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pathum dissanayake

on 26 August 2016

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Transcript of Nutrition

Nutritional Disorders
Dr Pathum Dissanayake
Lecturer in Paediatrics
University of Peradeniya

Infant feeding
Breast feeding
formula feeds/ TPN
feeding in special circumstances

Nutritional disorders

Topics to cover
the process of taking in and assimilating
nutrients to achieve satisfactory
growth and avoid deficiency states

Energy for daily living
Growth and development
Healing and repair
Maintain body functions
Different from rest of the childhood

Rapid growth

Weight increase by 300%
Height increase by 50%
Brain weight doubles

A rapid change from total liquids to
adult type food over a period of one year!!!!

Infant feeding
First 6 months
exclusive breast milk
during first six months
Benefits of Breast Feeding
Nutrition in optimum condition

Immunological and antimicrobial protection
(low ear/respiratory/GIT infections and reduced allergy)

Passage of breast milk hormones and growth factors

Provision of digestive enzymes

Facilitation of mother-infant bonding

Convenient and ready to drink

delay return of ovulation.(natural contraception)

Loss of pregnancy-associated adipose
tissue and weight gain.

Suppresses post-partum bleeding.

Decreased breast cancer rate.

Reduce mental stress/ feeling of well being

To Mother

Low iron and vit K levels
can overcome by supplementation
Pain, stress and infection can reduce breast feeding
can overcome by good support to mom
Can affect life style (sleep and work)
can overcome by life style modification/support

Breast feeding contra-indicated in some conditions
active pulmonary TB
HIV (in developed countries)
severe systemic illness in mom

Disadvantages - VERY FEW
Adequacy of breast feeding
very difficult to measure

individual variation - significant

some information may be misleading
measures used
urine output
weight gain
child's behavior after a feed
baby's feeding pattern
maternal sensation of breast emptying
A baby having adequate breast feeds
will ......
pass urine around 6 times per day

sleep for about 2hours after a feed

gain weight appropriate for it's age

finish a feed by 10 - 20 minutes
( continuous sucking of breast indicate
poor feeding - usually poor technique)
The most common reason for poor feeding is
poor technique
of feeding
less common reasons

maternal illness
endocrine/ metabolic/neurological
diseases of the baby
mother on certain drugs(chemotherapy
mouth in "O" position

lips curled out

nipple AND Areola
inside baby's mouth
mother holds baby turned
towards her, head and trunk
in line

baby lying along mother's

mother sitting with proper
support and maintain eye
contact with baby

How long to breast feed

Only food during first 6 month

A main food during second six months

A minor food in second year

Can continue even longer but should not affect main meals or daily routines of the child

Excess breast feeding during the second year onward
is a main cause for refusal of meals and failure to thrive

Working mother
working mothers can breast feed or provide expressed breast milk to maintain nutrition for the baby

expressed milk - can be kept for 6 hrs in room temp
can be kept 24 hrs in refrigerator

working mothers are entitled to one hour of leave
each day during first 6 months for breast feeding
Formula feeds
Useful in
premature babies (special premature formula)
conditions contraindicating breast feeds
Maternal loss
Adopted child
Social restrictions ( eg – single working mom)

Well babies -
feed on demand in an appropriate frequency acceptable to mother(avoid unnecessary overfeeding)
Sick Babies cared in hospital
Day 1 - 60ml / Kg 10% dextrose / milk
Day 2 - 80-90ml / Kg 10% + Na+K+Ca / milk
Day 3 - 100-120ml / Kg
Day 4 - 130-140ml / Kg
Day 5 onwards - 150ml / Kg i.v.fluids
- upto 200ml / Kg milk
Feeding premature babies
Breast milk should be introduced as early as possible to any preterm.

Problem – difficult to breast feed

Poor suck reflex ( < 34 weeks)
Poor suck-swallow coordination
Poor muscle function – exhaust easily
Systemic illness – respiratory distress, infection

Tube feeding is the best way to introduce
breast milk (expressed from mom or banked milk)
gavage feeding

NG tube – nasogastric tube
OG tube – orogastric tube

Trophic feeds in preterm babies
Introducing minute amount of feeds
(0.5 ml 3 hrly) to prime the gut

Stimulate premature gut mucosa
Improves gut blood flow
Improves gut motility
Reduces the incidence of NEC
Shorter hospital stay

Total Parenteral Nutrition
Nutrition introduced to the body bypassing
the gastro-intestinal tract

Intravenous route used

Due to high viscosity and higher osmolarity of nutrients, a larger central vein is preferred than a peripheral vein
eg - Umbilical vein, saphenous, brachial vein

Nutrients given - dextrose, amino acids,lipids
minerals, vitamins
Extreme premature infants

necrotizing enterocolitis

GI surgery

Critically ill neonates
infection introduced through
venous access site


cholestatic jaundice

electrolyte imbalance

supplementation during infancy
babies with good birth weight do not need supplements

fortified foods during the second six months are adequate to supply minerals and vitamins

Babies who are having IUGR and born prematurely will need vitamin and mineral supplements due to low stores at birth and high demand during catch up growth

Iron supplements
introduced after first 4 weeks
given as a single daily dose (2mg/kg)
continued up to at least 1 year
multivitamin and folate
introduced after 2 weeks
continued until at least 6 months
multivitamins - daily, folic acid - EOD 1 mg
Phosphate and calcium
given for premature babies with osteopenia of
continued till AlkPo4 and PO4 levels normalize

Gradual introduction of solid foods in order to
establish adult feeding habits

Testing time for both mom and child
Different texture of food
Different tastes
Different frequencies
Uncover Allergies

2nd six month of infany
common rules
start with thick puree -> semisolids -> solids

once a day -> two meals -> three meals
later on can add snacks in between

introduce one food at a time

breast feed after the meal (NOT before)

start from a spoonful -- gradually increase

NO salt or sugar until infancy
when pincer grasp present encourage self feeding

encourage sitting at a table to eat

encourage feeding with other members

encourage chewing during late infancy

do not give processed/artificial foods

do not bribe during feeds

do not distract during feeds (television)









milk rice




formula feeds

Disorders of growth
under nutrition
excess nutrition




micro nutrient deficiency
Under nutrition
acute state of nutrition deficiency leading to

low weight for height

commonly due to disease and starvation

a state of nutrient deficiency leading to
low weight for age
commonly due to poverty, chronic disease

a long standing nutrition deficiency leading to

low height for age
commonly due to poverty, chronic disease
Important to remember
under weight and stunting can occur without a
nutrition deficiency

genetic status
endocrine diseases
familial short stature
physical and emotional abuse
WHO definition and grading of undernutrition
( The older version)
(Wt / Ht)
under weight
wt / age
Ht / Age
89 - 75%
74 - 60%
< 60%
100 - 90% 89 - 80% 79 - 70% < 70%
100 - 95% 94 - 90% 89 - 85% < 85%
Later versions of classifying
under nutrition
Use of z score charts

< - 1 = tendency towards under nutrition

< - 2 = moderate

< - 3 = severe
wt / age can sometimes mislead
child with severe malnutrition and edema
can have a normal weight for age due to
added weight of edema fluid !!!

(Protein energy malnutrition)
The most common nutritional deficiency
state seen in the developing world

Clinically divided into

derived from the greek word
- wasting

represent an
state for prolonged
protein and energy(calorie) malnutrition.

low intake of energy insufficient for body's

Body fat stores are used first
and then protein stores used

Derived from the ga language of Ghana
- "the sickness the baby gets when the new baby comes"
very low intake of protein
(stopping of breast milk and
low protein weaning foods)

Represents a

state during starvation
further protein stores(muscle) utilized
poor production of proteins/ amino acids
fat maldistribution (fatty liver)
In PEM....
The primary deficiency is protein and energy


vitamin and mineral deficiencies
also set in when the condition progress and give rise to certain signs and symptoms
Causative factors
adolescent / maternal malnutrition
adolescent --> adult female --> child --> adolescent
water and sanitation
childhood infections ( RTI and diarrhea)
poor weaning practices
family size
maternal education
clinical features
loss of body fat and muscles
thin and wasted appearance
"old man face" in severe form
poor hair growth

failure to thrive with OEDEMA
moon facies
swollen belly (pot belly)
hepatomegaly ( fatty liver)

skin manifestations
flaky paint dermatitis (dark cracked skin with pale skin
in between cracks)
hair depigmentation (brown, red hair)
intermittent malnutrition - Flag sign ( pale and dark
bands in hair)
dry, brittle, thin, lusterless hair
fissured or ridged nails

clinical features of PEM due to associate
micronutrient deficiencies
few examples

Vit C - bleeding gums, petechiae etc
Fe - anaemia, poor wound healing etc
niacin - diarrhea, dermatitis, dementia - pellagra
zinc - poor wound healing, prolonged diarrhea
acrodermatitis enteropathica

Effects on body systems due to PEM
GIT - mucosal atrophy, malabsorption

Liver - fatty liver

CVS - reduced myocardial function, slow pulse
Renal - renal atrophy, kidney failure

CNS - global development delay

Endocrine - hypo functioning of all glands
Management of PEM
severe malnutrition has to be managed in a hospital setting.
Done in three phases

Phase 1
- early stabilization(first 48 hrs)

Phase 2
- re-establishing feeding(1-2 weeks)

Phase 3
- consolidation and follow-up
Phase 1

FBC and blood picture and blood culture


serum electrolytes

renal and liver functions

serum calcium, PO4

UFR, Stool full report, cultures

Phase 1
During the first 48 hours the main aim is to treat
life threatening complications




electrolyte imbalance

Phase 2
main aim is to establish feeding slowly

start with liquids --> semisolids --> solids

start with low calorie load and gradually build up
to high calorie load

special re-feeding food products are used in the hospitals before going into more conventional
F 75 formula - 75Cal/ 100 ml
F 100 formula - 100Cal/ 100ml

BP 100 biscuit - 1 bar has 300 Cal
Rapid re-feeding can be dangerous

high calorie at rapid rate --> insulin surge

insulin --> drive potassium into cells --> life threatening hypokalemia

high calorie --> increased ATP production --> PO4 is used up rapidly --> severe hypophosphotemia

high volume load --> heart failure
Phase 3
slow establishment of normal well balanced diet

nutritional education

education on hygiene and prevention of disease
- managing diarrhea at home
- correct preparation of ORS

multi-vitamin and mineral supplementation
- vit A, C, B, D
- iron, Zinc, calcium

follow-up to reinforce changes and monitor growth
Iron deficiency
single most prevelent micronutrient deficiency in the world

Iron deficiency (ID) - Hb normal but iron low
Iron deficiency anaemia (IDA) - Low Hb and iron

Iron - hemoglobin production
immune functions ( T cell development)

ID can cause irreversible neuro development damage.
Therefore treating with iron only when anemia is detected may be too late

prevention and treatment
iron supplementation during infancy

LBW and prematurity - start at day 28 of life
2 mg/kg/day till one year

breast fed infants(term and good birth weight)
start supplementing at 4-6 months with iron
at 1 mg/kg/day

formula fed infants/ commercial weaning foods
no need for supplement as the food product itself is already fortified with iron

oral iron treatment is the best option

Given at 6 mg elemental iron/kg/day until Hb is normal AND continued for 3 months at least to
build up iron stores..

blood transfusion done only if patient has acute blood loss or having hemodynaemically unstable

parenteral iron (i.m) given ONLY if patient has severe vomiting and difficulty in taking oral iron

diagnosing ID and IDA
ferritin level (microg/L) Total iron binding capacity

Low High

serum iron (microg/L)


hemoglobin level ( IDA only)
6 months - 5 yrs 5 yrs onwards
normal > 11g/dl > 11.5g/dl
mild 10 - 10.9 11 - 11.4
moderate 7 - 8.9 8 - 10.9
severe < 7 < 8

response to iron treatment
first 48 hrs - improvement in mood and appetite

day 3-5 - increase in reticulocyte count

Hb rise - 0.8 - 1 g/dl / week
Vitamin A deficiency
Vitamin A important for

corneal,macular and retinal development

growth and health of skin and mucosa


maturity of immune system

release of iron from iron stores
vitamin A mega dosing schedule in Sri Lanka to prevent vit A deficiency
post partum mothers - 200,000 IU

child - 100,000 IU
first dose - 6 months
thereafter - repeat doses every 6 months
till 5 years of age
school - two doses at grade 4 and 7
over nutrition
overweight - increased wt for age and height
due to excess water,fat,muscle or bone
BMI > 85%
BMI > 2 SD

Obesity - presence of excess fat which leads to
unfavorable outcome to health
BMI > 95%
BMI > 3 SD
WT/HT > 120%
Causative factors
Excess in take of calorie rich diet
fizzy drinks, fast foods, biscuits, buns

lack of exercises

Lack of awareness/ education

wrong beliefs

wrong food habits
feeding while watching TV, using computer

Effects of childhood obesity
Type 2 DM

Metabolic syndrome




Obstructive sleep apnoea
slipped upper femoral epiphysis

Fatty liver

precocious puberty

Effects of obesity
low self esteem and bullying

behavior abnormalities ( social withdrawal or
Under nutrition
Macro nutrient
Micro nutrient
Vitamin deficiency
A, D, C, B, etc

Mineral deficiency
Fe, Zn, Iodine etc
Problems related to feeding children
The child can eat
but won't eat
The child want to
eat but can't eat
feeding problems
Physical problems
Structural defects
cleft lip and palate
choanal atresia
tracheo-esophageal fistula
multiple chocking episodes

aspiration pneumonia

failure to thrive
motility defects
Gastro-esophageal reflex disease
Swallowing dysfunction
( Cerebral palsy, myopathy, neuropathy)
coughing and gagging during feeds
nasal and oral regurgitation
recurrent aspiration
excessive crying in infants
abnormal posturing during feeding
drug side effects
genetic and metabolic disorders
chronic illness
multiple food allergies
Functional problems
food refusal and
picky eating
poor feeding habits
problems of
poor parenting
textures of food
delayed self feeding
poor feeding habits
feeding while watching TV
feeding done with "bribes"
extra sugar to "improve" feeding
force feeding
Not allowing to self-feed at the desired age
Inappropriate texture of feeds

continuing to give pureed food even after
1 year of age. Child does not adapt to eating solid foods.
poor parenting
over anxious parent
lack of knowledge

Not always straight forward ..........

some normal feeding patterns may look abnormal
some abnormal feeding patterns may look normal

some children may grow normally even when feeding problems are present
... some may even grow too well.....
Importance of identifying feeding problems
Can lead to poor growth and development

Can affect behavior of child

Can disrupt normal function of the whole family

Can lead to poor intellectual development in later life

Can reduce quality of life of both child and parent
Correct or bypass underlying structural/functional problems

cleft lip/palate - special feeding teat/ bottle

coanal atresia/ TOF - surgery

GORD - anti-reflux treatment

severe swallowing dysfunction - NG feeds or gastrostomy tube feeding

Treatment contd....
speech and language therapy

Behavior therapy/ psychotherapy

Education for the care giver

regular monitoring

Occupational and physiotherapy for children with motor dysfunction

improves oromotor coordination
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