Nutrition

Chapter 10 Nutrition



Jerold C. Woodhead





When Should Nutrition Be Discussed?


Nutrition is one of the first topics that you will discuss with parents of newborn infants, and it will continue to be a key component of health supervision visits throughout childhood. You will need to include nutritional advice during anticipatory guidance at every health visit. Practical information can be found in Bright Futures in Practice: Nutrition and in the American Academy of Pediatrics’ Pediatric Nutrition Handbook.



What Nutritional Issues Should I Discuss with Families?


Parents ask questions about breast-feeding, formula, food choices, the readiness of a child for new foods, the value of vitamin supplements, feeding behaviors, food allergy, and inadequate or excessive weight gain. To answer the questions, you need to know about the nutritional needs of human growth (see Chapter 8) and the child’s developmental capabilities at different ages (see Chapter 9). Be sure to ask about nutritional beliefs that guide family eating as well as ethnic, cultural, or health-related dietary issues. Inquire about family risk factors for early cardiovascular disease and type 2 diabetes mellitus. Obesity is the most prevalent nutritional disorder in the United States, so the weight of family members, eating habits, and growth patterns (including body mass index [BMI]) will be important information. Adults who have large waist circumference are at high risk for metabolic complications associated with obesity. Recent evidence supports a similar risk for children who have a waist circumference-to-height ratio (WC:Ht) > 0.50. In other words, keeping waist circumference below half of the height is an important message. Poor weight gain occasionally causes concern for an infant or young child, and parents will need guidance to improve nutrition. Toddlers present challenges because of behavior. Adolescents need nutritional advice for topics ranging from the high-calorie needs of athletes to the severely restricted diets of individuals with eating disorders. You must be prepared to discuss the risks of obesity and of fad diets with teenagers. Disease presents nutritional challenges for acute problems, such as gastroenteritis, and chronic diseases such as diabetes mellitus, inflammatory bowel disease, cystic fibrosis, celiac disease, and chronic kidney disease. Unsubstantiated “nutritional” information from the Internet often links food with disease and vague health problems. Your best response is to provide reliable sources of information such as the Web sites of the Centers for Disease Control and Prevention (CDC) or the American Academy of Pediatrics (AAP).



Are Nutritional Deficiencies Common?


Iron and calcium deficiency affect large numbers of otherwise healthy children and adolescents in the United States, but most other nutritional deficiencies are uncommon in Western society. Nutritional deficiencies may be identified if patients or families do not eat specific foods. Iron deficiency is common among adolescent girls and may be more common in families who restrict red meat from their diets. Some ethnic groups are at high risk for calcium deficiency because they do not include dairy products in the diet, either for cultural reasons or because of the high prevalence of lactose intolerance beyond childhood. Infants nursed by women who are strict vegetarians (vegans) have high risk of B vitamin deficiency. Goat milk is deficient in folic acid and should not be the major source of nutrition for an infant or young child. Be aware that many children live in poverty and that food may not be adequate to meet their needs.



How Does Illness Affect Nutrition?


Acute illnesses such as gastroenteritis may cause inadequate intake of fluids and calories. Disease may impair nutrient absorption, as is seen with fat malabsorption in cystic fibrosis and with lactose malabsorption after prolonged diarrhea. Hereditary disaccharidase deficiency, usually lactase deficiency, typically manifests in preschool or school-age children. Disorders of lipid metabolism may require fat-restricted diets, although the restriction is usually not implemented until late childhood. Consumption of specific foods may be contraindicated in certain conditions such as celiac disease (gluten) and phenylketonuria (phenylalanine). Occasionally, foods may cause illness, as occurs with anaphylactic reactions to nuts, shellfish, and milk. Contamination of foods with bacteria, viruses, or toxins may result in diarrhea and food poisoning.



INFANTS



How Are Newborns and Young Infants Fed?


Approximately 70% of U.S. mothers begin breast-feeding at birth, but most breast-fed infants are switched to formula before 6 months. Active encouragement of breast-feeding and support from clinicians, family, and friends, plus accommodations for lactating women in the workplace, will enhance the likelihood that a mother will choose to nurse her newborn and persist with breast-feeding until the infant is at least 6 months old. Mothers who choose to formula feed or cannot breast-feed also need support, plus information about appropriate formulas. In addition, most parents begin to diversify the diets for their infants by adding “baby foods” after ages 4 to 6 months and will need advice about appropriate foods. “Whole” cow milk is not appropriate for infants younger than 12 months because it often produces occult gastrointestinal bleeding and leads to iron deficiency anemia (Chapter 63). Cow milk also has excessive protein and poorly absorbed fat and iron.



How Do Human Milk, Formulas, and Cow Milk Differ?


Table 10-1 provides a comparison of human milk, formulas, and whole cow milk. All have the same energy content, 20 kcal/oz (667 kcal/L), although human milk varies somewhat. See the nutritional formulary at your hospital or a resource such as The Harriet Lane Handbook for more detailed information. You can also find information about formulas designed to meet the needs of premature infants and infants with a variety of metabolic and nutritional disorders.



Table 10-1 Composition of Human Milk, Standard Formulas, and Cow Milk

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What Are the Benefits of Human Milk?


Human milk contains the protein, fat, carbohydrates, and essentially all other nutrients needed to promote growth from the time of full-term birth to at least 6 months of age. The volume of milk produced by the lactating mother increases in response to the infant’s nursing, reaching a peak when the infant is about 4 to 6 months old. Non-nutritional components of human milk protect against infection and are especially concentrated in colostrum, the first milk produced immediately after birth. Breast-feeding promotes close contact and positive emotional and behavioral outcomes for both infant and mother. Human milk can be fortified to meet the caloric needs of premature infants.



What Is Special about the Nutrients in Human Milk?


Human milk protein is predominantly whey (60% to 70%), which is highly soluble and easily digested. Protein content decreases from 14 g/L at birth to 8 g/L at 6 months, and averages 9 g/L in mature milk. This change parallels the decrease in the infant’s protein requirement. The protein content of human milk occasionally may be limiting after age 6 months for the large infant, but this is not a concern if other protein containing foods are introduced. Lipids provide about 50% of calories in human milk and the milk-fat globule contains a lipase to facilitate absorption. Human milk contains arachidonic and docosahexaenoic acids, which are essential omega-3 fatty acids not present in cow milk. Maternal dietary fat intake affects the composition of fatty acids in human milk but not the total quantity of lipid or the presence of essential fatty acids. Lactose is the principal carbohydrate source of calories in human milk; oligosaccharides provide important protection against infection. Essentially all infants digest lactose. Calcium and phosphorus are better absorbed from human milk than from formula, because they are bound to digestible proteins or are present as complexes or in ionized forms.



Which Nutrients Appear in Low Concentrations in Human Milk?


The few nutrients that have low concentrations in human milk are those that have toxic effects if taken in excess (iron, vitamin D, and fluoride) or that are synthesized by the infant after birth (vitamins D and K). The full-term infant’s iron stores are adequate to maintain hemoglobin production until ages 4 to 6 months of age, after which supplementation with iron-fortified foods should be started. The infant needs 200 IU of vitamin D daily, but human milk contains ≤ 25 IU/L. Because most infants do not have the sun exposure needed for synthesis of vitamin D, the American Academy of Pediatrics recommends that all breast-fed infants receive supplemental vitamin D beginning in the first 2 months of life. Vitamin K must be administered to all newborn infants at birth to prevent vitamin K deficiency bleeding (hemorrhagic disease of the newborn). Fluoride supplementation is not necessary during infancy.

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Jun 19, 2016 | Posted by in PEDIATRICS | Comments Off on Nutrition

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