Nutrition, Growth and Development

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Nutrition, Growth and Development
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Classification System

• Low Birth Weight (LBW)
• Very Low Birth Weight (VLBW)
• Extremely Low Birth Weight (ELVW

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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

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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

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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

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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

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Growth Height

• 1 year 50 increase in height
• 4 years double birth length
• 13 years triple birth length
• Adolescence rapid increase

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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

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Body Proportions

• At birth Head 1/4 of total length
• Leg 3/8 of total length
• When growth ceases
• Head 1/8 of total length
• Leg 1/2 of total length

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Collecting and Assessing Food Intake

• 24-hour recall
• Diet history
• Diet Record 1, 3 and 7 day or more
• FFQ

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Who should be asked about Diet Intake?

• If the subject is a boy the caregiver should be asked.
• If a girl under 12 years of age, caregiver.
• Why?

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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

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Red Flags

• Anthropometric ht or wt less than 5th tile
• Infant formula under or over diluted
• whole cows milk before 1 year
• reduced fat cows milk before 2 years
• semi-solid foods before 4 months
• bottle fed to go to sleep

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Other Assessments Made

• parents nutrition knowledge
• adequacy of foods offered
• parents knowledge of community services
• delays in feeding skills
• behavior patterns that affect intake
• motivation of parent for change

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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.

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Organic Feeding Problems
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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

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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

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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

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Formulas types

• Source of Formula and Use
• Cows milk based formulas.
• Soy based formulas.
• Specialized formulas.

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Cows 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

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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

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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 (Avogadros number) of particles.
• If too high water sucked out and causes diarrhea

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Osmolality Renal Solute Load

• Human milk low, less than 300 mosmolar, gut can
  easily handle
• Creates Renal Solute Load of 13 mosmol/100kcal
• Cows milk Higher osmolality
• Renal Solute Load of 46 mosmol/100kcal
• Skim milk RSL of 86 mosmol/100kcal
• Formulas 18-27 mosmol/100kcal

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Potential Problems

• Mixing formulas too strong (or weak)
• Skim milk to infants or children under 2 yo
• Whole milk under 1 yo

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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

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Energy

• Age Energy
• 6mo-1 year kg x 98
• Consider range of intake of intake requirements

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Protein

• Infant requirements based on amount found in
  breast milk
• Extrapolation from nitrogen balance studies
• RDAs
• Age Protein
• 6-12 months 1.6 g/kg

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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)

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When to reduce fat intake in kids?

• Fat shouldnt 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 dont worry
  until after puberty too late

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Water

• Age Amount
• 3 days 80-100 ml/kg/day
• 10 days 125-150 ml/kg/day
• 3 mo 140-160 ml/kg/day
• 6 mo 130/155 ml/kg/day
• 9 mo 125-145 ml/kg/day
• With BF and formula none additionally needed

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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
  cows 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.

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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.

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Fluoride Supplementation

• Amount in Water age supplement
• 2-3 years 0.5
  mg/day
• after 3 y 1.0
  mg/day
• 0.3-0.7 ppm 2 to 3 y 0.25 mg/day
• 3-16 years 0.5
  mg/day
• over 0.7 no supplementation

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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, meats,
  finger foods

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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

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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 mothers diet
• Cows milk, or items

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Colic
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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

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Screening Infants for special needs

• Nursing Bottle Syndrome feeding baby to go to
  sleep with bottle
• Increases tooth decay
• Treatment dont put baby to bed with a bottle
• Infant Obesity95tile wt for age, Wt for ht
• Not predictive of obesity in later life
• Adequate nutrition should be the key dont
  restrict foods

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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

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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

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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

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Growth Retardation 4 Types

• 1. Small for Gestational age but appropriate
  growth since
• intrauterine growth retardation, but appropriate
  since then
• parental height small stature

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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

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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

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Growth Retardation

• 4. Deceleration of growth due to lag down
• familial short stature

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Determination of Short Stature

• Chronological age actual age
• Height age compared to 50tile 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

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Height Prediction Is the child exhibiting
appropriate growth?

• Female Child
• mother ht(cm) (father ht-13) 8.5 cm
• 2
• Male Child
• (mother ht(cm)13) father ht 8.5 cm
• 2

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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 75tile and actual is
  5tile, most likely there is some environmental
  influence.

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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

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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
  isnt able to develop their own satiety gauge

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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.

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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

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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