March Board Review
Nutrition
Test Question
• Sean Payton should be suspended for the
whole 2012-2013 season
– A. True
– B. False
Current Evidence for Infants
• Meta-analyses or systematic reviews strongly
favored breastfeeding for a reduced risk of:
–
–
–
–
–
–
Acute otitis media
*GI infections
Asthma (regardless of family history)
Type 2 DM
Leukemia
SIDS
• Lower risk for atopic derm in infants with family
history for BF exclusively for 3 months
• *Reduced risk of hospitalization for LRTI in infants
who were breastfed exclusively for 4 months
Current Evidence for Mamas
• Reduced risk of breast cancer in
premenopausal women
• Association between BF and a reduced risk of
ovarian cancer (more studies needed)
• Reduced risk of type 2 DM in women who did
not have a history of gestational DM
Beyond the Evidence
• Attachment and bonding between infant and
mother
• Psychological and developmental benefits for
both
• Skin-to-skin contact
– Positive attachment
– Successful breastfeeding
– Longer duration of breastfeeding
– Allow in the first hour after birth
Question #1
• As you are completing the physical exam on a newborn, the
father mentions that he and his wife have allergic rhinitis
and asthma. He asks whether his son is at increased risk for
allergies and how to reduce his chance of developing them.
• Of the following, the MOST appropriate next step is to
explain:
– A. Because both parents have asthma, breastfeeding will not
reduce the risk of eczema
– B. Breastfeeding or formula choices do not matter now, because
mom did not restrict her diet during pregnancy
– C. You need to obtain a cord blood IgE level to determine the
risk
– D. Exclusive breastfeeding with the addition of hypoallergenic
formula if needed is the best option to decrease and delay
allergies
– D. The parents should start a cow milk formula, and then switch
to breastfeeding if he develops eczema
Breastfeeding to Avoid Allergy
• *Breastfeeding for the first 6 months with
supplementation with a hypoallergenic
formula will decrease the severity and delay
the onset of allergic disease
– 42% reduction in atopic dermatitis (with family
history)
– 27% reduction in risk of asthma (no family history)
– 40% reduction in risk of asthma (with family
history)
Question #2
• A mother is trying to decide between breastfeeding
and formula feeding and asks you for information on
the composition of human milk compared with cow
milk infant formula.
• Of the following, the MOST accurate statement is that
human milk has a
– A. Lower concentration of protein than cow milk formula
– B. Higher concentration of vitamin D than cow milk
formula
– C. Higher concentration of vitamin K than cow milk formula
– D. Same amount of cells, enzymes, and antibodies as cow
milk formula
– E. Lower concentration of docosahexaenoic acid (DHA)
than cow milk formula
*Protein
Human Milk
Cow Milk
Total protein
1.8 g/dL
2.8 g/dL
Casein
30%
82%
Whey
70%
18%
Colostrum
• “The first immunization”
– *High concentrations of antibodies and infectionprotective elements
– *Provides local GI immunity against organisms
entering the body via GI tract
• High in total protein, low in carbohydrate, and
lower in fat than mature milk
• After processing, cow milk and infant formula
contain no cells, no enzymes, and no antibodies
or other active protective agents
– Do not support the maintenance of physiologic gut
flora
Vitamins
• Vitamin C is significantly higher in human milk
• Vitamin D
– Diminished from skin exposure to sun
– Women pass less to the fetus, so newborns lack
sufficient stores
– Breastfed infants are given 400 U daily from birth
– Formula contains 400 U in 26 to 32 oz
• Vitamin K
– *Low content in human can contribute to
hemorrhagic disease of newborn
– All newborns receive 1mg IM at birth regardless of
proposed feeding method
Question #3
• There are numerous bioactive factors in human
milk that boost the immune system.
Immunoglobulins are the most recognized and
studied.
• Which of the following is found in the highest
concentrations in human milk?
–
–
–
–
A. IgG
B. IgA
C. IgM
D. IgE
Immunology
• Human milk bolsters the infant’s immature
immune response and mucosal immunity
• Bioactive factors
– *Igs are predominantly secretory IgA
• Smaller amounts of IgM and IgG
• *Act at mucosal level in infant’s mouth, nasopharynx, and GI
tract
• Actual antibodies against specific microbial agents depend
on mom’s exposure and response to particular agents
– Other proteins include: lactoferrin, lysozyme, alphalactalbumin, casein
– Lactose, oligosaccharides, glycoconjugates, lipids,
nucleotides, cytokines, hormones, and growth factors
Question #4
• You are addressing a group of expectant mothers about
the benefits of breastfeeding. One woman asks if it is
ok to breastfeed if she has had CMV in the past. You
explain that there are only a few infections that are
contraindications to breastfeeding.
• Of the following, breastfeeding is MOST likely to be
contraindicated if a mother:
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–
–
–
–
A. Has genital herpes without breast lesions
B. Is a CMV carrier
C. Tests positive for West Nile Virus
D. Is being treated with antibiotics for a Staph mastitis
E. Has active, untreated pulmonary TB
Infectious Disease
• *Viral infections
– HTLV-1 or -2 - contraindication to breastfeeding
– HIV - advised not to breastfeed
• Unless in area with increased infectious disease,
nutritional deficiencies, morbidity, mortality, etc.
– Latent or recent CMV - not a contraindication to
BF
• Unless preterm, low-birthweight
Infectious Disease (cont’d)
• *Viral infections (cont’d)
– WNV is transmitted through human milk, but not
clinically significant, so no contraindication to BF
– HSV, Varicella-zoster, vaccinia, or variola require
temporary avoidance of BF and milk from a breast
with identified lesion
– Hepatitis
• Hepatitis B surface antigen positive – can BF after
routine prophylaxis (Hep B vaccine and HBIG)
• Hepatitis C antibody positive – can BF safely (unless
also HIV +)
Infectious Disease (cont’d)
• *Bacterial Infections
– TB mastitis
• BF can continue once mother on appropriate anti-TB
therapy and infant is on isoniazid
– Staph or group A Strep
• Temporary suspension of BF during first 24 hours of abx
therapy for the mom
– Group B Strep
• Temporary suspension of BF during first 24 hours of abx
therapy for the mom
• Transmission via BF is uncommon compared to close
direct contact
*Disorders of Breast
• Previous breast surgery
– No contraindication
– May cause ineffective lactation
• Inverted or flat nipples
– Use nipple shields and lactation consultation
• Breast cancer
– No contraindication as long as not on antineoplastic
medications
• Candida breast infection
– Continue to BF
– Treat both mother and infant
Question #5
• A soon-to-be mother in your practice asks you to
look at the list of medications that she is on at
home to make sure that they are safe to take
while breastfeeding.
• Of the following, in which situation is it SAFEST to
recommend breastfeeding?
– A. A mother on tetracycline for a skin infection
– B. A cocaine addict who has failed to comply with her
methadone maintenance program
– C. A diabetic mother on insulin therapy
– D. A mom with leukemia on methotrexate
– E. A mother with hyperthyroidism receiving
radioactive iodine treatment
Maternal Medications
• Drugs that are routinely administered to
infants are safe to prescribe breastfeeding
mother
• Large molecules such as insulin, heparin, and
many Igs do not pass into milk
• *Maternal ingestion of drugs with sedative
properties can potentially cause sedation in
breastfed infants
*Maternal Medications
• Drugs of abuse or street drugs are considered
contraindicated
– Women who have been stable on a methadone
maintenance program should be permitted to
breastfeed
• Immunosuppressant drugs are contraindicated
(ex: methotrexate)
• Radioactive compounds
– Use ½ life to calculate clearance time and determine
how long a mother needs to pump and dump
*Maternal Medications
*Maternal Medications
INFANT FORMULAS
Cow Milk-based Formulas for Term
Infants
• “Standard” infant formulas
• Available in:
– Ready-to-use liquids
• 20 cal/oz
– Powder or liquid concentrates
• Can yield caloric densities b/t 20-30 cal/oz
Content of Cow Milk-based Formulas
for Term Infants
• Protein
– Whey vs. casein
• The numbers:
– Human milk: whey-to-casein ratio 70:30
– Bovine milk: whey-to-casein ratio 18:82
• The difference:
– Casein forms large curds on exposure to gastric acid
– Whey is resistant to precipitation and undergoes more rapid
gastric emptying
• Formula:
– 50% higher total protein content to match the quality of human
milk
– Contains supplemental taurine
– Casein-predominant (20:80), whey-predominant (60:40), and
100% whey formulas have all been shown to support normal
growth patterns in term and preterm infants
Content of Cow Milk-based Formulas
for Term Infants
• Carbohydrate
– Lactose
• In both cow milk-based formulas and
human milk
• Fat
– Human milk
• Rich in palmitic, oleic, linoleic, and linolenic fatty acids
• Docohexaenoic acid (DHA) and arachidonic acid (ARA) are
LCPUFA present in human milk
– Found to accumulate rapidly in the fetal retina and brain during
the last trimester 2 years of age
Content of Cow Milk-based Formulas
for Term Infants
• Fat (con’t)
– Formula
• Contains specific blends of vegetable oils designed to
mimic the ratios of saturated, monounsaturated and
polyunsaturated fatty acids in human milk
• Now supplemented with DHA and ARA
– Based on recent studies that have shown that higher doses of
DHA and equal amounts of ARA yielded improved visual and
neurodevelopmental outcomes
– No negative effects observed
Question #6
• The mother of a 5-month-old boy has come to your office seeking
nutritional advice. She exclusively breastfed the infant for the first 4
months, then weaned the baby to a standard, cow milk proteinbased infant formula. One week after weaning, she noted that the
baby "strained with stool." Because of her concerns regarding the
development of constipation, the mother switched him to a low
iron formula (containing 2 mg/L iron).
Of the following, the MOST important dietary recommendation for
this infant is to
– A. Add pureed vegetables to the diet
– B. Change back to a cow milk protein-based formula containing 12
mg/L iron
– C. Change to a soy protein-based formula
– D. Continue the present regimen and supplement with 4 oz/day
diluted apple juice
– E. Substitute oatmeal for rice cereal in the diet
Content of Cow Milk-based Formulas
for Term Infants
• Vitamins and minerals
– Iron
• Absorbed at a higher rate from human milk (20-50%)
compared with cow’s milk (4-7%)
• In order to compensate for lower bioavailability, all
fortified formulas contain double to triple the amount
of iron
• Formula-fed infants should be on iron-fortified formula
Content of Cow Milk-based Formulas
for Term Infants
• Nucleotides
– Composed of one RNA nucleoside, one 5-carbon
sugar moiety, and one or more phosphate groups
– Supplementation shown to (?):
•
•
•
•
Enhance growth in SGA infants
Enhance IgA and IgM concentrations in preterm infants
Decrease incidence of diarrheal disease
Enhance Ab response to certain vaccines
Content of Cow Milk-based Formulas
for Term Infants
• Prebiotics, probiotics and synbiotics
– Basic principles
• BF infant intestinal flora
– Bifidobacterium, Lactobacillus
• Formula-fed infant intestinal flora
– Complex; also includes Bacteroides, Enterobacteriaceae,
Clostridium and Streptococcus
Content of Cow Milk-based Formulas
for Term Infants
– Pre/pro/synbiotics attempt to reproduce the intestinal
flora of a BF infant
– Specifics:
• Prebiotics: stimulate growth and function of specific species
of bacteria
• Probiotics: live microorganisms that survive digestion and
colonize the colon more beneficial colonic microbiota
• Synbiotics: combination of pre and probiotics
– Proposed benefits (probiotics)
• Decreased incidence of clinical eczema in high-risk infants
• Decreased incidence of NEC and all-cause mortality in VLBW
infants
• Decreased respiratory and intestinal infections
Preterm Infant Formulas
• Higher caloric density
– 24 cal/oz
• Increased protein content (whey-predominant)
• Fat and CHO compositions designed to overcome
nutrient losses from low concentrations of lipase,
bile salt and intestinal lactase
– Medium-chain triglyceride (MCT) oil provides b/t 4050% of total fat
– 60:40 or 50:50 mixture of glucose polymers and
lactose
Preterm Infant Formulas
• Higher amounts of vitamins and minerals
– Calcium
– Phosphorous
– Vitamins A&D
• Intake of some nutrients may be excessive if
preterm formulas are consumed in quantities
>12 oz/d
– Preterm formulas should always be d/ced before
hospital discharge
Preterm Transitional Formulas
• 22 cal/oz
• Have intermediate nutrient concentrations
• Transition usually occurs at 1800-2000g or 34
weeks
– Continued until 6-9 months of age
• 2007 Cochrane meta-analysis found no
evidence that these formulas lead to
improvement in growth or
neurodevelopmental outcomes
Human milk Fortifiers
• EBM alone inadequate to meet the nutritional
needs of preterm infants (especially VLBW
infants)
• Contain protein, fat, CHO and 23 vitamins and
minerals
– Matches growth and metabolic effects of premature
infant formulas
• Ongoing use may eventually lead to excessive
intake of certain nutrients (with potential for
toxicity)
Question #7
• A young mother has brought her newborn to
your clinic for his first visit. She has heard that
soy formulas are better than milk-based
formulas. For which of the following conditions is
soy formula indicated?
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–
–
–
–
A. Allergic enteropathy
B. Colic
C. Galactosemia
D. GER
E. Prematurity
Soy Formula
• What’s the difference?
– Protein: higher concentrations to improve biologic
value, supplemental aa
– CHO: glucose polymers, maltodextrin (NO
LACTOSE)
– Fat: similar to cow milk-based formula
– Vitamins and minerals: 20% higher concentrations
(Ca, Phos, Zinc, Fe) due to decreased
bioavailability
Soy Formula
• Safe for term infants
– NOT Preterm infants
• Cannot meet increased requirement for Ca and Phos 
osteopenia
• Increased aluminum concentrations decreased Ca
absorption further effects on bone mineralization
• *Indications*
– Congenital lactase deficiency
– Galactosemia
– (IgE-mediated allergy to cow’s milk)
• 8-14% with cross-reaction
Question #8
• Atopic dermatitis may be delayed or prevented in
high risk (non-BF) infants with the use of which
type of formula?
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–
–
–
–
A. Soy
B. Extensively hydrolyzed
C. Premature
D. Pre-thickened
E. Follow-up
Soy Formula
• NOT indications
– Infantile colic
– Cow milk protein allergy
• 30-64% have a cross-reaction to soy protein
– Prevention of atopic disease
– Transient lactase deficiency
Hydrolyzed and Amino Acid-based
Formula
• What’s the difference?
– Protein: hydrolyzed casein or free amino acids
– CHO: glucose polymers (lactose-free)
– Fat: variable, similar to cow milk-based formula; some
products contain MCT*
• Examples
– Extensively hydrolyzed (EHFs): Nutramigen,
Pregestimil*, Alimentum*
– Amino acid-based: Nutramigen AA, Neocate*,
Elecare*
Question #9
• A mother brings in her 2 mo infant due to some blood
streaks noted in her stool. She takes Enfamil Lipil 4oz q34h, and there has been no recent change in formula. In
addition, she has been more irritable than usual and
spitting up more frequently. Her stools are normal (other
than the blood that was noted), occurring 1-3 times per
day. On PE, you notice her weight has dropped from the
50th percentile at her 1 mo visit to just above the 10th
percentile at this visit. There are no anal fissures. Stool is
FOBT positive, but the infant otherwise appears well. Of the
following, what are you most likely going to suggest to this
mother?
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–
–
–
–
A. Change to soy formula
B. Increase Enfamil feeds to 6 oz q4h to promote weight gain
C. Change to an extensively hydrolyzed formula
D. Change to whole milk
E. Thicken feeds with 1-3 tsp of rice cereal
Hydrolyzed and Amino Acid-based
Formula
• Indications
– Infants with proven CMPA that are not BF should
be fed EHFs
• AA formulas should be reserved for those who do not
respond to EHFs
– Infants at high risk for developing atopic disease
(have one first-degree relative with atopy) who
are not BF exclusively for 4-6 mos or are formulafed
• Atopic dermatitis may be delayed or prevented with
the use of EHFs
Finally…
• Pre-thickened formulas not superior to
formula thickened later with rice cereal
• Follow-up formulas (for term infants) have no
clear advantage over infant formulas designed
to meet all nutritional needs throughout the
first postnatal year
Content Specs Not Covered
• Age at which cow’s milk should be introduced into the
diet…
– 12 mos
• Deficiency that infants fed goat milk exclusively are prone
to…
– Folate
• Signs and symptoms of CMPA…
– (non-IgE) Vomiting, diarrhea, blood-tinged stools, irritability
– (IgE mediated) Sx of allergic reaction
• Difference b/t CMPA and lactose intolerance…
– Amount of product required for a reaction, lactose intolerance
less common in younger children (especially infants), severity of
symptoms (sometimes:))
PROTEIN-ENERGY MALNUTRITION
(PEM)
Question #10
• You are called at by an ER physician about admitting an 8 month old
male for suspected abuse and neglect. You ask your colleague to
report growth parameters and physical exam findings. The boy is
<3rd percentile for length, weight, head circumference, and weight
for height. He has an emaciated appearance with dry skin, little
subcutaneous fat, no ascites or hepatosplenomegaly, and no
edema. On further history, he has severe constipation and
developmental delay.
• Of the following, the MOST likely diagnosis is:
–
–
–
–
–
A. Kwashiorkor
B. Marasmus
C. Combined-type protein-energy malnutrition
D. Iron deficiency anemia
E. Complications of a vegan diet
Kwashiorkor
• A form of PEM characterized by insufficient
protein intake and reasonable carbohydrate
intake
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–
–
–
–
Hypoalbuminemia (universal)
*Edema
Dermatosis
Growth retardation
Occurs after age 1 when weaned from breastfeeding
to diet rich in carbohydrates but poor in proteins
• Results from: malabsorption syndromes, neglect,
or extreme dietary restrictions
Kwashiorkor
• *Clinical features
– Irritability
– Mild growth failure
– Developmental delay
– Edema of extremities (hallmark)
– Distended abdomen with hepatomegaly
– Neurologic, hematologic, and immunologic
dysfunction
– Normal or near normal weight and height for age
Kwashiorkor
Marasmus
• *Characterized by severe
caloric restriction
• Clinical features
– Decreased weight for
height
– Little subcutaneous fat
– Dry skin
– Severe constipation
– Emaciated appearance
without edema
– Occurs before age 1
Combined Type PEM
• Combined Kwashiorkor and Marasmus
• Deficiencies of many essential nutrients
– Vitamin B6 and B12
– Niacin
– Riboflavin
– Thiamine
– Zinc
– Fatty acids
Management
• 1) Correct fluid and electrolyte imbalances,
replace deficient vitamins and nutrients, and
treat any infections
– Fluid and sodium increased cautiously to prevent
cardiac overload
• 2) Initiate nutrition
– Can be delayed 24 to 48 hours
– Start with a low amount and advance slowly
Question #11
• Your patient in the previous question is admitted to the
hospital for child neglect and severe malnutrition
consistent with marasmus. You stabilize the patient by
correcting electrolyte abnormalities with IVFs and plan
to initiate nutrition. You are worried about refeeding
syndrome and plan to continue to check electrolytes as
you slowly start feeds.
• Of the following, which is the primary electrolyte
disturbance seen in refeeding syndrome?
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–
–
–
–
A. Hyperphosphatemia, hyperkalemia, hypermagnesemia
B. Hyperphosphatemia, hyperkalemia, hypercalcemia
C. Hyperphosphatemia, hyperkalemia, hypochloremia
D. Hypophosphatemia, hypokalemia, hypermagnesemia
E. Hypophosphatemia, hypokalemia, hypomagnesemia
Refeeding Syndrome
• Results from abnormal fluid and electrolyte
shifts in a body that is already fluid- and
electrolyte depleted
• *Primary electrolyte disturbances
– Hypophosphatemia
– Hypokalemia
– Hypomagnesemia
Refeeding Syndrome (cont’d)
• *Clinical manifestations
– Neurologic impairment
– Cardiac arrhythmias
– Impaired cardiac and respiratory function
– Death
• Monitor electrolytes and watch for signs of
and symptoms during initiation of feedings
CHILDHOOD OBESITY
Some Scary Statistics
• Prevalence of overweight/ obese
children >33%
– Prevalence in children 6-19 yo tripled from 20032006
– Prevalence in children 2-5 yo rose from 5% to
12.4%
• Type II DM being diagnosed in morbidly obese
9 yos
• Bariatric surgery has been performed in
children as young as 12 yo!
Question #12
• You are seeing a 14 yo F in your clinic for a
well-child check. When you plot her BMI, you
find that it is in the 90th percentile for age.
This means (by definition) that she is:
– A. Obese
– B. Normal
– C. Overweight
– D. Underweight
– E. Tall
Definitions
• Obesity occurs when energy intake exceeds
expenditure
• BMI=kg/m2
– Overweight: BMI 85%-95%
– Obese: BMI>95%
Factors Contributing to Increased
Childhood Obesity
• Prenatal influences
– Prenatal nutritional deprivation
– Gestational DM
– High birthweight
• Having an obese parent
• Genetic factors
• Environmental factors
Question #13
• Little Johnny’s mother comes to you with concerns
about his weight. His BMI is currently in the 85th
percentile for age (8 yo), and Mom is worried that he
will grow up to be obese. She wonders what she can
do at home to help prevent more weight gain. All of
the following are appropriate environmental
modifications to promote a healthy lifestyle, EXCEPT:
– A. Eating family dinners at the table away from the
television
– B. Limiting screen time to 4 hours per day
– C. Avoiding prepackaged foods at the grocery store
– D. Removing televisions from the bedroom
– E. Choosing outdoor/active weekend activities for the
family
Factors Contributing to Increased
Childhood Obesity
• Environmental factors
– Demise of the family dinner
– Prepackaged food with high ratios of saturated fat and
high-fructose corn syrup
– Less accessible and lower intake of fruits and
vegetables in the average urban family
– Lack of safe areas to play
– Sedentary lifestyles
– Diminished school PE requirements
– Media
– Feeding trends
Protective Factors
• Breastfeeding
• Being a part of families who have active
lifestyles
• Minimal TV usage
• Having non-obese parents
The Bottom Line…
• Being an obese infant/child being an obese
adolescent being an obese adult
Question #14
• All of the following are medical complications
of pediatric obesity, EXCEPT:
– A. Hypertension
– B. High HDL
– C. Type II DM
– D. Coronary artery disease
– E. High LDL
Complications of Obesity
Laboratory Evaluation
Treatment: The Pediatrician’s Role
• First Step: regularly track BMI and recognize
when overweight or obesity status occurs
• Second Step: react to an increasing BMI with
an approach that promotes positive family
change without decreasing the parents’ or
patient’s self-esteem
• So what EXACTLY does that include??
Treatment: The Pediatrician’s Role
• Interventions
– Frequent office visits
• Overweight quarterly visits
• Obese monthly visits
– Motivational interviewing to promote change
• Interventions tend not to work unless both the patient
and the parent are ready for change
– Family involvement
• Cut out their own weight-related talk
– “Talk less and do more”
Treatment: The Pediatrician’s Role
• Interventions
– Family involvement (con’t)
• Removing TV sets from bedrooms
• Limiting television and video game usage
• Discourage eating in front of the TV or computer to
stop the child from eating more than anticipated
– Medications
• Metformin
• Orlistat
• Sibutramine (in adolescents> 16yo)
Treatment: The Pediatrician’s Role
• Interventions
– Diet modifications
• Weight Watchers
• Protein-sparing modified fast
– Bariatric surgery
• Suitable surgical candidates must:
– Have achieved abstract thought or the ability to forsee
consequences
– Have the ability to follow through with needed medical F/U
– Be forewarned that they may need plastic surgery later for
excess skin reduction (which may not be covered by ins)
The Cleveland Clinic Pediatric Obesity
Initiative
• Behavioral approaches
– 5-2-1-0
•
•
•
•
5/day fruits and veges
2 hours or less of screen time
1 hour or more of exercise
0 sugar-sweetened beverages
– “5 to GO!”
The Cleveland Clinic Pediatric Obesity
Initiative
• Behavioral approaches
– Stoplight diet
• Red light foods (cakes, fried chicken)= STAY AWAY!
• Yellow light foods (ground beef, dark chocolate, olive oil)=
proceed with caution
• Green light foods (salmon, brown rice, low-fat yogert)= GO!
• School involvement
– Replacement of soda pop in vending machines with
water, milk, and 100% juice
– Improvement in school lunch menus
The Cleveland Clinic Pediatric Obesity
Initiative
• Community involvement
– The Cleveland Clinic
•
•
•
•
No trans fats
No nondiet soda pop
Only healthy options in vending machines and food services
Benefits for employees:
– Free fitness facilities
» $100 for going 10 times for 10 months
– Free Curves or Weight Watchers memberships
– Coverage of benefits for offspring
– GO! foods at eye level at local grocery stores (and sold
at sporting events!)
The Cleveland Clinic Pediatric Obesity
Initiative
• Community Involvement
– Safe playgrounds, green spaces, bike paths, and
“walking school buses.”
Question #15
• Which of the following is the strongest
predictor of being able to successfully reduce
BMI?
– A. Early detection of obesity
– B. Weight at diagnosis
– C. BP at diagnosis
– D. Number of PCP visits after diagnosis
– E. Family hx negative for obesity
Take Home Message…
• Early detection of childhood obesity predicts
better outcomes long term
– In a British study, the strongest predictor for
successfully reducing BMI was younger age at the
time of diagnosis
• So……
Normal Nutritional Requirements
GENERAL
Early Feeding of Solid Foods
• *Early (before 6 months of age) feeding of
complementary foods such as cereals to
breastfed infants is an increased likelihood of
gastrointestinal infection
• The direct relationship between early
complementary feedings and the incidence of
diarrheal illness is based on several casecontrol studies
*Age-related Changes in Digestion
• Until pancreatic maturity is achieved (around 4
months of age) dietary starches may be
hydrolyzed incompletely
– undigested carbohydrate pass into the colon, where
bacterial fermentation results in gas production
• Lactase concentrations reach mature values in
the small intestine by the 36th week of gestation
in all healthy infants
– Congenital or early-onset primary lactose intolerance
is an extremely rare condition that is associated with
severe diarrhea
*Adolescent Nutritional Deficiencies
• Low consumption
– Fruit and vegetables
– Whole grains
– Calcium
– Low-fat dairy foods
• High consumption
– Sweetened beverages
– Fast food
*Dietary Practices
• Vegetarian
– Monitor Vitamin B12, Folate, and Omega-3 Fatty
Acid intake
• Vegan
– Same as vegetarian
– Use soy formula in needed
– Begin zinc supplements when starting solids
• Goat’s Milk
– Causes folate deficiency (megaloblastic anemia)
Normal Nutritional Requirements
MINERALS
Iron
• *Full-term neonates have adequate iron
stores
– Exclusively breastfed term infants receive a
supplement of elemental iron at 1 mg/kg per day,
starting at 4 months of age
– The preterm infant has lower iron content and
requires initiation of iron supplementation
between 2 and 4 weeks of age
Iron
• *Iron deficiency anemia is major nutritional
deficiency of American youths
– Typical lab findings: low MCV and MCH; a
hypochromic, microcytic peripheral blood smear;
and a normal or low reticulocyte count
– Symptoms: tachycardia, fatigue, pallor
Calcium and Phosphorous
• *The American Academy of Pediatrics
recommends that preadolescents and
adolescents (9 to 18 years of age) consume
1,300 mg of both calcium and phosphorus
daily
– 40% of total lifetime bone mineral content is
accrued during adolescence
– Optimizing calcium intake is important during
adolescence, and those who experience delayed
puberty have an increased risk for osteoporosis
and fracture
Normal Nutritional Requirements
VITAMINS
Vitamin D
• Children and adolescents need 400 IU/day
– Start at birth in breastfed infants
Normal Nutritional Requirements
PROTEIN
Protein
• *Know the protein requirements of preterm
and fullterm infants
– The estimated protein requirement for a preterm
infant is 3.0 to 4.0 g/kg per day compared to 1.5
to 2.0 g/kg per day for the term infant
– Protein content declines in the first weeks of
lactation (Human milk fortifier for preterm milk)
DEFICIENCY STATES AND
HYPERVITAMINOSIS
Vitamin Deficiency States
• Vitamin D Deficiency
– Rickets: hypocalcemia, hypophosphatemia, poor
growth, tetany, muscle weakness, bone
deformations
• Folate Deficiency
– May develop in malabsorption syndromes
– Results in megaloblastic anemia, irreversible
neurologic damage
Mineral Deficiency States
• Zinc deficiency
– short stature, hypogonadism, skin disorders
including alopecia, cognitive dysfunction, impaired
development, peripheral neuropathy, anorexia,
diarrhea, platelet dysfunction, and altered wound
healing
– Acrodermatitis enteropathica
• erythematous-to-vesiculobullous or pustular lesions,
have sharply demarcated borders
• perioral, perianal, and acral areas of the body
Mineral Deficiency States
• Selenium deficiency
– skin and hair pigment loss, macrocytosis, and in
severe cases, cardiomyopathy
• Copper deficiency
– neutropenia, hypochromic anemia unresponsive to
iron administration, bone abnormalities, and hair and
skin depigmentation
• Menkes- steely hair
• Chromium deficiency
– a cofactor for insulin; impaired glucose, fat, and
protein metabolism and growth retardation