Download PowerPoint Presentation - NUTRITION FOR INFANTS, CHILDREN

NUTRITION FOR INFANTS,
CHILDREN AND
ADOLESCENTS
Andrew Tershakovek, MD
Associate Professor of Pediatrics
University of Pennsylvania School of Medicine
Director, Weight Management Program
Children’s Hospital of Philadelphia
Lisa Hark, PhD, RD
Director, Nutrition Education and Prevention Program
University of Pennsylvania School of Medicine
©2000 University of Pennsylvania School of Medicine
Objectives
 To recognize the changing nutritional needs of
developing children, from infancy to adolescence.
 To understand that nutritional recommendations for
children vary by age, stage of development,
and gender.
 To recognize that nutritional and dietary behaviors
learned in children can have a significant impact on
adult health concerns such as obesity, cardiovascular
disease, and osteoporosis.
©2000 University of Pennsylvania School of Medicine
Why is Nutrition Important?
 Energy of daily living
 Maintenance of all body functions
 Vital to growth and development
 Therapeutic benefits

Healing

Prevention
©2000 University of Pennsylvania School of Medicine
Growth in Infants
 Rapid body growth and brain
development during the first year:

Weight increases 200%

Body length increases 55%

Head circumference increases 40%

Brain weight doubles
©2000 University of Pennsylvania School of Medicine
Major Determinants of
Caloric Needs
 Basal metabolic rate (BMR)
 Activity level
 Growth (2x BMR during first year)
 Stress (infection, surgery, illness)
 Misc. (thermic effect of food)
©2000 University of Pennsylvania School of Medicine
Monitoring Growth
 Use updated growth charts

www.cdc.cov
 Monitor trends in growth not one value using
wt, ht, HC (< 2 yrs), BMI.
 In general, normals fall within 5th-95th%ile.
 Evaluate changes in %iles.
 Malnutrition results in:

Decreased weight (acute), then height,
then head circumference (chronic).
©2000 University of Pennsylvania School of Medicine
Feeding the Newborn
 What are the options?

Breast feeding


The American Academy of Pediatrics
recommends exclusive breast feeding
for 6 months.
Formula feeding
©2000 University of Pennsylvania School of Medicine
Breast Feeding Questions
 Why should I breast feed my baby?
I thought formula was the identical alternative.
 How often and for how long will my baby nurse?
 How do I know if the baby is getting enough?
 How many months can I breast feed the baby
and when can I add formula?
©2000 University of Pennsylvania School of Medicine
Breast Feeding
Advantages to Infants
 Immunologic benefits (>100 components)
 Decreased incidence of ear infections, UTI,
gastroenteritis, respiratory illnesses, and bacteremia.
 Convenient and ready to eat.
 Reduced chance of overfeeding?
 Fosters mother-infant bonding.
©2000 University of Pennsylvania School of Medicine
Breast Feeding
Advantages to Mothers
 May delay return of ovulation.
 Loss of pregnancy-associated adipose
tissue and weight gain.
 Suppresses post-partum bleeding.
 Decreased breast cancer rate.
©2000 University of Pennsylvania School of Medicine
Assessment of
Breast Feeding
 Weight pattern - consistent weight gain.
 Voiding - # wet diapers/day, soaked?
 Stooling - generally more stools than formula.
 Feed-on-demand ~ every 2-3 hours.
 Duration of feedings - generally 10-20 min/side.
 Need for high fat hind milk.
 Activity and vigor of infant.
©2000 University of Pennsylvania School of Medicine
Breast Fed Infants
 My 8 week old breast fed baby has not had a bowel
movement in 6 days. He gets 1 or 2, 4 oz bottles of
iron fortified formula at night as well. He is happy
and active. His appetite is good. He is not vomiting.
His abdomen is soft and nontender. What should I
do?
©2000 University of Pennsylvania School of Medicine
What should I do? - cont.
 Discontinue the iron formula, it may be constipating.
 Give 1 tsp of mineral oil per day until he goes.
 Give a suppository each day until he goes.
 Add cereal to the bottle to help his bowels and to
sleep.
 Dilute the formula to give more water.
 Give 1 oz apple juice per day until he goes.
 Do nothing, breast fed infants may not have a bowel
movement for up to 7 days.
©2000 University of Pennsylvania School of Medicine
Supporting Breast Feeding
 Ask patients if they plan to breast feed.
 Give prenatal guidance, materials and support numbers.
 Support hospital initiatives to encourage breast feeding, such as
lactation counselors.
 Ask about breast feeding support available to mother.
 Become familiar with how to manage common problems such as
mastitis and inverted nipples.
 Understand issues related to pumping and helping moms return
to work or wean the infant.
©2000 University of Pennsylvania School of Medicine
Infant Formula
 3 Forms:

Ready to feed - most expensive, does not
require water.

Concentrate - requires mixing with water in
equal parts.

Powder - requires mixing with water.
©2000 University of Pennsylvania School of Medicine
Composition of Standard
Infant Formula
 Caloric density: standard formulas contain
20 calories/oz (0.67 calories/cc).
 Protein content: ratio of whey to casein variesmost are 60:40 similar to human milk.
 Fat: most provide ~50% of calories from fat from
saturated and polyunsaturated fatty acids.
 Carbohydrate: lactose, beneficial effect on mineral
absorption (Ca, Zn, Mg), and on colonic flora.
 Micronutrients: Higher vitamin and mineral content
than human milk to cover 97% of the population.
©2000 University of Pennsylvania School of Medicine
Special Formulas
 Soy: used for vegetarians, lactase deficiency,
galactosemia.
 Lactose free: cow’s milk-based formula.
 Protein hydrolysate: infants who can not digest
or are allergic to intact protein.
 Free amino acids.
 Pre-term infant: unique for premies,
predominant whey protein, cow’s milk based,
higher protein and calcium, 20-50% MCT.
 Pre-term follow up
©2000 University of Pennsylvania School of Medicine
Assessing Readiness
to Feed
 At what age it is best to introduce solid foods?
How do I know if he is ready to eat?
 What food should I give the baby first?
 Should I put cereal in the bottle? It seems to
help the baby sleep at night.
 My baby likes to go to sleep in the crib with a
bottle. Is that OK?
©2000 University of Pennsylvania School of Medicine
Feeding Skills Development
 4-6 mos - experience new tastes.

Give rice cereal with iron.
 6-7 mos - sits with minimal support.

Add fruits and vegetables.
 8-9 mos - improved pincer grasp.

Add protein foods and finger foods.
 10-12 mos - pulls to stand, reaches for food.

Add soft table food, allow to self-feed.
©2000 University of Pennsylvania School of Medicine
Feeding Skills Development
 12-18 mos - increased independence.

Stop bottle, practice eating from a spoon.
 18 mos -2 yrs - growth slows, less interest in eating.

Encourage self-feeding with utensils.
 2-3 yrs - intake varies, exerts control.
©2000 University of Pennsylvania School of Medicine
Pre-school (1 to 6 Years)
 1-2 years: on average, grows 12 cm, gains 3.5 kg.
 Rate of growth slows by 4 years.

6-8 cm/year

2-4 kg/year
 Brain growth triples by 6 years.
©2000 University of Pennsylvania School of Medicine
Common Complaints
 My 2 year old is such a picky eater.
I am worried about his diet.
 My 3 year old eats noodles for dinner
every night. Is that ok?
 I think my 4 year old is anorexic. She
won’t eat when we have meal time.
©2000 University of Pennsylvania School of Medicine
Cow’s Milk
 My son is 9 mos and formula is so expensive.
Can I start giving him whole milk now?
 My daughter is 14 mos and we drink skim milk.
Can I give her skim milk so I only have to buy
one type of milk for the family?
©2000 University of Pennsylvania School of Medicine
Developing Healthy Habits
 Offer a variety of healthy foods and snacks.
 Encourage fruit and vegetable intake.
 No junk food snacking.
 Limit intake of juices ( 4 oz per day).
 Increase intake of water (no soda).
 Encourage low fat dairy products (3-4 servings/ day).
 Make fun physical activity a habit.
 Limit TV to no more than 1 to 2 hours per day.
 Track growth and development carefully.
 Be a good role model.
©2000 University of Pennsylvania School of Medicine
Nutritional Concerns in
Childhood and Adolescents
 Malnutrition and poverty.
 Growth spurt-onset of menses for girls-changes
in body size/image.
 Food fads, vitamins, athletes.
 Eating disorders: anorexia and bulimia nervosa.
 Overweight and obesity.
 Hyperlipidemia and heart disease.
 Bone mineralization and osteoporosis.
©2000 University of Pennsylvania School of Medicine
Poverty and Malnutrition
 18 million (22.7%) of children under 18 in
the US live in poverty.
 Income <$14,306/year for family of 2 adults
and 2 children.
 Iron deficiency anemia most problematic.
 Low vitamin C intake.
 Exposure to lead.
©2000 University of Pennsylvania School of Medicine
Poverty and Malnutrition
 Poor nutrition and cognitive function:

Decreased brain growth and or CNS development.

Poor performance on measures of cognitive ability.

Malnourished children are unprepared to benefit from
age-appropriate educational experiences.
©2000 University of Pennsylvania School of Medicine
Adolescent Growth Spurt
 Physiological growth stage (Tanner staging) rather
than chronological age, is the best indicator for
establishing requirements or evaluating intake.
 Females: 11-14 years:

Grow 8.4 - 9.0 cm/year.

Girls deposit more total body fat.
 Males: 13-16 years:

Grow 9.5 - 10.3 cm/year.

Boys deposit more muscle mass.

Boys tend to gain more weight at a faster rate and skeletal
growth continues longer than girls.
©2000 University of Pennsylvania School of Medicine
Eating Disorders in
Adolescents
 An estimated 20% of teens engage in some type
of abnormal eating.
 5% of high schools girls have been diagnosed
with an eating disorder.
 Adolescents are frequent users of OTC diet pills.
 Multiple factors contribute: thin “ideal” , family
pressure, exhibiting body control.
©2000 University of Pennsylvania School of Medicine
Diagnostic Criteria for
Anorexia Nervosa (DSMIV)
 Refusal to maintain body weight over a minimal
normal weight.
 Intense fear of gaining weight or becoming fat,
even though underweight.
 Denial of low body weight.
 In females, absence of at least 3 consecutive
menstrual cycles.
 Specific types: restricting or binge purging.
©2000 University of Pennsylvania School of Medicine
Diagnostic Criteria for
Bulimia Nervosa (DSMIV)
 Recurrent episodes of binge eating characterized by:

Eating a larger amount of food than most people would eat
in a specific period of time.

A sense of lack of control over eating at this time.
 Recurrent inappropriate compensatory behavior to
prevent weight gain (vomiting, laxatives, exercise).
 Binge eating and other behaviors occur, on average,
at least twice a week for three mos.
 Self-evaluation is unduly influenced by body shape /
weight.
 Specify type: Purging type or non-purging type.
©2000 University of Pennsylvania School of Medicine
Eating Disorders
Physician’s Role
 Know the diagnostic criteria and ask questions.
 Look for warning signs.
 Convey your concerns to the patient without
focusing on weight.
 Expect denial, anger, or defensive reaction.
 Know your limits and refer to an experienced
eating disorder team.
©2000 University of Pennsylvania School of Medicine
Obesity in Childhood
and Adolescents
 >20% of children/adolescents are overweight.
 Increased by 50-100% over last 20-30 years:

More sedentary lifestyle and behavior (TV/video games).
 Prevalence increasing more rapidly among AfricanAmericans.
 Obese children and adolescents become obese
adults.
 Recent reports indicate 8-45% of newly diagnosed
pediatric pts with diabetes are diagnosed with type 2.
©2000 University of Pennsylvania School of Medicine
Obesity:
Health Consequences
 Cardiovascular disease risk
 Type 2 diabetes (epidemic)
 Hypertension
 Orthopedic
 Sleep apnea
 Gall bladder disease/steatohepatitis
 Psychosocial problems
©2000 University of Pennsylvania School of Medicine
Pediatric Obesity
Etiology and Treatment
 Etiology:

Genetic predisposition: 80% risk if both parents obese

Environment

Dietary intake

Physical activity / sedentary activity
 Treatment:

Multidisciplinary and comprehensive

Formal behavior modification

Family-based
©2000 University of Pennsylvania School of Medicine
Prevention of
Cardiovascular Disease
 Atherosclerotic process begins in childhood.
 Childhood cholesterol levels associated with
degree of early atherosclerotic changes.
 Cholesterol levels track.
 Behavior tracking?
©2000 University of Pennsylvania School of Medicine
Prevention of CVD
Current Recommendations
 NCEP guidelines apply to children over 2 yrs.
 Diet: <30% fat, <10% sat. fat,
<300 mg cholesterol/day.
 Check fasting lipid profile when there is a positive
family history of early CVD, or elevated cholesterol
(hyperlipidemia) in a 1st degree relative.
 Combine dietary intervention with healthy lifestyle
for maximum benefits.
©2000 University of Pennsylvania School of Medicine
Osteoporosis
 Bone mineralization peaks in teenageyoung adult years.
 Maximizing peak bone mineralization may
decrease the risk of adult osteoporosis.
 Maximizing bone mineralization:


Diet

Calcium

Sodium, protein, phosphorus
Weight bearing exercise.
©2000 University of Pennsylvania School of Medicine
Dental Health
 Cariogenic Bacteria

Food

Adherence

Frequency of eating

Sugar
 Fluoride
©2000 University of Pennsylvania School of Medicine
Disease Prevention
Developing Healthy Eating Habits
 Discourage dieting and obsession with weight.
 Pack healthy lunch at least twice a week.
 Limit fast food eating out.
 Encourage a balanced diet.
 5 servings of fruits/vegetables a day.
 Encourage low fat dairy products (3-4 / day).
 Prepare meals that kids and teens enjoy.
 Encourage teens to learn to cook healthy food.
 Teach kids and teens label reading.
 Be a role model.
©2000 University of Pennsylvania School of Medicine