Transcript Document 7231158

Nutrition, Growth and
Development
Classification System
Low Birth Weight (LBW)
<2500 grams or 5.5 pounds
Very Low Birth Weight (VLBW)
<1500 grams of 3.3 pounds
Extremely Low Birth Weight (ELVW
<1000 grams or 2.2 pounds
Classification System
Small for gestational age (SGA)
Birthweight less than the 10th %tile
Appropriate for gestational age (AGA)
Birthweight between 10th and 90th %tile
Large for gestational age (LGA)
Birthweight greater than the 90th %tile
Infant Growth
Occurs in genetically predetermined way
Can be compromised by nutritional status
calorie or nutrient undernutrition or
imbalance.
Undernutrition:
First affects weight gain
If severe enough, affects linear growth
Growth
After birth genetic influences are target
seeking
Catch Up Growth: Grow faster to get
closer to genetically determined size
Usually shift growth channels by 3 to 6
months
Lag Down Growth:
Usually shift growth channels by 13 months
Rules of Thumb
Weight:
4 months: Double birth weight
12 months: Triple birth weight
then 2.3 kg/year until 9 or 10
then adolescent growth spurt
Growth: Height
1 year: 50% increase in height
4 years:double birth length
13 years: triple birth length
Adolescence: rapid increase
Adolescent Growth Spurt
2 years later in males than females
intensity, duration highly variable
Growth continues until after the epiphysis
closes
Generally by 4 years post onset of puberty
Body Proportions
At birth: Head

Leg
When growth ceases:

Head

Leg
1/4 of total length
3/8 of total length
1/8 of total length
1/2 of total length
Collecting and Assessing
Food Intake
24-hour recall
Diet history
Diet Record 1, 3 and 7 day or more
FFQ
Who should be asked
about Diet Intake?
If the subject is a boy < 13 or 14 years of
age, the caregiver should be asked.
If a girl under 12 years of age, caregiver.
Why?
After diet has been taken
accurately, then analysis
is required
How?
Food Guide Pyramid
Nutrient analysis using food composition
table/ computer analysis
Micaelsen room 104
Red Flags
Anthropometric: ht or wt less than 5th
%tile
Infant formula under or over diluted
whole cow’s milk before 1 year
reduced fat cow’s milk before 2 years
semi-solid foods before 4 months
bottle fed to go to sleep
Other Assessments Made
parent’s nutrition knowledge
adequacy of foods offered
parent’s knowledge of community services
delays in feeding skills
behavior patterns that affect intake
motivation of parent for change
Feeding problem: organic
or inorganic
Organic: problem with muscle
coordination, development
Inorganic: stress in family, emotional
Occupational therapists, speech
pathologists are trained to make these
types of evaluations: if feeding problem
exists, you may need to make a referral to
determine cause.
Organic Feeding Problems
Stressors
Moving
Death, divorce,
separation
Marriage, pregnancy
Serious injury or
illness
Loss of work
Family fights
Money problems
Drinking
Trouble with the law
Other serious
problems
Parents of Maladjusted
Children
Often are:
younger
more dependent on relative
unstable mentally
have marital or other conflicts
have a disturbed relationship with their
child
Infant Feeding Choice
Breast feeding best choice but
 approx. 80 % of infants receive formula
at sometime during first year
types of formulas available:
ready to serve
concentrated
powdered
Formulas: types
Source of Formula and Use
Cow’s milk based formulas.
Soy based formulas.
Specialized formulas.
Cow’s Milk Formulas
2 types:
 1. Protein diluted to reach amount in
human milk
add back CHO, Fat, vitamins and minerals
2. Casein diluted to reach amount in
human milk
add back lactalbumin, fat, vitamins and
minerals
Soy Based and Specialized
Formulas
Soy protein used as the protein base
add back CHO, fat, vitamins, minerals, and
methionine (limiting amino acid)
e.g.: Prosobee
Specialized: For special needs
e.g.: Lofenalac: used with PKU infants
Low in phenylalanine
Osmolality
Measure of solute in solvent
e.g.: particles in milk
osmolality: osmoles of solute in 1 kg of
solvent
osmole: solute that dissociates in solution to
form one mole (Avogadro’s number) of
particles.
If too high: water sucked out and causes
diarrhea
Osmolality & Renal Solute
Load
Human milk: low, less than 300 mosmolar,
gut can easily handle
Creates Renal Solute Load of 13
mosmol/100kcal
Cow’s milk: Higher osmolality
Renal Solute Load of 46 mosmol/100kcal
Skim milk: RSL of 86 mosmol/100kcal
Formulas: 18-27 mosmol/100kcal
Potential Problems:
Mixing formulas too strong (or weak)
Skim milk to infants or children under 2
yo
Whole milk under 1 yo
Nutrient Needs of Children
Energy Needs based on:
body size and composition
physical activity
rate of growth
surface area to volume ratio
Infancy more surface area to volume then later in
life
More loss of energy to surrounding environment
Energy
Age
Energy
< 6 months kg x 108
6mo-1 year kg x 98
Consider range of intake of intake
requirements
Protein
Infant requirements based on amount
found in breast milk
Extrapolation from nitrogen balance
studies
RDA’s
Age
Protein
<6 mo
2.2 g/kg
6-12 months 1.6 g/kg
Fat
No RDA but 40 to 50 % of infant Kcals
Fat energy spares protein from being used
as an energy source
45 to 50 % of infant formulas kcals are
from fat
55% of human milk kcals are from fat
Essential fat recommendation > 1.2% of
kcals (linoleic and linolenic acid)
When to reduce fat intake
in kids?
Fat shouldn’t be a concern until after 2
years of age.
Then start incorporating lower fat food items
into the diet
reduced fat milk and milk products are ok
If these are accepted early, the risk of chronic
disease could be reduced
Controversy: Am Ac of Pediatrics says don’t
worry until after puberty: too late
Water
Age
3 days
10 days
3 mo
6 mo
9 mo
With BF and
needed
Amount
80-100 ml/kg/day
125-150 ml/kg/day
140-160 ml/kg/day
130/155 ml/kg/day
125-145 ml/kg/day
formula: none additionally
Iron(Fe)
In the fetus, Fe stores are related to body
size, therefore lbw and premature babies
are at increased risk for iron deficiency
Human milk: 49% of iron is absorbed,
only 1% of cow’s milk
Human milk not a very good source of Fe so
after 4 to 6 months, baby may be deficient in
Fe. Iron fortified cereals with vitamin C.
Fluoride(Fl)
Major role in tooth and bone development
Adequate intake reduces dental decay
Becomes incorporated in tooth and resists
acid breakdown. Acid produced by cariogenic
bacteria in mouth.
Supplementation dependent on Fl in
water supply.
Fluoride Supplementation
Amount in Water
< 0.3 ppm


0.3-0.7 ppm

over 0.7
age
supplement
2 wk-2 y 0.25 mg/day
2-3 years 0.5 mg/day
after 3 y 1.0 mg/day
2 to 3 y
0.25 mg/day
3-16 years 0.5 mg/day
no supplementation
Age of Introduction of
Solid Foods
Developmental readiness, generally 4 to 6
months
depends on oral skills: tongue thrust,
munching pattern, brings objects to mouth
palmer grasp develops
interest: if child reaches for food
First Foods: iron-fortified cereals for
infants
6-8 months: strained vegies, fruits,
Adding Foods
New foods should be added one at a time,
no more than one every three days
Check for tolerance
As infant approaches 9 to 12 months,
increase in texture to mashed and finger
foods can progress
Avoid potential choking foods
hot dogs
Feeding Problems
Colic: gas production, and bloating
Cause? Not always known: formula fed, may
change formula to casein hydrolysate
but not always successful
Breastfeeding?
Foods in the mother’s diet
Cow’s milk, or items
Colic
Spitting up
Normal occurrence
Unless projectile vomiting:
Organic problem: pyloric sphincter closure
What You Should Know About
Gastroesophageal Reflux (GER) in Infants and
Children - December 1, 2001 - American
Academy of Family Physicians
Screening Infants for
special needs
Nursing Bottle Syndrome: feeding baby to
go to sleep with bottle
Increases tooth decay
Treatment: don’t put baby to bed with a
bottle
Infant Obesity:>95%tile wt for age, Wt
for ht
Not predictive of obesity in later life
Adequate nutrition should be the key: don’t
restrict foods
Neonatal Care
Level 1: uncomplicated births and healthy
infants
Level 2: normal infants and expertise in
screening and referral of high risk infants
care for moderately ill neonates and
convalescing neonates
Level 3: equipped to cope with most
serious neonatal problems, illnesses,
abnormalities
Role of Nutritionist in
Neonatal Care
Should be able to
 screen for various nutrition problems,
monitor and assess nutritional progress,
develop and implement nutrition
management plans
Failure to Thrive
Failure to regain birth weight by 3
weeks
Wt. loss of >10% of birth weight by
2 wks
Wt dropping below the 3rf %tile
Deceleration of growth velocity
Evidence of malnutrition
Growth Retardation: 4
Types
1. Small for Gestational age but
appropriate growth since
intrauterine growth retardation, but
appropriate since then
parental height small stature
Growth Retardation
2. Small or appropriate for gestational age
but subnormal growth velocity
ongoing growth insult
examples: poor intake, overdiluting formula,
in appropriate breastfeeding schedule, family
stress, poverty
Growth Retardation
3. Depression in growth velocity
Some transient growth insult but has since
been alleviated
Seasonal low intake of nutrients due to low
income
Growth Retardation
4. Deceleration of growth due to lag down
familial short stature
Determination of Short
Stature
Chronological age: actual age
Height age: compared to 50%tile on
growth chart
Bone age: x-ray needed and radiologist
measures the width of growth plate to
determine bone age. The thicker the
growth plate, the younger the bone age
and the longer the time for continued
growth
Height Prediction: Is the child
exhibiting appropriate
growth?
Female Child
mother ht(cm) + (father ht-13)
cm

2
Male Child
(mother ht(cm)+13) + father ht
cm

2
+ 8.5
+ 8.5
Height Prediction
Compare this height to age 18 on growth
chart to determine % tile.
Compare this %tile to the current %tile of
child and see if it compares favorably.
If considerably below, cause for further
investigation
e.g.: If prediction shows 75%tile and actual is
5%tile, most likely there is some environmental
influence.
Development of Food
Patterns in Young Children
First 5 or 6 years are important for
developing food likes and dislikes
Goals for food pattern development:
1. Children eat in a matter-of -fact manner
2. Independent eating
3. Introduction of new foods
Ellyn Satter Theory
Caregiver: Gatekeeper: decides what
foods are offered
Child: Decides whether to eat, and how
much to eat
Child then develops their own regulation of
food intake
If caregiver forces food or withholds food, child
isn’t able to develop their own satiety gauge
Guidance for introducing
new foods
Have then explore food first
Feel, smell, play with?
Use small portions.
Why?
Decision to consume is left up to the child
Positive reinforcement when consumption
happens.
Guard against negative reinforcement, or
coercing.
New foods
Gradually intro new textures
Add individual foods first before mixtures
Add when child most receptive to food
Often in morning when well rested
Often not late in the day when they are tired
Be patient with self-feeding efforts
Self-esteem
Setting up the food
environment
Physical environment
spills, space, distractions
Emotional environment
free from arguing, fighting
Role model
Eat the foods you want your kids to eat