Pediatric Nutrition and Feeding PDF

PHARMACOTHERAPY OF PEDIATRICS NUTRITION AND FEEDING INTRODUCTION Nutrition is one of the most important modifiable determinants of health. At birth, the brain’s potential for change with minimal intervention is almost infinite. Early feeding can influence e...

PHARMACOTHERAPY OF PEDIATRICS NUTRITION AND FEEDING INTRODUCTION Nutrition is one of the most important modifiable determinants of health. At birth, the brain’s potential for change with minimal intervention is almost infinite. Early feeding can influence epigenetic changes, neuroendocrine pathways, and behavioral patterns that establish the trajectory for lifelong eating, metabolism, and weight. Healthy growth and development are the important objectives to consider in children. To achieve this, proper nutrition, knowledge and information is a must to discuss. As problems economically arise, people tend to prefer time saving and hassle-free choices available in the market thus resulting in poor nutrition in their food choices hindering their full potential. Improper nutrition in infants and children can lead to several health issues resulting in certain complications, diseases and/or nutritional deficiencies including malabsorption, increased nutritional demands, metabolic disorders and even death particularly in severe cases. Health professionals particularly the OBGYNs, pediatricians and nutritionists play an important role in this area guiding parents and caregivers in making informed decisions about proper choices and feeding schedule that reduces potential health risks. KEY CONCEPTS Malnutrition refers to deficiencies or excesses in nutrient intake, imbalance of essential nutrients or impaired nutrient utilization. The condition for malnutrition is interfacing as it is brought about by the imbalance of the nutrients taken against the amount of nutrients required. Malnutrition can take the form of undernutrition, which includes wasting and stunting and further attends to the micronutrient deficiencies. Overnutrition manifests as overweight and obesity. The World Health Organization defines malnutrition as a public health problem for it greatly affects everyone irrespective of age, but vulnerable populations are children, the elderly, and people with chronic illnesses. According to World Health Organization (WHO): Every infant and child has the right to good nutrition according to the "Convention on the Rights of the Child". Undernutrition is associated with 45% of child deaths. Globally in 2022, 149 million children under 5 years old were estimated to be stunted (too short for age), 45 million were estimated to be wasted (too thin for height), and 37 million were overweight or obese. About 44% of infants 0–6 months old are exclusively breastfed. Few children receive nutritionally adequate and safe complementary foods; in many countries less than a fourth of infants 6–23 months of age meet the criteria of dietary diversity and feeding frequency that are appropriate for their age.  Over 820 000 children's lives could be saved every year among children under 5 years, if all children 0–23 months were optimally breastfed. Breastfeeding improves IQ, school attendance, and is associated with higher income in adult life. Improving child development and reducing health costs through breastfeeding results in economic gains for individual families as well as at the national level. According to United Nations Children's Fund (UNICEF): At least 1 in 3 children under 5 is undernourished or overweight and 1 in 2 suffers from hidden hunger, undermining the capacity of millions of children to grow and develop to their full potential. Globally, at least 1 in 3 children under 5 is not growing well due to malnutrition in its more visible forms: stunting, wasting and being overweight. Globally, at least 1 in 2 children under 5 suffers from hidden hunger due to deficiencies in vitamins and other essential nutrients. Undernutrition continues to exert a heavy toll. In 2018, almost 200 million children under 5 suffered from stunting or wasting while at least 340 million suffered from hidden hunger. Overweight and obesity continue to rise. From 2000–2016, the proportion of overweight children (5 to 19 years old) rose from 1 in 10 to almost 1 in 5. The number of stunted children has declined in all continents, except in Africa while the number of overweight children has increased in all continents, including in Africa. The triple burden of malnutrition is driven by the poor quality of children’s diets: 2 in 3 children are not fed the minimum recommended diverse diet for healthy growth and development. Only 2 in 5 infants under six months of age are exclusively breastfed, as recommended. Breastfeeding could save the lives of 820,000 children annually worldwide. Use of breastmilk substitutes is of concern. Sales of milk-based formulas grew by 41 per cent globally and by 72 per cent in upper middle-income countries such as Brazil, China and Turkey from 2008–2013. Poor diets drive malnutrition in early childhood: 44 percent of children aged 6 to 23 months are not fed fruits or vegetables and 59 per cent are not fed eggs, dairy, fish or meat. Only 1 in 5 children aged 6 to 23 months from the poorest households and rural areas is fed the minimum recommended diverse diet for healthy growth and brain development. Many school-going adolescents consume highly processed foods: 42 percent drink carbonated soft drinks at least once a day and 46 percent eat fast food at least once a week. The triple burden of malnutrition – undernutrition, hidden hunger and overweight – threatens the survival, growth and development of children, young people, economies and nations. Stunting – a clear sign that children in a country are not developing well – is both a symptom of past deprivation and a predictor of future poverty. Wasting can be lethal for children, particularly in its most severe forms. Contrary to common belief, most wasted children around the world live in Asia and not in emergency settings. Hidden hunger harms children and women. Iron deficiency reduces children’s ability to learn and iron deficiency anemia increases women’s risk of death during or shortly after childbirth. Child overweight can lead to early onset of type-2 diabetes, stigmatization and depression, and is a strong predictor of adult obesity, with serious health and economic consequences. The greatest burden of all forms of malnutrition is shouldered by children and young people from the poorest and most marginalized communities, perpetuating poverty across generations. ACUTE MALNUTRITION IN CHILDREN Acute malnutrition is a nutritional deficiency resulting from either inadequate energy or protein intake. Children with primary acute malnutrition are common in developing countries as a result of inadequate food supply caused by social, economic, and environmental factors. Secondary acute malnutrition is usually due to an underlying disease causing abnormal nutrient loss, increased energy expenditure, or decreased food intake. Acute malnutrition leads to biochemical changes based on metabolic, hormonal, and glucoregulatory mechanisms. Most children with primary acute malnutrition can be managed at home with nutrition-specific interventions (i.e., counseling of parents, ensuring household food security, etc.). In case of severe acute malnutrition and complications, inpatient treatment is recommended. Secondary acute malnutrition should be managed by treating the underlying cause. Primary acute malnutrition in children is the result of inadequate food supply caused by socioeconomic, political, and environmental factors, and it is most commonly seen in low and middle-income countries. Responsible factors include household food insecurity, poverty, poor nutrition of pregnant women, intrauterine growth restriction, low birth weight, poor breastfeeding and inadequate complementary feeding, frequent infectious illnesses, poor quality of water, hygiene, etc. Therefore, primary acute malnutrition is mostly social rather than biomedical in origin, but it is also multifactorial. For example, poor water quality, sanitation and hygiene practices are increasingly believed to be the cause of the condition called “environmental enteropathy” that contributes to acute malnutrition in childhood. The repetitive exposure to pathogens in the environment causes small intestinal bacterial colonization, with accumulation of inflammatory cells in the small intestinal mucosa, damage of intestinal villi, and, consequently, malabsorption of nutrients, which results in malnutrition. Secondary acute malnutrition is usually due to abnormal nutrient loss, increased energy expenditure, or decreased food intake, frequently in the context of underlying, mostly chronic, diseases like cystic fibrosis, chronic renal failure, chronic liver diseases, childhood malignancies, congenital heart disease, and neuromuscular diseases CLINICAL IMPLICATIONS Pathophysiology of Acute Malnutrition in Children Inadequate energy intake leads to various physiologic adaptations, including growth restriction, loss of fat, muscle, and visceral mass, reduced basal metabolic rate, and reduced total energy expenditure. The biochemical changes in acute malnutrition involve metabolic, hormonal, and glucoregulatory mechanisms. The main hormones affected are the thyroid hormones, insulin, and the growth hormone (GH). Changes include reduced levels of tri-iodothyroxine (T3), insulin, insulin-like growth factor-1 (IGF-1) and raised levels of GH and cortisol. Glucose levels are often initially low, with depletion of glycogen stores. In the early phase there is rapid gluconeogenesis with resultant loss of skeletal muscle caused by use of amino acids, pyruvate and lactate. Later there is the protein conservation phase, with fat mobilization leading to lipolysis and ketogenesis. Major electrolyte changes including sodium retention and intracellular potassium depletion can be explained by decreased activity of the glycoside-sensitive energy-dependent sodium pump to increased permeability of cell membranes in kwashiorkor. Acute malnutrition has been recognized as causing reduction in the numbers of neurons, synapses, dendritic arborizations, and myelinations, all of which resulting in decreased brain size. The cerebral cortex is thinned and brain growth slowed. Delays in global function, motor function, and memory have been associated with malnutrition. The effects on the developing brain may be irreversible after the age of 3–4 years. ANALYSIS OF MALNUTRITION Figure 1: UNICEF Conceptual Framework for Causes of Malnutrition Clinical Syndromes of Acute Malnutrition in Children 1. Marasmus- Marasmus is the most frequent syndrome of acute malnutrition. It is due to inadequate energy intake over a period of months to years. It results from the body’s physiological adaptive response to starvation in response to severe deprivation of energy and all nutrients, and is characterized by wasting of body tissues, particularly muscles and subcutaneous fat, and is usually a result of severe restrictions in energy intake. Children younger than five years are the most commonly involved because of their increased caloric requirements and increased susceptibility to infections. These children appear emaciated, weak and lethargic, and have associated bradycardia, hypotension, and hypothermia. Their skin is xerotic, wrinkled, and loose because of the loss of subcutaneous fat, but is not characterized by any specific dermatosis. Muscle wasting often starts in the axilla and groin (grade I), then thighs and buttocks (grade II), followed by chest and abdomen (grade III), and finally the facial muscles (grade IV), which are metabolically less active. In severe cases, the loss of buccal fat pads gives the children an aged facial aspect. Severely affected children are often apathetic but become irritable and difficult to console. 2. Kwashiorkor- Kwashiorkor is thought to be the result of inadequate protein but reasonably normal caloric intake. It was first reported in children with maize diets (these children have been  called “sugar babies”, as their diet is typically low in protein but high in carbohydrate). Kwashiorkor is frequent in developing countries and mainly involves older infants and young children. It mostly occurs in areas of famine or with limited food supply, and particularly in those countries where the diet consists mainly of corn, rice and beans. Kwashiorkor represents a maladaptive response to starvation. Edema is the distinguishing characteristic of kwashiorkor, which does not exist in marasmus, and usually results from a combination of low serum albumin, increased cortisol, and inability to activate the antidiuretic hormone. It usually starts as pedal edema (grade I), then facial edema (grade II), paraspinal and chest edema (grade III) up to the association with ascites (grade IV). Besides edema, clinical features are almost normal weight for age, dermatoses, hypopigmented hair, distended abdomen, and hepatomegaly. Hair is usually dry, sparse, brittle, and depigmented, appearing reddish yellow. Cutaneous manifestations are characteristic and progress over days from dry atrophic skin with confluent areas of hyperkeratosis and hyperpigmentation, which then splits when stretched, resulting in erosions and underlying erythematous skin. Various skin changes in children with kwashiorkor include shiny, varnished-looking skin (64%), dark erythematous pigmented macules (48%), xerotic crazy paving skin (28%), residual hypopigmentation (18%), and hyperpigmentation and erythema (11%). 3. Marasmic Kwashiorkor- Marasmic kwashiorkor is represented by mixed features of both marasmus and kwashiorkor. Characteristically, children with marasmic kwashiorkor have concurrent gross wasting and edema. They usually have mild cutaneous and hair manifestations and an enlarged palpable fatty liver. Malnutrition Evidence-Based Treatment Recommendations Assessment of Malnutrition Proper assessment is a must before initiating treatment. This includes the following: 1. Nutritional Screening: Screening using the Malnutrition Universal Screening Tool (MUST) or the Mini Nutritional Assessment tool may be done to screen for risk. 2. Clinical Evaluation: Detailed history and physical examination to assess for signs of malnutrition. 3. Biochemical Analysis: Blood tests for albumin, prealbumin, electrolytes, and other related markers may be performed to provide an insight about nutritional status. THERAPEUTIC RECOMMENDATIONS Therapeutic Recommendation for Acute Malnutrition in Children Management strategies for acute malnutrition depend on the type of malnutrition, identification of its cause, and its severity 1. Primary Acute Malnutrition In primary moderate acute malnutrition, management at home is recommended, including counseling of parents, with emphasis on continuing breastfeeding and appropriate complementary feeding (nutrition-specific interventions). Ideally, these children should receive 25 kcal/kg per day of energy in excess of what their healthy peers receive, and their diets should contain animal-source foods rich in essential fatty acids and micronutrients including vitamin A, iron and zinc [5,31,32].  Severe acute malnutrition without any complications Children with severe acute malnutrition without any complications can be managed in the community with ready-to-use therapeutic food (peanut paste, milk powder, vegetable oil and a mineral and vitamin mix as per WHO recommendations). Severe acute malnutrition with complications Children who have been treated for complications and have appetite can also be treated in the hospital with ready-to-use therapeutic food. Severe acute malnutrition complications (i.e., severe diarrhea, hypoglycemia, hypothermia, pneumonia, urinary tract infection, sepsis, etc.) require hospitalization until children are ready to continue management at home The stabilization phase of treatment for complications includes : (i) treat hypoglycemia with oral or intravenous glucose if the child is lethargic, unconscious or convulsing; (ii) treat and prevent hypothermia; (iii) treat shock; (iv) treat and prevent dehydration (preferably with the special rehydration solution for malnutrition, ReSoMal, 5 mL/kg body weight orally or by nasogastric tube every 30 min for the first 2 h, then at 5–10 mL/kg/h in alternate hours for up to 10 h); (v) treat and prevent infection. Oral amoxicillin at 15 mg/kg eight-hourly for five days is suggested if the child has no complications, while ampicillin at 50 mg/kg i.m./i.v. six-hourly for two days, followed by oral amoxicillin for five days and gentamicin at 7.5 mg/kg i.m./i.v. once daily for seven days in case of complications. If the child fails to improve clinically by 48 h or deteriorates after 24 h, a third-generation cephalosporin (i.e., ceftriaxone at 50–75 mg/kg i.v. or i.m. once daily) may be started with gentamicin; (vi) start careful feeding. Feeding should be started as soon as possible after admission with the WHO-recommended milk-based starter formula F-75, which contains 75 kcal/100 mL and 0.9 g protein/100 mL. The feeding frequency is gradually decreased (Table 2). 2. Secondary Acute Malnutrition For the management of secondary acute malnutrition, it is crucial to identify the underlying disease by history taking, examination and laboratory investigations. Exclusive breastfeeding for the first six months along with iron supplementation is adequate for preterm and low-birth-weight infants. They are at risk of necrotizing enterocolitis if aggressive enteral feeding is delivered. In mild inflammatory bowel disease or disease in remission, the intake of a normal diet can be suggested. Commercial, specially prepared liquid formulas are helpful for some patients with inflammatory bowel disease. In advanced chronic liver disease, the diet may need to be protein sparing for the prevention of hyperammonemia. A combination of lipids and carbohydrates with a minimal amount of protein should be used. Another important feature in chronic liver disease is decreased bile salt excretion into the small intestine, which can cause malabsorption of fats and fat-soluble vitamins. This can be faced by using medium-chain triglycerides as the source of dietary fat, since they do not depend upon bile salts for absorption. Water-soluble forms of the usually fat-soluble vitamins (A, D, E and K) should be used. Children with chronic renal disease may benefit from high-energy as well as high-quality protein in quantities that will not induce or worsen uremia. Children with congenital heart disease need to be provided with sufficient energy and protein without increasing the fluid volume too much. They have reduced food intake due to fatigue, dyspnea and frequent lung infections. The heart failure and increased breathing efforts induce a hypermetabolic state that further increases the demand for more nutrients. Children with cancer, chemotherapy, radiation, surgery and infections often present  with cachexia, due to tumor necrosis factor-α and tumor metabolites. The diet has to be modified to cater to the increased caloric needs. Parenteral nutrition can be used to improve nutrition in case of poor tolerance to large volumes of enteral feeds. Other Therapeutic Suggestions Management of malnutrition would have to be multi-layered as discerned by the individual needs: 1) Nutritional Interventions Dietary Adjustments: Calorie supplementations with nutrient dense food. High-protein supplementations would be needed in undernourished patients. Oral Nutritional Supplements (ONS): Recommended for patients who are unable to obtain their needs from diet. Products should be individualized based on preference and tolerance. Enteral Nutrition: Patients with medical conditions that render them incapable of taking adequate nutrition orally, like dysphagia, necessitate enteral nutrition through feeding tubes (e.g infant diarrhea, lactose intolerance, etc.). Parenteral Nutrition: Total parenteral nutrition (TPN) may be necessary in more severe cases if enteral feeding cannot be undertaken. 2) Pharmacological Interventions Of course, no medications can be directed at malnutrition per se, but some pharmacologic agents may prove helpful in recovery. Appetite Stimulation: Appetite stimulants are medications, supplements, or other substances that increase feelings of hunger. An appetite stimulant is also known as an orexigenic. In specific circumstances, medications such as megestrol acetate or dronabinol might be administered to stimulate appetite. Micronutrient Stimulation: Vitamins and minerals play essential roles in human biology, including the metabolism of protein, carbohydrate, and fat, maintenance of the structure of the human body (e.g., vitamin K in bone matrix, calcium in bone tissue), and antioxidant activity, among many others. Administration of vitamins and minerals (e.g., vitamin D, iron) is typically required based on deficiencies established during the evaluation. Note that these products only meant to supplement the child’s diet and not to replace them. 3) Monitoring and Follow-Up A healthcare professional should monitor weight, dietary intake, biochemical markers, and clinical signs periodically to establish whether interventions are indeed working. Changes should be instituted in response to ongoing evaluations. Interdisciplinary Collaboration is needed in which cooperation among health professionals including dietitians, physicians, nurses, and pharmacists is a good approach in the effective management of patient's states. Recent Recommendations Evidence-based recommendations from authoritative bodies have lately been provided in managing malnutrition states. The American Society for Parenteral and Enteral Nutrition (ASPEN) puts great emphasis on early identification and intervention among patients suffering with malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) has presented consensus recommendations that patients' nutritional care must be tailored based on patient-specific factors. These policies indicate that the management of malnutrition should, in addition to directing attention to macronutrients, also give attention to micronutrient deficiencies, always keeping in mind potential underlying conditions whose results may impact nutritional status. CONCLUSION In summary, malnutrition, whether due to undernutrition or overnutrition, has significant clinical implications that impact multiple organ systems, leading to increased morbidity and mortality. Appropriate care for malnutrition involves appropriate assessment and then individualized nutrition interventions supported by pharmacologic therapy if needed, with follow-up evaluation to ascertain that methods remain effective over time. REFERENCES 1. United Nations Children's Fund. (2019). The State of the World's Children 2019, Children, Food and Nutrition https://www.unicef.org/media/60806/file/SOWC-2019.pdf 2. World Health Organization. (2020). Malnutrition. https://www.who.int/news-room/fact-sheets/detail/malnutrition 3. John Hopkins Medicine. (n.d.). Malnutrition https://www.hopkinsmedicine.org/health/conditions-and-diseases/malnutrition 4. British Association for Parenteral and Enteral Nutrition. (n.d.). Malnutrition https://www.bapen.org.uk/malnutrition/introduction-to-malnutrition/what-are-the-consequences-of- malnutrition/ 5. Leonard, J. (2023, March 30). How to stimulate appetite. https://www.medicalnewstoday.com/articles/326142 6. Micronutrients in Health and Disease | Nutrition Guide for Clinicians (pcrm.org) 7. Pediatric nutrition—What’s new? | British Columbia Medical Journal. (n.d.). https://bcmj.org/council-health-promotion/pediatric-nutrition-whats-new 8. World Health Organization (2023). Infant and young child feeding. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding 9. National Librarry of Medicine (2024). Acute Malnutrition in Children: Pathophysiology, Clinical Effects and Treatment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7469063/ 10. ASPEN | Malnutrition Solution Center. (n.d.). https://www.nutritioncare.org/guidelines_and_clinical_resources/Malnutrition_Solution_Center/?fb clid=IwY2xjawFZ6IRleHRuA2FlbQIxMAABHWoJwa059U4Pi-qjO-YnxNcffNicZwdxlTfDHfvoOFCfx ILv62DQ97R_1Q_aem_nRuRA3ClofDYhdxK5iuDVQ 11. Thibault, R., Abbasoglu, O., Ioannou, E., Meija, L., Ottens-Oussoren, K., & European Society for Clinical Nutrition and Metabolism. (2021). ESPEN guideline on hospital nutrition. In Clinical Nutrition (Vol. 40, pp. 5684–5709) [Journal-article]. https://www.espen.org/files/ESPEN-Guidelines/ESPEN_guideline_on_hospital_nutrition.pdf 12. Figure 1.1. UNICEF Conceptual framework for causes of malnutrition.... (n.d.). ResearchGate. https://www.researchgate.net/figure/UNICEF-Conceptual-framework-for-causes-of-malnutrition-A dopted-from-UNICEF-1997_fig1_348303303 GROUP 2 Members: (PPG_WCPh-5D) ENCENDENCIA, HANNAH MAE U. GABALES, ANN JELLA M. GALVAN, MICHELLE P. GAMBOA, THEA P. GENABE, JENNICA ANN MAE C.