1 nutritional requirements for small children matthias brandis prof. of paediatrics former chairman...

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Nutritional requirements for small Children

Matthias Brandis

Prof. of Paediatrics

Former Chairman of Paediatrics

Senator of the National Academy of Science

Department of Paediatrics and Adolescent Medicine

University Hospital

Freiburg, Germany

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Nutritional requirementsin infants and small children

• The averagre need for any child in the world is known since 150 years and can be expressed as– Energy intake per day– Divided in

• Protein• Crabohydrates• Fat

– Micronutrients like Ca, Fe, Znc, Vit D

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Consequences of longstanding malnourishment

• Children suffering from chronic malnourishment tend to adapt to the reduced amount of food

• The consequences are lethargy, motoric inactivity, diminshed muscular strength

• Retarded psychomotor development

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Health consequences of nutrition in early childhood

long time, secondary sequelae

• Metabolic program• Metabolic diseases like Obesity,

hypertension and cardiovascular diseases are correlated to birth weight, growth and feeding patterns

• Fat content should not exceed 25% of energy intake

• Protein should not exceed 15%

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Health consequences of nutritioan in early childhood

• Breastfeeding of 4-6 month exclusively leads to ideal serum lipid profile, reduced incidence of atopic dermatitis

• Neuro-cognitive development is correlated to long chain polyunsaturated fatty acids content of the diet

• Meat intake has proven to be beneficial to psychomotoric development. In Ghana only 6% of the children have regularly meat as part of their diet

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Nutrition and health development in women and children

What are the questions?• Are the basic nutritional needs guaranteed

for pregnant mothers?• Are the Basic principles of feeding an infant

and small child adequately known?• Are the parents educated enough to

understand the real necessities?• What are the reasonable measures to be

taken routinely and in emergency situations• Emergencies are e.g. wars and droughts

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Age Kcal/

Kg /d

Protein

g/kg

Fe

Mg/d

J

ug/d

0-4 m 91 1,5-2,7 0,5 40

4-12m 90/ 1,1-1,3 8. 80

4-7 y 82 1,0 8 100

Nutritional needs for infants and children

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Breastfeedingas basic nutrition in infants

adequate propagation

• Advantages– Sterility– Adequate ratio between protein, carbohydraes and fat– Feeding by demand– Continuation of breast milk to toddlers diet up to 30%

guarantees adequate supplement of fat and Vitamin A– Breast feeding might contribute to birth control

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Nutritional mixaccording to regional ressources

• Agricultural local products– E.g. Maize, Millet, Sorghum, Cassava– Nuts,peanuts, beans, Yam et al.

• Animal products– Meat– Milk

• F100: Substitute for micronutrients, where necessary

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Consequences

• The first goal is:– Feed the mother adequately– Teach the mother by simple information about

her own demands during pregnancy and while breastfeeding

– Teach the parents about the local availibility of agricultural and animal products as well as micronutrients

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Preharvest

Controlled study in school children in Benin, 2002(Mitchipkeet al. Public Health Nutr. 2009, 12, 414 )

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Postharvest

Controlled study in school children in Benin, 2002(Mitchipk et al. Public Health Nutr. 2009, 12, 414 )

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Controlled study in school children in Benin, 2002(Mitchipke et al. Public Health Nutr. 2009, 12,

414 )

14 Controlled study in school children in Benin, 2002(Mitchipke et al. Public Health Nutr. 2009, 12, 414 )

15 Controlled study in school children in Benin, 2002(Mitchipke t al. Public Health Nutr. 2009, 12, 414 )

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The Importance of Micronutrients

• Micronutrients are– Iron– Calcium– Zinc– Vitamins

• Any local traditional diet may be deficient in micronutrients which lead to anemia and rickets, which are frequent diseases in central Africa

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Micronutrient deficiency

• Iron deficiency: – Leads to anemia , retarded pschomotor development

and stunting

• Calcium and Vit D deficiency: – leads to the world wide persisting prevalence of

rickets, with growth stunting

• Iodine deficiency:– Leads to neuro- intellectual retardation

• Zinc deficiency– Leads to stunting, diarreha, skin disease:

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Zotor,FB and Amuna,P, Proc.Nutr.Soc.,2008. 67, 98

20Zotor,FB and Amuna,P, Proc.Nutr.Soc.,2008. 67, 98

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Hypernatremia

• Hypernatremia: Na > 150 mEq/L (Serum-osmolality increase by 20 mosmol/L)– causes:

• Water loss > than salt• Salt ingestion(very rare)

• Rehydratation slowly: Lowering of the elevated osmolality not faster than 5 mosmol/L in 6-12 hours

• Restitution can last up to 48 hours!• Salt ingestion has to be treated by emergency PD

Finberg et al.1979Finberg et al.1979

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700 mlIntake

700 mlExcretion

1400 ml ECV

Fluidexchange in an 7kg infant per day= 50 % of ECV

2000 ml intake 2000 ml excretion14000 ml ECV

Fluidexchange in adult(70 kg)= 14 % of ECV

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• Calculation of salt and water needs for a child of 10 kg BW– 100ml / kg BW= 1000ml– 2 mEq/ kg Na = 20 mEq

• All commercial infusion solutions have a 2 to 3 times higher sodium concentration

• Calory intake: e.g. 50 -70 Kcal/KG– Glucose- containing solutions have 200 Kcal/L, that is 20 Kcal/KG– During parenteral fluid therapy for several days additional calory

intake might be necessary, e.g. 2o% Glucose, Amino Acids, Fat

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Oral Rehydration

• Oral Salt solutions– Na-content 60-90 mmol/L– Glucose content 5 g%– Tube feeding– Up to 100 ml/kg/ day in small fractions or

continuous infusions

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Salt and Water regulationSummary

• In General it is practical experience to start to treat a child in an emergency situation with clear indications of a volume deficit with the following regime:– 20ml /kg BW in 1 hour Isotonic solution, if not plasma

or blood substution is needed.– In this 1 hour all necessary calculations and lab

results can be achieved and the next steps can be taken under the safe knowledge of the diagnosis

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Conclusions

• There is an overwhelming global evidence about the nutritional needs and demands in pregnant and lactating women as well as in infants and toddlers

• A high percentage up to 50% of children are malnourished and may suffer from stunting, anemia, rickets and retarded neuro-intellectual development

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Conclusions

• After decades of concern by local governments and international organisations the situation is as prevalent as ever or even worse.

• Severe droughts, ongoing wars with millions of children living in refugee camps have worsened the situation particularly for children and are not adequately compensated.

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Conclusions

• Which steps can be successfull and are mandatory:

–1 Teaching the families about the basic principles of diets

– 2 Rely on the local accessablilty of the agricultural products

– 3 Define the potential needs for supplementation of micronutrients(F100)

– Emergency situationas have to be undertaken in sitiations of humanitarian need, but should always lead to early reinstitution of the local food culture.

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Conclusions

• Education of children and parents seems after so many years of support programs the prominent task for any government, to guarantee a better future for the society

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• Thank You for Listening