Nutrition in Children

Florianne Feliza F. Valdes,M.D.Fellow, Philippine Pediatric Society,Inc.

Section Head,Ambulatory Pediatrics

The Medical CityAteneo School of Medicine and Public Health

October 27,2010

Nutrition

Combination of processes by which living organisms receive and utilize the materials necessary for growth, maintenance of functions, and repair of component parts

Del Mundo,et al. Textbook of Pediatrics and Child Health

Metabolism

All changes occurring in food from absorption from the GIT until end-products are eliminated by the different excretory organs

Nutritional Requirements

FNRI DOST,NRC RENI

Advisable intake-variable, observed, approximated intake by a group of healthy individuals

Minimum requirement- least amount of nutrient needed for optimum health

Recommended Energy and Nutrient IntakesPhil.,2002

Recommended Energy and Nutrient IntakesPhil.,2002

RENI

In the Philippines, the revised edition of the dietary standards changed from Recommended Dietary Allowances (RDA) to Recommended Energy and Nutrient Intake (RENI)

Levels of intake of energy and nutrients which on the basis of current scientific knowledge, are considered:

Adequate for the maintenance of health and well being of nearly all healthy persons

Adequate intake based on the experimentally observed average intake of health individuals

Essential Nutrients

Water

FoodMacronutrients

CHO, Fat, proteins

Carbohydrates – 55 – 70%

Fats and fatty Acids- 10-15%

Proteins – 30-40%

MicronutrientsVitamins

Minerals

Electrolytes

Water

Infants and children must receive adequate amounts of fluids

Healthy infants : fluid consumption – 10-15% of Body weight

Adults: - 2-4 % Absorption : intestinal tract Interstitial compartment fluid: depends

on protein and electrolyte concentrations

Water

Balance depends on Fluid intake Diet:proteins and minerals Solute load Metabolic and respiratory rates Body temp

Evaporation: 40-50%lungs and skin Renal excretion

Approx daily requirements of Filipino Infants and Children

Neonates: 120-150 mL/kg 1-12 months: 150 1-3 years: 140 4-6 years: 120 7-9 years: 100 10-12: 90 13-15: 70 16-19: 50

Macronutrients

CARBOHYDRATES Children: growth and development Energy production Storage of calories as glycogen Conversion to fat,AA synthesis Cellulose as roughage Growth Repair of tissues Production of new cells and tissues

Carbohydrates

Deficiency: Underweight Ketosis General

weakness Fainting Collapse seizures

Excess: Obesity Diarrhea Syndromes due to

inborn errors of sugar metabolism

Carbohydrates

Sources: Starch, bread, cereals,rice and products Noodles, potatoes, roots, Tubers

Sugars, fruits, jams, preserves, jellies Cakes Cookies, candies MILK

Macronutrients

PROTEINS: Building blocks 20-22 amino acids Essential amino acids necessary to avoid

neg nitrogen balance Isoleucine, leucine, lysine,methionine,

phenylalanine,threonine, tryptophan,valine, and histidine

Proteins

Functions: AA for building and repairing body tissues Heat and energy supple when there is

CHO and fat shortage Ions in nitrogen balance

Proteins

Deficiency: Neg N2 balance Weakness Prominent abdomen Edema Retarded growth Slow recuperation Underweight Reduced resistance

to infection Kwashiorkor and

marasmus

Excess: Hyperammonemia Azotemia Acidosis

Proteins

Sources: Garbanzos,tokwa Peanut butter, munnggo, other beans Cereals, nuts Milk, meat,liver, heart,

kidney,poultry,eggs, fish, shellfish

Macronutrients

Fats – without this, malnutrition is a risk Low fat milk: low Vit A , linoleic acid, < 20 % of caloric intake- diarrheas, high

renal solute load Supplies essential fatty acids Carries fat soluble vitamins Structural part of every cell Reserve energy resource

FATS

Protein sparer Fats needed for satiety and appetite stimulation! Linoleic/arachidonic acids-

for growth, skin and hair integrity, regulation of cholesterol metabolism, lipotropic activity, Prostaglandins decreased platelet adhesiveness, reproduction

Fats

Omega 3 – special group of fatty acids Low rates of cardiovascular diseases in

Greenland Eskimos Fish oil Alpha linolenic acid, DHA- retinal development and cognitive

performance DHA /EPA- promote anti inflammatory

and immune effects

FATS

Deficiency: Underweight No appetite Skin

changes( linoleic a deficiency

Hair loss

Excess: Obesity atherosclerosis

Fats

Sources: Margarine, nuts, oils, shortening Milk Cream Meat , lard

Maronutirents and Micronutients

Energy/Calories Protein Fats Water

Vitamins Minerals Electrolytes

Minerals

Absolutely necessary for maintenance of LIFE Indispensable for new tissue cells and growth Sodium Potassium Calcium Magnesium Chloride Sulfur

MINERALS

Calcium Chromium Copper Fluoride Iodine Iron Magnesium Manganese

Molybdenum Phosphorus Potassium Selenium Sodium Chloride Zinc

Vitamins

First called “accessory factors” (1906) by English biochemist Sir Frederick Gowland Hopkins

Other substances necessary for health

Historical Background

“VITAMINE” (Polish American biochemist, Casimir Funk) an amine (organic base) essential to life

1912, Hopkins and Funk vitamin hypothesis of deficiency

Thiamine

Vitamins

A class of 13 organic compounds “that are essential in small quantities for the normal metabolism of other nutrients and maintenance of physiological well being”*

Help body turn food into energy and tissues

Most prescribed and MOST requested prescription in everyday pediatrics

* Reference: Burton BT: Human Nutrition, 3rd ed, McGraw, New York, 1976: 85

Functions of Vitamins

Vitamins do not directly yield energy but are required for energy yielding processes in the body

Some are co-factors in enzyme activity.

Some are antioxidants (prevent oxygen from doing damage in the body)

One vitamin (Vit. D) is a prohormone.

Functions of Vitamins

Normal growth

Maintenance of life

Normal function of the digestive tract

Normal nutrition, especially utilization of mineral elements

Proper oxidation of carbohydrates

Tissue resistance to bacterial infections

Normal reproduction

Functions of Vitamins

Act as catalysts or coenzymes (vit C)

No direct yield of energy but are necessary for some energy-yielding processes in the body (Krebs Cycle)

May vary from species to species

Differ in chemical structure and no common chemical grouping (water and fat soluble)

Classification of Vitamins

Fat SolubleVitamin A

Vitamin D

Vitamin E

Vitamin K

Water SolubleVitamin C

B complexB complex

Folic Acid

Pantothenic Acid

Fat Soluble Vitamins

Rickets

Water Soluble Vitamins

BERIBERI

Scurvy

MINERALS

Interactions between Micronutrients

Nutritional Status of the Filipino Child

Children O - 5 years of age: 68% normal weight for age, 32% underweight, 0.4% overweight 66% normal height, 34% stunted,0.4% tall 93% normal wt for ht 6% wasted, 0.9 % overweight for height

Children 6 -10 years of age: 27% are underweight for age (2.5 Million) 37% are stunted or short in height for age (3.4 Million)

* Reference: FNRI, 2003 data

Nutritional Status of the Filipino Child (0-5 years) – FNRI 2003

Normal Weight71.7%

Underweight26.9%

Stunted29.9%

Normal Height69.5%

Nutritional Status of the Filipino Child (6-10 years) – FNRI 2003

Normal Weight71.7%

Underweight26.9%

Stunted29.9%

Normal Height69.5%

Nutritional Status of the Filipino Adolescent, FNRI, 2003

11-12 years old 49% normal weights for height 26% underweight 4% overweight

13-19 years old 68% normal weights for height 12% underweight 3 % overweight

Energy and Nutrient Requirements(RENI)

13-15 years old 16-18 years old 19-29 years old Nutrients Male Female Male Female Male Female

Energy (kcal) 2800 2250 2840 2050 2490 1860 Protein (g) 71 63 73 59 67 58 Vitamin A (g RE) 550 450 600 450 550 500 Vitamin C (mg) 65 65 75 70 75 70 Thiamin (mg) 1.2 1.0 1.4 1.1 1.2 1.1 Riboflavin (mg) 1.3 1.0 1.5 1.1 1.3 1.1 Niacin (mg NE) 16 14 16 14 16 14 Folate (g DFE) 400 400 400 400 400 400 Calcium (mg) 1000 1000 1000 1000 750 750 Iron (mg) 20 21 14 27 12 27 Iodine (g) 150 150 150 150 150 150 Magnesium (mg) 225 220 260 240 235 205 Phosphorus (mg) 1250 1250 1250 1250 700 700 Zinc (mg) 9.0 7.9 8.9 7.0 6.4 4.5 Selenium (g) 31 31 36 36 31 31 Flouride (mg) 2.5 2.5 2.9 2.5 3.0 2.5 Manganese (mg) 2.2 1.6 2.2 1.6 2.3 1.8 Vitamin D (g) 5 5 5 5 5 5 Vitamin E* (mg) 12 12 13 12 12 12 Vitamin K (g) 50 49 58 50 59 51 Vitamin B6 (mg) 1.3 1.2 1.3 1.2 1.3 1.3 Vitamin B12 (g) 2.4 2.4 2.4 2.4 2.4 2.4

Potential Nutrition related problems in Adolescents

Undernutrition-Micronutrient malnutrition and chronic energy deficiency resulting in thinness (low Body Mass Index) and /or stunting

Obesity,Metabolic syndrome Eating Disorders: anorexia nervosa,

bulimia

Nutritional Status of Adolescents,using BMI

% Prevalence Underweight Overweight Gender/Age

1993 1998 2003 1993 1998 2003 Male 11-12 13-19 All

27.1 19.1 21.6

34.0 19.3 23.0

31.0 17.0 20.5

2.6 2.5 2.6

1.8 1.0 1.2

4.9 2.9 3.4

Female 11-12 13-19 All

19.2 5.9 9.5

27.2 12.9 16.4

20.6 6.4

10.1

1.5 2.5 2.2

3.2 5.2 4.7

3.4 3.9 3.8

Both 11-12 13-19 All

23.5 12.6 15.8

30.6 16.2 19.8

25.9 12.0 15.5

2.2 2.5 2.4

2.5 3.1 2.9

4.2 3.4 3.6

Energy and Nutrient Requirements

Increased nutritional needs-growth spurt Increased physical activity-males( protein and

energy) Poor eating habits Special considerations/stresses:

Sports Menstruation Pregnancy Drug abuse Special diets-

Vegetarian Religious reasons Allergies Intolerance

Nutritional Requirements

Energy: increased in males Protein – 1 g/kg /day – males;0.8

g/kg/day females Minerals: Iron, Calcium, Zinc,Iodine Vitamins – B12, folate, D,A,C,E,

thiamine, niacin, riboflavin Calories:

Males: 2400-2800 Females: 1800-2200

Calories CHO(grams)

FAT Cholesterol(mgs)

Big-MacWhopperQuarter pounder cheese

563660740

4149

3341

86

?

French fries

KFC leg/thigh

270

643 each

31

46

15

35

13

180

PHSuper Supreme

Coca-cola 10.5 oz

2 slices –340

96

42

24

11

0

22

Nutritional Status of the Filipino Child

* Reference: FNRI, 2003 data

Estimated prevalence of anemia in 2003 66% among infants 0-6 months old

29.1% in children 1-5 years old

37 - 40% in children >5 years old

Food & Nutrient Intake among Children, 2003

Energy & Nutrients

Energy (kcal)*

Protein (g)**

Iron (mg)**

calcium, (g)**

Vitamin A (mcg, Retinol equivalent)**

Thiamin (mg)**

Riboflavin (mg)**

Niacin (mg)**

Ascorbic Acid (mg)**

Proportion of households meeting

(>) RENI

Proportion of households not

meeting (<) RENI43.1

66.3

19.4

16.0

28.9

56.9

33.7

80.6

84.0

71.1

45.1

27.3

90.9

31.8

54.9

72.7

9.1

68.2

Marasmus( infantile atrophy, Inanition,Athrepsia,Cachexia, Decomposition)

Kwashiorkor( pr malnutrition, malignant malnutrition, melnarschaden)

Nutritional Assessment of Children and Adolescents

Assessment of Nutritional Status

1. HistoryDietary history of mother and child

History of wt and ht changes

Other lifestyle issues

2. Anthropometric IndicatorsDeviations from average ht and wt

Depletion of fat depots

Decrease in muscle mass

Assessment of Nutritional Status

3. Change in psychic reaction

4. Reaction to infection

5. Evidence of specific deficiencies

Anthropometric Measurements

Not a 1 time assessment Rate and velocity Use appropriate equipment for weight,

stature/length

Assessment of Nutritional Status

Measurements:Weight

Height or length

Weight for height – acute malnutrition

Head circumference

BMI

Skinfold thickness

Midarm circumference

Bone age

Growth velocity

Weight

Various types: infant scales, beam balance scales,platform scales, digital

Regualr calibration Weigh with minimal clothing

Length/Stature

Depends on the child’s ability to stand/ambulate

2 years and below: recumbent, tape measure, fixed head and foot board (infantiometer)

Charts taped to wall, barefoot Heels, buttocks, shoulders, head

touching wall

Weight for height

Ratio of Actual weight to the ideal weight for height

Independent of age Differentiates stunting from wasting

B0YS: 0-36 monthsLength for age and Weight for Age percentiles

Girls:0-36 monthsLength for age and Weight for Age percentiles

BOYS: 2-20 yearsStature for Age and Weight for Age percentiles

Girls 2-20Stature for age and Weight for Age percentiles

Head Circumference

Up to age 3 : growth slows down Tape measure to cross forehead above

the supraorbital ridges, pass around the head at same levels of both sides of occiput

Tape is moved,pressed on hair

Boys: 0-36 monthsHead circumference for age and weight for length percentiles

Girls: 0-36 monthsHead circumference for age and weight for length percentiles

Mid arm circumference

LEFT Muscle growth indicator Between acromion and olecranon

Indicators of Nutritional Status

<5th percentileStunting/shortness length or stature-for-age

Head circumference-for-age

<5th percentile

<5th percentile>95th percentile

Underweight weight-for-length BMI-for-age

Indicators of Nutritional Status

Overweight Weight-for-length BMI-for-age

>95th percentile

Risk of overweight BMI-for-age

85th to 95th percentile

Provides a reference for adolescents not previously available

Consistent with adult index so can be used continuously from age 2 to adulthood

Tracks childhood overweight

Advantages of BMI for age

Relates to health risks

CORRELATES with clinical risk factors for CVS diseases, DM, hypertension

Why Use BMI-for-Age?Why Use BMI-for-Age?

Guidelines for Overweight in Adolescent Preventive

Services (Am J Clin Nutr 1994;59:307-316) Obesity Evaluation and Treatment: Expert Committee Recommendations (Pediatrics 1998 Sept;(102)3:e 29) Assessment of Childhood and Adolescent Obesity: International Obesity Task Force (Am J Clin Nutr 1999, 70,suppl)

BMI-for-Age CutoffsBMI-for-Age Cutoffs

> 95th percentile Overweight

85th to < 95th Risk of overweight percentile

< 5th percentile Underweight

Charts are useful for Filipinos

CDC promotes one set of growth charts for all racial and ethnic groups.

Racial- and ethnic-specific charts are not recommended because studies support the premise that differences in growth among various racial and ethnic groups are the result of environmental rather than genetic influences.

reference population lacked sufficient numbers of specific racial/ethnic groups to consider separate charts.

factors that affect differences in growth among racial and ethnic groups, if they truly exist, remain unclear and more research is needed

BOYS: BMI for age percentiles

Girls: 2-20BMI for Age percentiles

Nutritional Status of the Filipino Adolescent

Body Mass Index BMI = weight(kg) /height(m2)

<18.5 Underweight 18.5 – 25 Healthy weight/normal 25 – 30 Overweight >30 Obese

Infant Nutrition: Breastfeeding

Breastfeeding

breastfeeding is the ideal method of feeding and nurturing infants and recognizes breastfeeding as primary in achieving optimal infant and child health, growth, and development.

Benefits of Breastfeeding

health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits

Benefits of Breastfeeding

Significantly decreases risk for a large number of acute and chronic diseases.

Research in the United States, Canada, Europe, and other developed countries, among predominantly middle-class populations, provides strong evidence that human milk feeding decreases the incidence and/or severity of diarrhea lower respiratory infection otitis media bacteremia bacterial meningitis botulism urinary tract infection necrotizing enterocolitis

Breastfeeding benefits

possible protective effect of human milk feeding against sudden infant death syndrome

Prevents insulin-dependent diabetes mellitus Crohn's disease ulcerative colitis Lymphoma allergic diseases other chronic digestive diseases

Breastfeeding has also been related to possible enhancement of cognitive development

Health Benefits for Mothers

-Increases levels of oxytocin-less postpartum bleeding ,rapid uterine involution

-Lactational amenorrhea - Earlier return to prepregnant weight- Delayed resumption of ovulation with increased

child spacing -Improved bone remineralization postpartum -With reduction in hip fractures in the

postmenopausal period-Reduced risk of ovarian cancer and

premenopausal breast cancer

Socio economic benefits

In addition to individual health benefits, breastfeeding provides significant social and economic benefits to the nation, including reduced health care costs and reduced employee absenteeism for care attributable to child illness.

AAP Policy Statement on Breastfeeding,1997

Infant Feeding

Weaning 6 months Breast to bottle Milk to solids Breast to cup/glass Developmental readiness of infants- head

control, oral motor coordination Mature GIT and kidneys

Lecture Focus

Nutrition Nutritional Requirements based on age

RENI Essential Nutrients

Macronutrients Micronutrients

Nutritional Deficiencies Nutritional Assessment

Anthropometrics BMI Growth Charts

Breastfeeding