Chapter 16

Nutrition during InfancyInfant growth during first year

Reflects nutrient intakeBirthweight changesInfant’s length

Energy requirement Twice that of an adult

Weight Gain of Infants in Their First Five Years of Life

Nutrition during Infancy Energy nutrients

Birth weight should double by 5 months and triple by 12 months

Kcal needs : 100 kcal/kg, unlike ~30 kcal/kg for adults

6-12 months kcal include solid foodsCarbohydrates (glucose) especially needed for brain

Brain size proportionately larger than adult’sFat provides most of the energy in brst milk/formulaProtein- MOST important for growth

Basic building material of body’s tissues Protein overload stresses liver, kidneys

Acidosis, diarrhea, high serum ammonia & urea Feeding with nonfat milk or conc. formula

Nutrition during Infancy

Vitamins and mineralsNeeds are greater than adults

WaterPercentage of body weight as water highest as

young infantDehydration from vomiting, diarrhea, high

temperature require supplemental water or electrolyte fluid (Pedialyte)

Recommended Intakes of an Infant & an Adult Compared Based on Body Weight

Percentages of Energy-Yielding Nutrients in Breast Milk & in Recommended Adults Diets

6%

Protein

21%

55%

Fat

26%

39%

Carbohydrate

53%

Breast milk

Recommended adult diets

Key:

Slower growth

More activity

Breast MilkPractice of breastfeeding

Length of exclusive breastfeeding 6 monthsBreastfeeding and complementary foods 6-12

monthsFrequency and duration of feedingsBreast milk more digestible and less fillingEnergy nutrients

Lactose Oligosaccharides not in cow’s milk or formula Essential fatty acids Protein- less than cow’s milk, α-lactalbumin more

digestible

Breast Milk

Practice of breastfeedingVitamins and minerals

Vitamin D tends to be low in breast milk, supplement it

Iron less but highly bioavailable, due to lactoferrin

Immunological protectionColostrum Bifidus factors Antibodies and white blood cellsLactadherin inhibits replication of diarrhea

virus

Immunological Protection of Breast Milk

Allergy, infection and disease protectionColostrum Bifidus factors Antibodies and white blood cellsLactadherin inhibits replication of diarrhea virusLower incidence of allergic reactionsProtection against development of cardiovascular

diseaseProtection against excessive weight gainIntelligence

Controversial

Breast Milk

Breast milk banksDonation of breast milkScreeningLife-saving solution for fragile infants

Infant Formula

CompositionAttempt to copy

composition of breast milk

Iron-fortifiedNo protective

antibodiesSafe preparation

6% 9%

55%

Key:

49%

39%

Cow’s milk

29%

Breast milk

Infant formula

Protein

Fat

Carbohydrate

51%

42%

20%

Infant Formula

Risk of lead poisoningInfant formula standard set to “well-nourished

mothers during first or second month of lactation”Special formulas for preemies or genetic diseasesInappropriate formulas as total diet

Goat’s milkSoy milkRice milk

Nursing bottle tooth decay

Nursing Bottle Tooth Decay

Special Needs of Preterm Infants

1 of 8 births is pretermPreterm or premature

Incomplete fetal developmentLeading cause of infant deathsOften low-birthweight infants

Benefits of third trimester for infant’s nutrient stores

Preterm breast milk More protein, less volume Supplements can be added too

Introducing Cow’s Milk

Cow’s milk never advised before age 1Children 1 to 2 years of age

Whole milk 4% (red cap) milkIf it seems to be linked to chest and nasal

congestion, try goat’s milk, much closer to human milk

Benefits of goat's milkChildren aged 2 to 5

Gradual transition from whole to lower-fat milks

Introducing Solid Foods

When to beginBetween 4 and 6 months

Developmental capabilityPurpose of solid foods

Food allergiesSingle-ingredient foodsOne at a time in small portionsWaiting period before next food is introduced

Introducing Solid Foods

Choice of infant foodsProvide variety, balance, and moderationCommercially prepared vs. homemade foods

Food labelsNo fat information listed or needed for children

younger than two Need for fat due to growth rate and essential fatty

acids for brain development

Introducing Solid FoodsFoods to provide iron

Breast milk or iron-fortified formulaIron-fortified cerealsMeat and meat alternates

Foods to provide vitamin CFruits and vegetablesLimit 100% juice to 4-6 oz/day

Foods to omitHoney and corn syrupSoda, sweetened “fruit drinks”-- C-fortified or

not

Introducing Solid Foods

Vegetarian dietsNewborn is a lacto-vegetarianBeyond six months

Vegan diets slow down growth and development Well-balanced vegetarian diet is doable; continue

iron supplement and/or children’s MVI

Foods at 1 yearCow’s milk- 2-3 cups/day- no more

Displacement of iron-rich food sources by milk can lead to anemia

Mealtimes with ToddlersDeficiencies of vitamin D, vitamin B12, iron,

and calcium may develop. Energy-dense foods are required.

Feeding guidelines currently in vogueDiscourage unacceptable behaviorLet toddler explore and enjoy foodsDon’t force food on childrenProvide nutritious foods

Let child choose which ones and how muchLimit sweetsDon’t turn dining table into battleground

Nutrition during ChildhoodAnnual growth

HeightWeight

Body composition and shape changesEnergy needs, nutrient needs, and appetites during

childhood vary because of growth and physical activity. Hunger and nutrient deficiencies affect behavior.

Concerns include lead poisoning, high energy, sugar and fat intakes, iron deficiency, caffeine consumption, food allergies, and food intolerances. Adults and schools need to provide children with nutrient-dense foods.

The body shape of a 1 year old (left) changes dramatically by age 2 (right). The2 year old has lost much of the baby fat; the muscles (especially in the back,buttocks, and legs) have firmed and strengthened; and the leg bones havelengthened.

Energy and Nutrient Needs in Childhood

Appetites diminish around 1 year of age1 yr to adolescence: ↑2-3 inches, ↑5-6 lbs

Food intakes coincide with growth patternsEnergy intakes vary from meal to meal

Energy needs vary widely1 yr old- 800 kcal/d6 yr old- 1600 kcal/d

Growth and physical activity Difficulty meeting energy needs

Energy and Nutrient Needs in Childhood

Carbohydrate and fiberRecommendations are the same for children

and adultsFiber recommendations in proportion

Fat and fatty acidsDRI Committee recommendation

Fat should be 30-40% of total kcal for 1 to 3 year olds

Fat 25 - 35 % of total kcal for 4 to 18 year olds (same as adults)

Energy and Nutrient Needs in Childhood

Protein recommendationsConsiderations

Nitrogen balance Quality of protein Added needs of growth

Vitamins and mineralsNeeds increase with ageIron and vitamin DSupplements

Energy and Nutrient Needs in Childhood

Planning children’s mealsVariety of foods from each food groupNo added salt, sugar, or seasonings.

Amounts suited to appetite and needsFeeding Infants and Toddlers Study (FITS)

Findings Greater variety of nutrient-dense vegetables and

fruits are needed Inadequate intakes of vitamins and minerals

What have we learned from FITS 2008?

Where we’re improving Mothers are breastfeeding longer Fewer numbers of infants and toddlers are consuming sweets

Where we still need improvement25% of toddlers are not consuming a single serving

of fruit and 30% don’t eat a single serving of vegetables on a given day

Preschoolers are consuming more white potatoes than the healthier dark green or orange vegetables

Sodium intakes are above the upper limit for 70% of 2 year olds and 84% of 3 year olds

Preschoolers 24–48 months are consuming more than the recommended amount of saturated fat

Food Guide Pyramid for Young Children

Hunger and Malnutrition in Children

Even mild malnutrition affects intellectual performance

Very low-income familiesGreater risk of hunger and malnutrition

Meal skipping and academic performanceBenefits of breakfast consumption

Iron-deficiency and behaviorBehavior, attention span, and learning abilityTesting for iron status

Effects of deficiency occur before blood effects occur

Physical Signs of Malnutrition in Children

The Malnutrition-Lead Connection

Malnourished children are vulnerable to lead toxicity

Low intakes of certain nutrients increases risk of lead toxicityCalcium, zinc, vitamins C and D, and iron

Commonalities between iron deficiency and lead toxicityDisrupts normal brain development

The Malnutrition-Lead Connection

Effects of lead toxicityLearning disabilities Behavioral problems

Lead accumulation in bodyBones, brain, teeth, and kidneys

Federal laws have reduced lead exposureLead exposure is still a threat

Hyperactivity and “Hyper” Behavior

HyperactivityInterferes with social development / academic

behaviorNo evidence that sugar causes hyperactivityDietary changes and alternative therapies do not

solve true hyperactivity Sugar Certain food additives may contribute to hyperactivity

Symptoms tend to improve as child gets olderMisbehaving or “Hyper” Behavior

Use consistency in diet, schedule, sleep, exercise

Food Allergy and Intolerance

Prevalence of true food allergies in children is 3% - 5%Tend to diminish with age

True food allergyImmunologic response to food with the production

of antibodies, histamines, and other defensive agents

Reaction may be immediate or delayedDetecting food allergies

Testing for antibodiesTreatment

Food Allergy and IntoleranceAnaphylactic shock- life-threatening allergic

reactionMost common offending foods- usually a protein

Eggs, milk, soy, peanuts, tree nuts, wheat, fish, and shellfish

Often outgrow allergies to eggs, milk, and soySymptom of impending anaphylactic shock- airway

constrictionEpinephrine injections (adrenalin) as antidote

Food labelingEight most common allergy-causing foods required

to be listed, including possible cross-contamination Possible new technological solutions

Food Allergy vs. Intolerance

Food intolerance is not a food allergySigns of adverse reactions to foods

Stomachaches, headaches, rapid pulse rate, nausea, wheezing, hives, bronchial irritation, coughs, and other discomforts are.

Presence of symptoms but no antibody production

Causes of adverse reactions to foods Digestive enzyme deficiency Lactose intolerance: insufficient lactase to cleave

lactose into glucose and galactose

Childhood Obesity

Number of overweight children has dramatically increased per CDC Growth ChartsOverweight defined

Above 85th percentileObesity defined

Above 95th percentileSevere obesity defined

Above 99th percentile

Fig. 16-10, p. 550

1 year: 800 kcalories.6 years: 1,600 kcalories.10 years: 2,000 kcalories

Needs vary widely because of growth and physical activity.

Childhood ObesityOverweight children have higher potential of

becoming obese adultsRamifications

Genetic and environmental factorsParental obesity, role modeling > geneticsDiet and learned food behaviorsPhysical inactivity- TV, gaming, texting, computerConvenience foods and meals eaten away from

homeAvailability of refined sugars, starches- popular

snacks

Childhood ObesityGrowth

Characteristic set of physical traits Begin puberty earlier Stop growing at a shorter height than peers Greater bone and muscle mass, stockier

Physical healthAbnormal blood lipid profileIncreased risk for Type 2 diabetes,

hypertension and respiratory diseases Earlier age of onset for DM, Htn, CHF

Childhood Obesity

Psychological developmentEmotional and social problems

Stereotyped by peers and others DiscriminationPoor self-imagePassive approach to lifeLess participation in sports and other

exercise

Childhood Obesity

Integrated approach with diet, physical activity, psychological support, and behavioral changes

Prevention and treatment of obesityPrevention before adolescence is keyTreatment must consider many aspects of the

problemImprove long-term physical health through

permanent healthy lifestyle habitsSuccessful approaches are multi-dimensional

Prevention and Treatment of Childhood Obesity

Reduce rate of weight gain; weight loss is usually not recommended for growing children

Limit sugar-sweetened beverages. Eat fruits and vegetables every day. Eat age-appropriate portions of food. Eat foods low in energy density. Eat a nutritious breakfast. Eat a diet high in calcium.

Prevention and Treatment of Childhood Obesity

Eat a diet balanced in carbohydrate, fat, and protein.

Eat a high-fiber diet.Eat together as a family.Limit the frequency of eating out.Limit television watching.

Physical activityEngage in at least 60 minutes of activity per day.

Limit sedentary activities At least one hour of daily physical activity Parental example

Physical Activity Pyramid for Kids

Childhood ObesityPsychological support

Parental and caregiver involvement Parental attitudes about food

Behavioral changesFocus on how to eat, not what to eatLearn to ignore junk food advertising

DrugsSibutramine and orlistat a0pproved for

children & adolescent sBariatric surgery

Food Skills ofPreschool Children

Mealtimes at Home Choking prevention

Adult should be present when child is eatingGet playing done first

More attentive during meal timesSnacking

Limit access to concentrated sweets, including juice

No snacking within 1-2 hrs of meal Preference for sweets and salty, fatty food is innate

(chicken nuggets, nachos, tater tots/french fries, ice cream, cake, juice) but not necessarily healthy

Old School unpopular but still Safe and Effective

“As long as your feet are under my table, you will eat what is set before you.”

“There are children starving in India. Now be grateful that you even have food.”

“You’re not getting up from the table until your plate is clean.”

Parent doesn’t have to be a short-order cook. The whole family eats the same meal.

Fussy eating is nipped in the bud, so child’s taste buds can learn to appreciate a wide variety of flavors.

Teach children to cook. It’s a basic life skill.

Let them control the amount of seasoning.

Following a recipedevelops a part ofthe brain that can read and follow instructions.

Mealtimes at Home Preventing dental caries

Behaviors to encourage Brush and floss after meals Brush or rinse after eating snacks Avoid sticky foods? What about dried fruit? Select crisp or fibrous food frequently

Role modelsEat right yourself. Grocery shop without the kids whenever possible.If they want a food advertised on TV, buy the

smallest box or bag and use the food as a special treat or reward.

Nutrition at SchoolMeals at school

Administered by USDA School Breakfast Program National School Lunch Program 1/3 RDA for energy, protein, vitamin A, vitamin C, iron,

and calcium. Dietary Guidelines for Americans

Educational benefits Glucose to the brain Hunger is a distraction

Nutrition at SchoolCompeting influences at school

Short lunch periods and long waiting linesEmbarrassment over eligibility for free lunchSnack bars, school stores, and vending

machinesAthletic fundraisers vs state laws and school

policies.Federal legislation

Wellness policiesChild and Adult Care Food Program (CACFP)

Nutrition during AdolescenceGrowth and development

Adolescent growth spurt Growth patterns of males (12-13 yrs) vs. females (10-11 yrs) Height changes- + 8in. for males, + 6” for females Weight changes- more fat for females, more LBM for males

Energy and nutrient needsNeeds are greatNeeds vary greatly

Factors influencing energy needs Girls vs. boys

Obesity during adolescence

Nutrition during AdolescenceEnergy and nutrient needs- Vitamin D, Fe, Ca

Vitamins RDAs or AIs for most vitamins increase Need as much Vitamin D as an adult

Iron Boys for LBM Girls for menstruation Growth spurt for both

Calcium Peak bone mass building is NOW.

Nutrition during Adolescence

Food choices and health habitsIrregular eating scheduleBenefits of eating meals with familySkipping breakfastFast foodParental gatekeepers

Controlling type and availability of food at homeSnacks

1/4th of average teenager’s daily food intake Tend to be high in sugars, saturated fat, sodium, low

in fiber

Nutrition during AdolescenceFood choices and health habits

Beverages Soft drink consumption and milk displacement Choice affects bone density at a critical period

Eating away from home comprises 1/3 of adolescent meals If lunch was heavy, dinner can be lighter

Peer influence Choices often reflect opinions and actions of peers Milk as “babyish” Socializing in the quad instead of eating lunch

Nutrition during AdolescenceFood choices and health habits

Drug abuse destroys nutrients in the body, Alcohol abuseSmoking

Down to <30% for cigarette in past month Influences hunger, body weight, and nutrient status Smokers tend to eat less fruits/vegetables

Smokeless tobacco Health problems Other drawbacks

Childhood Obesity and the Early Development of Chronic Diseases

IntroductionAdult heart disease has become a major pediatric problem

U.S. children diagnosed with obesity and serious “adult diseases”Development of type 2 diabetes Risk is 30-40%Risk of kidney disease and short lifespan also

increasesRole of genetics

A “permissive” role (a potential) rather than a “determining” role (a fate)

Early Development of Type 2 Diabetes

Obesity is the most important risk factorType 2 diabetes is most likely to occur if

ObeseSedentaryFamily history of diabetes → resignation to and expectation of diabetes → continue family’s

eating behaviors

Early Development of Type 2 Diabetes

Physiological changesCells become insulin-resistant

Reducing amount of glucose entering cellsCluster of symptoms develops from insulin-

resistance Hypertension, dislipidemia Promotes early development of cardiovascular

disease (CVD)

Prevention and treatmentDepends on weight management of the child

Early Development of Heart Disease

Symptoms of heart disease rarely appear before age 30Disease begins much earlier

Atherosclerosis1)Development of fatty streaks on arterial walls before age

10

2)Progressive thickening with fatty plaque on arterial walls, strengthened by fibrous tissue during teens

3)Calcification of fibrous plaques in early adulthood

4)Heart disease rate rises at 45 yrs for men and 55 yrs for women May eventually block flow of blood to heart

Is not inevitable; early lesions can progress or regress

1 The coronary arteries deliver oxygen and nutrients to the heart muscle.

Plaque

1

2

2 Plaques can begin to form in a person as young as 15.

A healthy artery provides an open passage for the flow of blood.

33 When these

arteries become blocked by plaque, the part of the muscle that they feed will die.

Plaques form along the artery’s inner wall, reducing blood flow. Clots can form, aggravating the problem.

Early Development of Heart Disease

Blood cholesterolDifferences begin to emerge in childhoodTends to rise with increase in dietary saturated

fat and trans fat intakesObesity

LDL increases; HDL decreasesSelective screening of children and adolescents

who are overweight or obese or have family history of middle-age heart disease

Early Development of Heart Disease

Blood PressureHypertension accelerates development of

atherosclerosisConsiderations for children before diagnosis

Age, gender, and heightMay develop in first decades of life

Regular aerobic activity Lose weight Restrict sodium

Physical Activity

Association between blood lipids and physical activity, same as adults

Physical inactivity in youth often leads to physical inactivity in later years

Obesity and cholesterol statistically correlate with amount of TV time

Dietary Recommendations for Children

Eat a variety of foods and maintain a desirable weight

Limiting fat and cholesterolNot for infants or children under 2

Moderation, not deprivationBalance meals- lean animal protein,

fruits/vegetables, whole grainsAvoid extremes

Diet first, Htn drugs and statins later if indicated

Why is it “adult” to smoke?

SmokingMany children light up for the first time in

grade school80% of adult smokers began before age 18

Death from smoking-related causes to 50% of those teens who continue smokingImmediate health consequences of

smokingShortness of breathBad breath

If smoking is “adult”, why do most adult smokers want to quit?