Evidence of specific deficiencies
Anthropometric Measurements
Not a 1 time assessment Rate and velocity Use appropriate equipment for weight,
stature/length
Assessment of Nutritional Status
Measurements:Weight
Height or length
Weight for height – acute malnutrition
Head circumference
BMI
Skinfold thickness
Midarm circumference
Bone age
Growth velocity
Weight
Various types: infant scales, beam balance scales,platform scales, digital
Regualr calibration Weigh with minimal clothing
Length/Stature
Depends on the child’s ability to stand/ambulate
2 years and below: recumbent, tape measure, fixed head and foot board (infantiometer)
Charts taped to wall, barefoot Heels, buttocks, shoulders, head
touching wall
Weight for height
Ratio of Actual weight to the ideal weight for height
Independent of age Differentiates stunting from wasting
B0YS: 0-36 monthsLength for age and Weight for Age percentiles
Girls:0-36 monthsLength for age and Weight for Age percentiles
BOYS: 2-20 yearsStature for Age and Weight for Age percentiles
Girls 2-20Stature for age and Weight for Age percentiles
Head Circumference
Up to age 3 : growth slows down Tape measure to cross forehead above
the supraorbital ridges, pass around the head at same levels of both sides of occiput
Tape is moved,pressed on hair
Boys: 0-36 monthsHead circumference for age and weight for length percentiles
Girls: 0-36 monthsHead circumference for age and weight for length percentiles
Mid arm circumference
LEFT Muscle growth indicator Between acromion and olecranon
Indicators of Nutritional Status
<5th percentileStunting/shortness length or stature-for-age
Head circumference-for-age
<5th percentile
<5th percentile>95th percentile
Underweight weight-for-length BMI-for-age
Indicators of Nutritional Status
Overweight Weight-for-length BMI-for-age
>95th percentile
Risk of overweight BMI-for-age
85th to 95th percentile
Provides a reference for adolescents not previously available
Consistent with adult index so can be used continuously from age 2 to adulthood
Tracks childhood overweight
Advantages of BMI for age
Relates to health risks
CORRELATES with clinical risk factors for CVS diseases, DM, hypertension
Why Use BMI-for-Age?Why Use BMI-for-Age?
Guidelines for Overweight in Adolescent Preventive
Services (Am J Clin Nutr 1994;59:307-316) Obesity Evaluation and Treatment: Expert Committee Recommendations (Pediatrics 1998 Sept;(102)3:e 29) Assessment of Childhood and Adolescent Obesity: International Obesity Task Force (Am J Clin Nutr 1999, 70,suppl)
BMI-for-Age CutoffsBMI-for-Age Cutoffs
> 95th percentile Overweight
85th to < 95th Risk of overweight percentile
< 5th percentile Underweight
Charts are useful for Filipinos
CDC promotes one set of growth charts for all racial and ethnic groups.
Racial- and ethnic-specific charts are not recommended because studies support the premise that differences in growth among various racial and ethnic groups are the result of environmental rather than genetic influences.
reference population lacked sufficient numbers of specific racial/ethnic groups to consider separate charts.
factors that affect differences in growth among racial and ethnic groups, if they truly exist, remain unclear and more research is needed
BOYS: BMI for age percentiles
Girls: 2-20BMI for Age percentiles
Nutritional Status of the Filipino Adolescent
Body Mass Index BMI = weight(kg) /height(m2)
<18.5 Underweight 18.5 – 25 Healthy weight/normal 25 – 30 Overweight >30 Obese
Infant Nutrition: Breastfeeding
Breastfeeding
breastfeeding is the ideal method of feeding and nurturing infants and recognizes breastfeeding as primary in achieving optimal infant and child health, growth, and development.
Benefits of Breastfeeding
health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits
Benefits of Breastfeeding
Significantly decreases risk for a large number of acute and chronic diseases.
Research in the United States, Canada, Europe, and other developed countries, among predominantly middle-class populations, provides strong evidence that human milk feeding decreases the incidence and/or severity of diarrhea lower respiratory infection otitis media bacteremia bacterial meningitis botulism urinary tract infection necrotizing enterocolitis
Breastfeeding benefits
possible protective effect of human milk feeding against sudden infant death syndrome
Prevents insulin-dependent diabetes mellitus Crohn's disease ulcerative colitis Lymphoma allergic diseases other chronic digestive diseases
Breastfeeding has also been related to possible enhancement of cognitive development
Health Benefits for Mothers
-Increases levels of oxytocin-less postpartum bleeding ,rapid uterine involution
-Lactational amenorrhea - Earlier return to prepregnant weight- Delayed resumption of ovulation with increased
child spacing -Improved bone remineralization postpartum -With reduction in hip fractures in the
postmenopausal period-Reduced risk of ovarian cancer and
premenopausal breast cancer
Socio economic benefits
In addition to individual health benefits, breastfeeding provides significant social and economic benefits to the nation, including reduced health care costs and reduced employee absenteeism for care attributable to child illness.
AAP Policy Statement on Breastfeeding,1997
Infant Feeding
Weaning 6 months Breast to bottle Milk to solids Breast to cup/glass Developmental readiness of infants- head
control, oral motor coordination Mature GIT and kidneys
Lecture Focus
Nutrition Nutritional Requirements based on age
RENI Essential Nutrients
Macronutrients Micronutrients
Nutritional Deficiencies Nutritional Assessment
Anthropometrics BMI Growth Charts
Breastfeeding