pediatric nutrition darwin deen, md, ms rpsm july 27,2001
TRANSCRIPT
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:
– 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
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.