Nutrition PDF

Nutrition --------- - ##### Learning objectives: - Demonstrate variations in nutritional requirements for macro and macronutrients with age - Solve problems related to breastfeeding, feeding of solids, and other feeding issues - Answer questions related to nutritional disorders...

Nutrition --------- - ##### Learning objectives: - Demonstrate variations in nutritional requirements for macro and macronutrients with age - Solve problems related to breastfeeding, feeding of solids, and other feeding issues - Answer questions related to nutritional disorders ##### Nutritional Requirements ##### Water requirements: - Infancy: 120 - 13-18 years: 80-70 - 2-6 years: 100 - Adults: 50-40 - 7-12 years: 90-80 ##### Energy requirements: i. Maintenance of basal metabolism (50% of total caloric intake). ii. Physical activity (25% of total caloric intake). iii.Growth (12% of total caloric intake). ##### Protein requirements: ##### Energy and protein requirements according to age -- -- -- -- -- -- ##### Lipid requirement: ##### Vitamins and minerals: - ##### Infants feeding - ##### Breast feeding ##### Physiology of lactation: ##### Factors that influence milk production and secretion: 1. Maternal endocrine glands. 2. Mechanical factors: sucking is the best stimulus for milk secretion. 3. Psychic state of the mother: emotions, tension and anxiety will inhibit milk secretion, affecting the amount rather than the 4. Physical and nutritional state of the mother: adequate breast secretion requires a normal state of health of the mother maintained by proper diet, activity and adequate sleep. ##### Stages of lactation: 1. Colostrum: is the type of milk secreted in the first 2- 3 days after birth. It has a thick consistency yellow color, and alkaline reaction. Compared to mature milk, colostrum has elevated proteins and immunoglobulin levels, and lower fat and lactose. 2. Transitional milk: produced at the end of the first week after birth, 3. Mature milk. - ##### Advantages of breast feeding: 1. Breast milk is the only natural food designed for infants, the composition of various nutrients is ideal for the infants' requirements. 2. It is free. 3. It is sterile. 4. It is available whenever and wherever required and requires no preparation time. 5. It is fresh and free of contaminating bacteria. 6. It is supplied at the right temperature. 7. It can build a strong physical and emotional bond between mother and baby. 8. It contains antibodies that protect infants from infectious diseases, so they are less liable to gastroenteritis and other infections. 9. Less chance of being constipated. 10. Less likelihood of becoming obese. 11. It causes few allergic diseases. - ##### Maternal advantages: 1. Help uterine involution. 2. Natural contraception (not reliable). 3. Decreases incidence of breast cancer. - ##### Composition of breast milk - Breast milk is the ideal food for infants. Its composition completely fulfills their nutritional needs. Each 100 ml of human milk contains 87.5% water, 7 grams' carbohydrates, - Proteins: Whey to casein ratio is 60: 40, making breast milk an easily- digested food. Breast milk contains lactoferrin which helps iron absorption and inhibits bacterial infections. - Carbohydrates: lactose forms the main source of carbohydrate in breast milk. Oligosaccharides inhibit pathogenic bacteria and promote the growth of bifidus bacteria in the intestine. - Fat: mainly in the form of triglycerides. Fat globules are small, and hence easily digested. Breast milk contains an adequate amount of long chain polyunsaturated fatty acids, which are essential for brain development. It has also a low level of short chain fatty acids, which are irritant to the GIT. - Minerals and vitamins: breast milk contains adequate amounts of minerals and vitamins to fulfill the daily infant\'s requirements. Only its iron and vitamin D contents are insufficient, but their absorption is better than from formula. It also has optimal calcium: phosphorous ratio 1.5: 1. Sodium content is low to reduce renal solute load. ##### Comparison of mature breast milk and cow\'s milk +---------+---------+---------+---------+---------+---------+---------+ | | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | | - Whe | - - | | | | | | | y | - - | | | | | | | to | | | | | | | | cas | | | | | | | | ein | | | | | | | | rat | | | | | | | | io | | | | | | | | is | | | | | | | | 60: | | | | | | | | 40 | | | | | | | | | | | | | | | | - Lac | | | | | | | | toferri | | | | | | | | n | | | | | | | | is | | | | | | | | pre | | | | | | | | sent. | | | | | | | | | | | | | | | | - Con | | | | | | | | tains | | | | | | | | imm | | | | | | | | unoglob | | | | | | | | ulins. | | | | | | | | | | | | | | | | - Les | | | | | | | | s | | | | | | | | all | | | | | | | | ergic. | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | | - Mai | - 4gm | | | | | | | nly | % | | | | | | | lac | | | | | | | | tose | - Mai | | | | | | | | nly | | | | | | | - Con | lac | | | | | | | tains | tose | | | | | | | oli | | | | | | | | gosacch | - No | | | | | | | arides. | oli | | | | | | | | gosacch | | | | | | | | arides. | | | | | +---------+---------+---------+---------+---------+---------+---------+ | | - - | - - | | | | | | | Adequa | - - | | | | | | | te | | | | | | | | amo | | | | | | | | unts | | | | | | | | of | | | | | | | | ess | | | | | | | | ential | | | | | | | | fat | | | | | | | | ty | | | | | | | | aci | | | | | | | | ds | | | | | | | | and | | | | | | | | cho | | | | | | | | lestero | | | | | | | | l. | | | | | | | | | | | | | | | | - Les | | | | | | | | s | | | | | | | | amo | | | | | | | | unts | | | | | | | | of | | | | | | | | vol | | | | | | | | atile | | | | | | | | sho | | | | | | | | rt | | | | | | | | cha | | | | | | | | in | | | | | | | | fat | | | | | | | | ty | | | | | | | | aci | | | | | | | | ds | | | | | | | | | | | | | | | | - | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | | - - | - - | | | | | | | Optima | - - | | | | | | | l | | | | | | | | cal | | | | | | | | cium: | | | | | | | | pho | | | | | | | | sphorou | | | | | | | | s | | | | | | | | rat | | | | | | | | io | | | | | | | | 1.5 | | | | | | | | : 1. | | | | | | | | | | | | | | | | - Iro | | | | | | | | n | | | | | | | | and | | | | | | | | zin | | | | | | | | c | | | | | | | | are | | | | | | | | ina | | | | | | | | dequate | | | | | | | | , | | | | | | | | but | | | | | | | | hav | | | | | | | | e | | | | | | | | bet | | | | | | | | ter | | | | | | | | abs | | | | | | | | orption | | | | | | | |. | | | | | | | | | | | | | | | | - | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | | - Vit | | | | | - - | | | amins | | | | | | | | ade | | | | | | | | quate | | | | | | | | | | | | | | | | - Vit | | | | | | | | amins | | | | | | | | ina | | | | | | | | dequate | | | | | | | |. | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ - ##### Ten Steps to Successful Breastfeeding: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. 4. Inform all pregnant women about the benefits and management of breastfeeding. 5. Help mothers initiate breastfeeding within half an hour of birth. 6. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. 7. Give newborn infants no food or drink other than breast milk, unless medically indicated. 8. Practice rooming-in - that is, allows mothers and infants to remain together - 24 hours a day. 9. Encourage breastfeeding on demand. 10. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. - ##### Technique of Breast Feeding: - Breast feeding can be started after delivery as soon as both mother and baby are stable. Though milk is not yet secreted, these trials are of great importance as sucking is the best stimulus for milk secretion and to get the mother and neonate acquainted with each other. - Correct positioning and proper breast-feeding technique are necessary to ensure effective nipple stimulation and optimal breast - If the mother wishes to nurse while sitting, the infant should be elevated to the height of the breast and turned completely to face the mother. The mother\'s arms supporting the infant should be held tightly at her side, bringing the baby\'s head in line with her breast. The breast should be supported by the lower fingers of her free hand, with the nipple compressed between the thumb and index fingers to make it more protractile. - The mother may break suction gently, by inserting her finger into the angle of her baby's mouth. The baby will immediately leave the breast, trying to suck his mother's finger. - Both breasts are given at each feed; the first should be emptied completely. They are given alternatively. - A sensible guideline for duration of feeding is 5 minutes per breast at each feeding the first day, 10 minutes on each side at each feeding the second day, and 10--15 minutes per side thereafter. A vigorous infant can obtain most of the available milk in 5--7 minutes, but additional sucking time ensures breast emptying, promotes milk production, and satisfies the infant\'s sucking urge. - After feeding is complete, the breast is wiped with water and dried then a sterile dressing is placed on the nipples. The infant should be hold upright and tapped gently over the back to allow him to eructate the swallowed air. - ##### Determination of adequacy of breast milk supply: - Infant is satisfied after feeding, and can sleep 2-4 hours after most meals. - Infant is adequately gaining weight and is maintaining his growth chart percentile. - Good filling of the breast before feeds. - Let-down reflex ##### Common Problems: 1. Nipple tenderness requires attention to proper positioning of the infant and correct latch-on. Nursing for shorter periods, beginning feedings on the less sore side, air drying the nipples well after nursing and use of lanolin cream are helpful. Hand expression of milk to initiate its flow may be helpful. Severe nipple pain and cracking usually indicate improper infant attachment. Temporary pumping may be needed. 2. Engorgement is another common breast feeding problem. It results from failure to evacuate the breast completely with collection of milk, so the breast becomes enlarged and tender. It occurs in early days of lactation. Engorgement can be prevented by encouraging frequent breast feeding, gentle breast massage and application of warm compresses to the breast. Hand expression of milk may be required. 3. Breast-feeding jaundice: This is mild jaundice in the first few weeks of life in breast fed babies. Usually it is temporary, and no interference, but in severe cases, transient interruption of breast feeding for 1-3 days can resolve the condition. - ##### Drugs secreted in milk: - Antibiotics: chloramphenicol and tetracyclines are contraindicated. Penicillin, cephalosporins and erythromycin are safe alternates. - Analgesics: indomethacin is contraindicated. Paracetamol and ibuprofen are safe. - Vitamins: large doses of the fat soluble vitamins A and D are contraindicated. Water soluble vitamins B and C are safe. - Hormones: estrogen is contraindicated, as it inhibits milk production. Insulin and small doses of steroids are safe. - Sedatives: are safe in small doses only. - Other contraindicated drugs include: chemotherapy, anti-coagulants, anti- thyroid drugs and metronidazole. - ##### Contraindications of breast feeding: - Absolute contraindications to breast feeding are rare. They include active maternal tuberculosis, heart failure and other debilitating chronic diseases making the mother unfit to breast fed her baby, - Temporary contraindications include acute mastitis, breast abscess and maternal acute illness as pneumonia. - Drug intake may represent a temporary or permanent contraindication according to the nature of the illness. ##### Indications: 1. Complementary feeding: when breast milk amount is scanty and inadequate to fulfill the infant\' needs, breast feeds are completed by formula feeding. ###### Precautions: - Ensure that mother\' milk is inadequate, before advising complementary feeing. - Breast milk should be given first from both sides, before the feed is completed by bottle. - Only humanized milk formulas are allowed. 2. Supplementary feeding (some breast feeds are replaced by formula feeds): commonly required by working mothers and in twin delivery. 3. Substitutive feeding: all breast milk feeds are replaced by bottle feed: in the presence of a contraindication of breast feeding, or if the mother refused breast feeding. ##### Types of formulas: - **Standard humanized infant formula:** cow milk has been modified in composition, quality and caloric content to simulate human breast milk. It is the regular formula used by healthy infants. Fat is replaced by vegetable oils. Some formulae are fortified with iron. Caloric content is 67 calories/100 ml (similar to breast milk). Examples include Nan1, S26 and bebelac1. - ##### Formulas for special infants: ##### Weaning - Caloric contents of milk become inadequate to fulfill infant\'s requirement. - His iron stores are depleted. - GIT produces higher levels of digestive enzymes. - Infant can support his head and neck while sitting, and can bring his hand to mouth. - Loss of extrusion reflex: young infants refuse spoon-feeding and their tongues push the spoon and food out (extrusion reflex). This reflex disappears at the age of 4- 6 months, and the infant can transfer food from the front of the mouth to the back. - ##### Rules of weaning: 1. Start with a small amount of the new food, and gradually increase the amount with a corresponding decrease in the milk feed. 2. Additions should be tried separately, with no more than one new food at a time. 3. Foods should be added at a fixed time. 4. The new food should be presented in an attractive way, using colored plates and spoons. 5. Spoon feeding is recommended rather than bottle feeding. 6. If the new food is disliked, it should be stopped and re- tried again few weeks later. 7. The new food should have a new flavor or consistency. It should not be spicy. Sugar and salt should be limited. 8. The amount of food intake is determining essentially by the infant\'s appetite. 9. Common food allergens (as cow\'s milk, strawberry and egg white) should not be introduced before the end of the first year. 10. Whole cow\'s milk can be introduced after the first year of life. - ##### Suggested schedule of weaning: - At 6 months: iron fortified cereals are frequently the first added food. They may be mixed with infant\'s usual milk or water. - At 7 months: vegetable soap and yoghurt. - At 8 months: egg yolk and fruits as apple, pear and mashed banana. - At 9 months: beans and liver. - At 10 months: chicken and meat. - At the end of the first year: infant can share most table food, provided that they are delivered soft and in small pieces. - ##### Common problems related to weaning: 1. Allergic reactions to a newly added food. 2. Protein caloric malnutrition: in cases of weaning on starchy foods only. 3. Gastroenteritis: intake of contaminated foods.4- Colic and diarrhea. 4. Chocking. 5. Delayed weaning is associated with malnutrition, iron deficiency, and rickets. ##### Nutritional Disorders - Under-nutrition or protein- energy (calorie) malnutrition. - Over-eating or obesity. - Specific nutrient deficiency: as in ##### Protein- Energy malnutrition: PEM ##### Etiology: - Poverty and ignorance: Poverty leads to shortage of food, sanitary water supplies and limited access to medical care. Ignorance of parents cause improper weaning, and increased consumption of sugary foods and fluids. - Infections: malnutrition and infection interact with each other i.e. each is aggravating the other. Malnutrition lowers immunity, while infections cause marked decrease of food intake (anorexia, vomiting) and increased demands and losses (fever and diarrhea). ##### Clinical Manifestations: 1. Nutritional dwarfism: which is a mild to moderate form of chronic malnutrition starting from early infancy. It is the commonest clinical presentation. The affected child's weight and height are below 3rd percentile on growth charts for their age and sex, but within normal range on percentiles of weight to height. 2. Marasmus: a severe form of chronic under- nutrition. 3. Kwashiorker. 4. Marasmic-Kwashiorker: usually seen in marasmic patients if they receive diet poor in protein but highly rich in carbohydrates. They present with a combination of features of the two forms of PEM. ##### Marasmus: ##### Causes: 1. Nutritional: common in infancy due to scanty breast milk and the use of diluted formula. 2. Non-nutritional causes as: - Chronic infections as tuberculosis. - Chronic diseases as congenital cardiac defects, celiac disease, and esophageal corrosive strictures. ##### Clinical presentation: - Weight loss: the infant's weight is below the 3rd percentile for his age and sex. - Generalized loss of subcutaneous fat, the skin is thin and maybe redundant and wrinkled. - Generalized muscle wasting. - Mood: anxious (hungry). - He may pass greenish loose stool (starvation diarrhea). - Pallor (anemia) and hypothermia. ##### Complications: a. Dehydration and electrolyte imbalance. b. Infections: are usually serious as recurrent enteritis, respiratory infections, and skin infections. c. Hypothermia and hypoglycemia. d. Iron deficiency anemia. ##### Kwashiorkor: - Faulty weaning when milk is replaced with sugary food or fluids (rice water or starch pudding). - Post-infection: the condition maybe precipitated by a bout of infective diarrhea or respiratory infection with food restriction and liberal sugary fluid intake. ##### Clinical manifestations: 1. Growth failure: both physical and mental growth is delayed. There is failure to gain weight that is usually masked by the odema. Developmental milestones are also delayed. 2. Generalized odema: It starts in the face and lower limbs then it involves the dorsum of hands, scrotum and the whole body. Theodema is due to: a. Hypoproteinemia especially albumin. b. Water retention c. Disturbed capillary permeability. d. Increased antidiuretic hormone secretion e. Electrolyte imbalance 3. Mental changes: Apathy and misery. These changes are secondary to niacin deficiency, disturbed amino acids metabolism and the associated maternal deprivation if present. 4. Disturbed muscle/ fat ratio: There is muscle wasting (e.g. 1. Hair changes: lightening of color, sparseness, and easy pluckability. These are due to disturbed amino acids and copper metabolism. 2. Skin changes: Erythema, hypopigmentation, ulcerations especially over the thighs, buttocks, groin and axillae. These changes are due to deficiency of vitamin A, niacin, zinc and disturbed amino acids metabolism. 3. Hepatomegaly: due to fatty infiltration. The liver is soft and smooth. During recovery, an initial more enlargement of the liver may occur. It is called the recovery syndrome. 4. Anorexia, vomiting and diarrhea due to enzymatic deficiency, intestinal mucosal atrophy and intestinal infections. 5. Anemia and manifestations of vitamin deficiencies (A, B, and K). 6. Associated infections are usually the cause of death together with other complications as hypoglycemia and hypothermia. ##### Biochemical findings: 5. Decreased serum albumin, alpha and beta globulins and some amino acids. 6. Increased gamma globulins (due to infections). 7. Hypokalemia, hypoglycemia and hypomagnesemia. 8. Increased total body sodium, but serum sodium is decreased due to increased water content (dilutional hyponatremia). ##### Management of protein energy malnutrition: - Correction of fluid, glucose and electrolytes disturbances. - Control of infection and hypothermia. ##### B-Nutrition management: 1. Marasmic patient should receive: - A diet offering 150Kcal/Kg/day. - Start with the caloric intake that can be tolerated by the patient and gradually increase the intake. - The type of food depends on the patient age i.e. milk in young infants and milk with other food for older patients. 2. Kwashiorkor patient: - Diet: protein supply should be as 4-6gm/Kg/day. Milk, formula, beans, legumes, meat, chicken and yoghurt can be given according to age. - Food is given orally or by feeding tube. Parental therapy is rarely needed. - Vitamins and minerals supplementation: vitamin A, Iron and multivitamin and minerals preparations. ##### Prevention of protein energy malnutrition: - Encouraging breast feeding. - Health education of mothers about proper weaning. - Regular well- baby visits to manage early signs of PEM. ##### Vitamin D Deficiency Rickets Sources of vitamin D ##### Vitamin D metabolism: ##### Etiology - Inadequate intake of vitamin D is the major cause of rickets in Egypt and developed countries. - Vitamin D deficiency is caused by inadequate direct exposure to ultraviolet rays, or inadequate vitamin D intake, or both. It is important to notice that these rays do not pass through ordinary window glass. - Other contributing etiologic factors include: diets rich in phytic acids which precipitate calcium e.g. cereals, diets with on- optimal calcium: phosphorous ratio as cow\'s milk and dark ##### Patho-physiology ##### Clinical Manifestations ##### A- Skeletal manifestations - ***Head:*** The earliest sign of rickets is a ping-pong ball sensation of the skull (craniotabes) elicited by pressing firmly over the occipital or posterior parietal bones. - ***Thorax*:** The costochondral junctions may be palpable (rachitic rosary). - ***Upper and lower limbs***: wrists and ankles may be widened, with a horizontal groove at medial malleoli (Marfa sign). - ***Spinal deformities*** as scoliosis, kyphosis and lumbar lordosis. 1. Delayed gross motor development: sitting, standing and walking. 2. Abdominal distension due to downwards displacement of the liver and spleen, and weakness of the abdominal wall muscles. ##### C- Neurologic manifestations: ##### Diagnosis 1. The serum calcium level of children with rickets may be normal or low, but the serum phosphorus level almost always is less than 4 mg/dL. The serum alkaline phosphatase level also is inevitably elevated. 2. Plain x-ray at the wrist or ankle region is very helpful to spot the changes in ends of long bones and the stage of rickets: - Active rickets: broad epiphysis, cupping and fraying of the metaphysical plates, wide joint space, and generalizes rarefaction of bones. Deformities and green stick fractures maybe seen. - Healing rickets: the metaphyseal concave line of long bones is dense. Restoration of bone density. Deformities usually persist. ##### Treatment: ##### Other forms of Rickets: i. Malabsorption diseases as celiac disease, cystic fibrosis, and cholystatic disorders. ii. Hepatic Rickets: as cirrhosis iii. Renal Rickets: as in chronic renal failure, renal tubular defects,e.tc.