Transcript Nutrition - WordPress.com

Nutrition
Children- nutritional vulnerability
• Infants and children are more vulnerable to poor
nutrition than adults because of:
 Low nutritional stores ( preterm babies)



High nutritional demands for growth ( especially in infancy)
Rapid neuronal development
Acute ilness or surgery
• Undernutrition in childchood may result in later life
in lower height, increased incidence of coronary
heart disease, stroke, hypertension and noninsuline-dependent diabetes
Breast feeding
• Provides ideal nutrition during the first 6
months of life
• Reduces the risk of gastrointestinal infection
and NEC
• Reduces the risk of obesity, hypertension and
insuline- dependent diabetes in later life
Breast- feeding : advantages
• Easily digested (whey: casein ratio of 60: 40)
• Better digestibility and fat absorption ( rich in oleic acids)
• Improves calcium absorption ( calcium: phosphorus ratio of
2:1)
• Kidney protection ( low renal solute load)
• Highly bioavailable iron ( 40% absorption)
• Improves retinal and neuronal development (long- chain
polyunsaturated fatty acids)
• Has anti- infective efect ( secretory IgA, lysozyme, lactoferin,
interferon, bifidus factor, macrophages, lymphocytes )
Contraindications to breastfeeding
• Child: cleft palate, galactosemia,
phenyloketonuria
• Mother: active pulmonary tuberculosis, HIV,
drug addiction, radiotherapy, chemotherapy,
herpes infection of the nipple or breast
abscess (temporary)
Potential complications of breast- feeding
• Transmission of infections ( CMV, HBV, HIV)
• Transmission of drugs and contaminants
(nicotine, alcohol)
• Breast- milk jaundice ( mild, self- limiting)
• Vitamin K deficiency (haemorrhagic disease of
the newborn)
Cow’s milk
• Unmodified cow’s milk is unsuitable for
feeding in infancy because of high protein and
electrolytes load and because it is deficient in
vitamin A, C, D and iron
• Whole pasteurized cow’s milk is
recommended from 1 year of age
• Under the age of 12 months infant formula
(modified cow’s milk ) should be used if
necessary
Formula feeding
• Formula- feeding as well as breast- feeding is
recommended until the age of 12 months. After that
‘follow- on’ formula can be used
• Has mineral content and renal solute load
comparable with human milk
• Is fortified with iron, vitamins, probiotics
• Specialised formula can be used for cow’s milk
allergy, lactose intolerance, cholestatic liver disease,
cystic fibrosis
Solid foods
• Can be intruduced after 6 month of age when
breastmilk as sole feed does not provide
adequate energy, vitamins and iron
• First smal quantities of pureed fruits and root
vegetables
• Food high in salt and sugar should be avoided
Infant feeding guidelines
•
•
•
•
•
•
•
•
•
•
•
1 m: 7 x 90-100 ml infant formula
2 m: 6 x 110-130 ml
3 m: 6 x 130 ml
4 m: 6 x 150 ml
5 m: 5 x 180 ml ( 4 x infant formula + 1 x pureed vegetables/ peeled
apple/ juice/ gluten- free [rice/corn] gruel + ½ tea spoon of gluten
products)
6 m: 5 x 180 ml ( same as above + pureed vegetables/ soup with cooked
meat or fish)
7 m: 5 x 180-220ml ( same as above +1/2 egg yolk every other day)
8 m: 5 meals ( same as above)
9 m: 5 meals ( same as above + 1 egg yolk every other day)
10 m: 4- 5 meals ( same as above)
11-12 m: 4- 5 meals ( same as above + whole egg once or two time a
week, dairy products)
MALNUTRITION - DEFINITION
WORLD HEALTH ORGANISATION:
„the cellular imbalance between supply of nutrients
and energy and the body's demand for them to
ensure growth, maintenance, and specific functions”.
MALNUTRITION - INCIDENCE
Malnutrition is the most important risk factor for illness and
death, contributing to more than half of deaths in children
worldwide.
The WHO estimates that by the year 2015 the prevalence of
malnutrition will be about 17% globally, with about 113
million children < 5 years. The overhelming majority of these
children lives in developing countries (70% of them in Asia,
26% in Africa). Incidence in US is less than 10%, even in the
highest risk groups.
Currently, more than half of babies in South Asia and 30% in subSaharan Africa suffers from malnutrition.
MALNUTRITION - INCIDENCE
Rates of undernutrition have risen from 24%
to 26.8% since 1990, with the worst
increases occurring in the eastern region of
Africa.
The occurence of malnutrition increases in
hospitalized and chronically ill children also
in the United States.
Malnutrition
Malnutrition may result from inadequate food supply or
improper food absorption
• Poor food supply:
• famine in developing countries
• increased requirements during stress, disease, antibiotic therapy
• poor dietary habits, food faddism and emotional factors
• Inadequate food absorption
• all diseases contributing to dimished intestinal function
Malnutrition – causes
Poor food supply
• In developing countries-
– inadequate food intake is the most common cause of
malnutrition and is secondary to insufficient food
supply and early cessation of breastfeeding
– inadequate sanitation increases the risk of infectious
diseases and contributes to further nutritional losses
and alters metabolic demands.
• In developed countries – chronic diseases are the main cause
of undernutrition due to:
– increased metabolic demands and increased inflammatory burden
– impairment digestive and absorptive functions (liver and bowel
diseases)
Chronic diseases and conditions contributing to
malnutrition:
•
•
•
•
•
•
•
•
Cystic fibrosis
Chronic renal failure
Childhood malignancies
Congenital heart diseases
Neuromuscular diseases (SMA)
IBD
Prematurity
In utero toxin exposure
Marasmus and kwashiorkor
• Marasmus and kwashiorkor are two forms of
Protein-Energy Malnutrition (PEM)
• Marasmus - inadequate caloric intake,
kwashiorkor - insufficient protein intake
(impaired absorption - chronic diarrhea, abnormal
losses - nephrosis, burns, or impaired synthesis chronic liver disease) and inadequate caloric
intake
Marasmus and kwashiorkor
• Distinction is based on the presence (kwashiorkor) or
absence (marasmus) of edema
• Kwashiorkor is the most serious form of malnutrition
in the world today, especially in underdeveloped
countries, afects infants and children up to 5 y.
Protein Energy Malnutrition
Malnutrition – taking history


Poor weight gain
Behavioral changes - irritability, apathy,
decreased social responsiveness, and attention
deficits
Improper bowel movements:





constipation
starvation-type diarrhea with frequent small stools
containing mucus
Vomiting, anorexia
Increased susceptibility to infections: acute or
chronic (TB, HIV)
Physical findings in patients with PEM (1)
• Decreased subcutaneous tissue, particularly: legs,
arms, buttocks, and face
• Edema – may mask the failure to gain weight, first
present in internal organs
• Stomatitis
• Abdominal findings
o Abdominal enlargement (distention due to poor abdominal
musculature, ascites), flat abdomen
o Hepatomegaly
o Hypothermia, bradycardia, hypotension
o Loss of muscle tone, muscular atrophy
• Skin changes
• Dry, peeling skin
• Hyperpigmentation in irritated areas
• Nail changes: fissured or ridged
• Hair changes: thin, sparse, brittle, depigmented
Diagnosis of PEM (1)
• Accurate dietary history
• Evaluation of weight, height, head circumference
• Measurment of midarm circumference and skinfold thickness
Diagnosis of PEM (2)
laboratory tests
– Hematological studies: complete blood count with peripheral smear
(normo-micro-macrocytic anemia)
–
–
–
–
–
–
Low protein status: albumin, transferrin
Low plasma glucose (glucose tolerance curves may be in diabetic type)
K and Mg deficiencies - frequent
Severe hypophosphatemia is associated with increased mortality
Low serum cholesterol (returns to normal after a few days of treatment)
Increased activity of transaminases, amylase and alkaline
phosphatase
– Decreased levels of hormones and vitamins
Treatment in severe – malnourished children
•
•
•
Immediate management of acute problems: severe
diarrhea, renal failure, shock.
In severe dehydration fluids must be administered
intravenously
When dehydration is corrected - oral feeding starting
with small, frequent feeds (6 to 12 times/day) in limited
amounts (< 100 mL)
PEM-prognosis
• Mortality in children: 5 to 40%
• Mortality rate - lower in children with milder PEM and
those given intensive care
• Death is usually due to:
–
–
–
–
–
dehydration with severe electrolyte deficits
sepsis
hypothermia
heart failure
shock
PEM-prognosis
• Resolution of apathy, edema, and anorexia are favorable signs
• Recovery is more rapid in kwashiorkor than in marasmus
• Long-term effects
–
–
–
–
chronic malabsorption
pancreatic insufficiency
mild mental retardation
permanent cognitive impairment.
Clinical signs of micronutrient dificiences:
o Iron - fatigue, anemia, decreased cognitive function, headache,
glossitis, and nail changes
o Iodine - goiter, developmental delay, and mental retardation
o Vitamin D - poor growth, rickets, and hypocalcemia
o Vitamin A - night blindness, poor growth, and hair changes
o Folate - glossitis, megaloblastic anemia, and neural tube defects (in
fetuses of women without folate supplementation)
o Zinc - anemia, dwarfism, hepatosplenomegaly, hyperpigmentation
and hypogonadism, acrodermatitis enteropathica, diminished
immune response, poor wound healing
Iron Deficiency Anemia
• Affects 2 billion people
• 90% live in developing
countries
• Reduced
– physical activity
– mental activity
• Increased
– Worms
– Malaria
– HIV
• High iron rice could help
Rickets
Vit. A deficiency
• 500,000 children
become blind each
year – xerophthalmia
(dry eye)
• Rice diet lacking green
vegetables
Iodine deficiency
– affects 740 million people
worldwide
– single greatest cause of
preventable brain damage in
babies
– Goiter
– Stillbirth
– Miscarriages
– Mental Retardation
• Prevented by iodized salt
• Best sources of natural iodine
– Sea weed
– Sea food
OBESITY IN CHILDREN
Obesity in childhood - definition
• Obesity - excessive accumulation of body fat
• Obesity is diagnosed when the content of fat in the total body
mass in boys is more than 25% and in girls over 32 %
• There is a difficulty in differentiation between obesity ( fat)
from overweight ( body mass)
•  BMI is the most useful index used for screening populations
of adolescents for obesity
• About 1 in 5 children in UK and USA is overweight, the
number still increases
• Obesity increases with age among both males and females
Body mass index (BMI)
BMI= body mass (kg)/body height2(m2)
BMI
•
•
•
•
Under 16
16-19
20-25
26-30
31-40
over 40
Extremely underweight
Significantly underweight
Healthy weight
Overweight
Significantly overweight (obesity)
Extremely overweight
Percentile grid
BMI
age
Cole’s index (CI)
body weight [kg] x (standard body height [m])2
CI=——————————————————————x100%
standard body weight [kg] x (body height [m]2 )
CI Categories:
<75% cachexy
75-85% malnutrition
85-95% under weight
90-120% normal weight
>120% overweight
Etiology of obesity
• cultural factors
– poor eating habits
– lack of exercise
• biological factors
– medical illnesses
• endocrine: Cushing disease, hypothyroidism, hyperinsulinemia, growth
hormone deficiency
• neurological problems: (cerebral palsy)
• Down syndrome
– medications (steroids, psychiatric medications)
• behavioral factors
–
–
–
–
stressful life
family problems
low self-esteem
depression or other emotional problems
• genetic factors
– family history of obesity
– genetic syndromes (e.x.Turner syndrome)
Clinical manifestation of obesity
•
•
•
•
Increased body mass
Adiposity in mammary region (typical for obese boys)
Pendulous abdomen with white or purple striae on the skin
Small external genitalia in boys with penis embedded in pubic
fat
• Relatively small hands and tapering fingers
Screening obese children
•
•
•
•
•
Five criteria for diagnosis of obesity
family history – (parental obesity, cardiovascular
disease, elevated cholesterol, diabetes mellitus)
elevated blood pressure
high total body cholesterol
large annual increase in BMI
concern about weight: emotional attitude to
overweight
If one or more factors are positive – the patient
should receive careful medical evaluation
Complications of obesity in children
• Experience of social and psychological stress (social
stigmatization in school, children are isolated and
excluded from other activities) leading to psychologic
disturbances
• Glucose intolerance and non- insulin dependent diabetes
mellitus (NIDDM)
• Elevated serum cholesterol level, which probably may
contribute to increased risk of atherosclerosis (ischemic
heart disease, cerebral vessel disease, peripheral blood
vessel disease) Increased blood pressure
• Sleep apnea (7% of obese children)
Complications of obesity in children
• Cholelithiasis
• Orthopedic complications
• Endocrine disturbances: hyperandrogenemia,
polycystic ovary disease
• Elevated risk of being obese in adulthood (increased
risk: greater number of obese family members, decreased
time to adult age, greater severity of childhood obesity)
• The “pickwickian syndrom” – rare complication of
extreme obesity; cardiorespiratory distress with
alveolar hypoventilation: polycythemia, hypoxemia,
cyanosis, cardiac enlargement, congestive cardiac
failure, and somnolence
Treatment of the obese child
• Treatment should be considered for obese children
particularly those with hypertension and sudden weight
growth
• Implementation a plan for weight reduction
– Individual diet providing all necessary macro-and micronutrients with
the reduction of calorie supply appropriate to maintaining growth of
the child
– Modification of eating habits to promote a healthy
– active life – style
– plan of exercise acceptable to the child
Food pyramide
Diet for obese child
• Diet based on starchy foods rich in complex
carbohydrates, they are bulky, relative to the amount of
calories they contain. This makes them filling and
nutritious. Sources such as bread, potatoes, pasta, and
rice should provide half the energy in a child’s diet.
• instead of high-fat foods (chocolate, biscuits, cakes and
crisps) - healthier alternatives (fresh fruits); frozen
yoghurt is an alternative to ice cream
• grill or bake foods instead of fried ones
• elimination of fizzy drinks that are high in sugar with
substitution with fresh juices diluted with water or sugarfree alternatives
Treatment of obesity contraindicated in children
•
•
•
•
Surgery
Pharmacotherapy
Gastric baloons
Very-low calorie diets (risk of growth and development
impairment)
Prevention of obesity in children
• breastfeeding
• healthy diet with plenty of fresh fruits and vegetables
in family (children tend to stick to the eating pattern
that has been established at home)
• healthy, active life style
Malabsorption Syndromes
Malabsorption Syndromes (MS)
MS includes a number of different illnesses that
result in chronic diarrhea, abdominal
distention, and failure to thrive.
Malabsorption can be broken down into
several conditions:
• congenital and acquired
• gluten sensitive and non-sensitive
• regenerative and aregenerative
Pathophysiology
Carbohydrate, fat, or protein malabsorption
is caused by a disorder in the intestinal
digestion or transport across the
intestinal mucosa. Either a congenital
abnormality of these processes or, more
commonly, a secondarily acquired
disorder may result in malabsorption.
Frequency (1)
Congenital:
• celiac disease is considered the most common
inherited malabsorption syndrome with prevalence
close to 1%
• cystic fibrosis is the second most common
malabsorption syndrome
• other congenital disorders are rare, with the
exception of adult-type hypolactasia (a prevalence
varies greatly among different ethnic groups)
Frequency (2)
Acquired:
• cow's (and soy) milk protein allergic enteropathy is very
common with the prevalence around 3%
• malabsorption in infants after previous enteritis (mostly
rotaviral), which causes lactose intolerance - transient and
common
• secondary MS resulting from liver, pancreas, and intestinal
diseases are uncommon
Age
• neonates and young infants with MS are at
particularly high risk for chronic diarrhea and
malnutrition
• symptoms of a congenital disease are usually
apparent shortly after birth or after a short period
after presenting a particular substance into the diet
• protein sensitivity syndromes to milk or soy protein
usually occure in infants younger than 3 months, but
solid food protein sensitivity syndromes may occur in
older patients
History
• Diet history: breastfeeding, gluten, solid foods, and type
of formula
• Gastrointestinal tract symptoms (very common):
o Abdominal distention and watery diarrhea, with mild abdominal
pain, associated with skin irritation in the perianal area (due to
acidic stools) - characteristic for carbohydrate MS
o Periodic nausea, abdominal distention and pain, and diarrhea common in patients with chronic Giardia infections
o Vomiting, with moderate-to-severe abdominal pain and bloody
stools -characteristic for protein sensitivity syndromes,
inflammatory bowel disease
o Recurrent abdominal pain in all MS
o Poor appetite - common in food sensitivity syndromes
History - stool characteristics
o frequent, loose, watery stools - carbohydrate intolerance
o pasty or loose, foul-smelling stools - fat malabsorption
(steatorrhea):
o Giardia lamblia infections
o hepatic and pancreatic dysfunction
o protein sensitivity syndromes
o bloody stools - protein sensitivity syndromes, IBD
Other symptoms of MS
o systemic symptoms:
o weakness, fatigue
o failure to thrive
o clinical symptoms of macrocytic and microcytic
anemia
o delayed puberty
• signs of malnutrition: reduced muscle and fat mass,
atrophic tongue changes, enlarged liver or spleen, low
weight, low height, low weight-for-height percentiles
• psycho-motor retardation
• improper body proportions (long trunk, short limbs, large
abdomen)
Physical examination
• significant increase in peristaltic activity (decreased
intestinal transient time)
• constantly wet diaper and failure to properly dry the
buttocks and perianal area - result in erythema, skin
irritation, with evidence of bleeding seen in the diaper or
in stool
• eczematous rash - in protein sensitivity
Diagnosis (1)
• Stool analysis
– the presence of reducing substances indicates that
carbohydrates have not been properly absorbed
– pH level < 5.5 indicates carbohydrate malabsorption, even
in the absence of reducing substances
Stool analysis
– the amount of fat ( in celiac disease and cystic fibrosis)
– 1-antitrypsin indicates leakage of serum protein and
serves as a screening test for protein-losing enteropathy
– culture, viral examination, presence of parasites or
testing for the stool antigen of Giardia lamblia may reveal
infection – cause of acquired MS
Diagnosis
• urinalysis – culture for excluding urinary tract infection as a cause of
secondary MS
• blood analysis for anemia (megaloblastic or microcytic anaemia,
neutropenia in patients with Shwachman-Diamond syndrome-associated
with pancreatic insufficiency)
• total serum protein and albumin levels -lower in syndromes in which
protein is lost or is not absorbed (protein-losing enteropathy and
pancreatic insufficiency)
Diagnosis
• low-density lipoprotein (LDL) cholesterol - lower in bile acid
malabsorption
• fat-soluble vitamin lower in fat malabsorption or ileal resection
• inflammatory parameters (CRP, ESR) – elevated in bacterial infections and
IBD
Diagnosis
Carbohydrate malabsorption tolerance test
 lactose absorption test – assessment of serum glucose
level after administration of lactose
Diagnosis
• immunoglobulins (IgG,IgA), antiendomysial antibodies
(IgAEma), and tissue transglutaminase antibodies -in the
diagnosis of celiac disease
Histologic findings
fundamental test in obtaining a definitive diagnosis in many
circumstances (e.x. celiac disease)
• assessment of the duodenal mucosa during an upper
endoscopy:
– villous atrophy (protein-sensitive enteropathies, Giardia infection, bile
acid malabsorption)
– mucosal inclusions seen in abetalipoproteinemia, eosinophilic
gastroenteritis
Treatment of the child with MS
treatment the underlying disease
• In patients with deficiency of pancreatic enzymes (cystic fibrosis) –
administration oral supplements
• In children with chronic diarrhea secondary to bile acid
malabsorption, the use of cholestyramine (Questran) to bind bile
acids may help to reduce the duration and severity of the diarrhea
• Diet:
– gluten-free diet - celiac disease
– cow’s milk free diet (hydrolyzed protein formulas )- cow’s milk
protein allergy
– hypoallergic diet - food allergy
– lactose-free diet – lactose intolerance
– MCT oil - poor weight gain resulting from fat malabsorption
– fat-soluble vitamin supplements - fat malabsorption or short bowel
syndrome
ANOREXIA NERVOSA
What is anorexia?
A serious disorder in which a
person (usually girl) starves
herself.
Anorexia nervosa
•
•
•
•
Prevalence 1,5% in teenage girls
Female/male ratio 20:1
Familial pattern
Etiology – unknown, probably complex:
–
–
–
–
Social
Environmental
Psychological
Biologic factors
Clinical picture
•
•
•
•
Body weight < 85% of expected weight
Intense fear of gaining weight
Undue emphasis on body shape or weight
Amenorrhea
Types of anorexia nervosa
• Restricting Type
characterized by dieting,
fasting, or excessive
exercise
• Anorexic-bulimic Type
characterized by selfinduced vomiting or
misuse of laxatives or
diuretics. Vomiting is
common even after
small amounts of
food.This type carries
greater medical risk.
Warning Signs of Anorexia:
• Not eating or eating very little
• Intense fear of gaining weight
• Skipping meals by making up
excuses
• Eating lonely
• Wearing baggy clothing
• Denial of being hungry
• Excessive exercising
Warning Signs of Anorexia:
•
•
•
•
Hair growth on body and face
Hair loss on head
Absent or irregular menstrual periods
Taking pills to urinate or have a bowel
movement
• Reading food labels constantly
Anorexia affects whole body
• Hair thins and gets brittle
• Low blood pressure, slow heart rate, fluterring of the heart
• Weak muscles, swollen joints, bone loss, fractures,
osteoporosis
• Kidney stones, kidney failure
• Low potassium, magnesium and sodium
• Constipation, bloating
• Amenorrhea
• Dry yellow skin, bruise easily, hair all over the body
• Moody, irritable, bad memory, fainting