nni nursesmodule

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2014, Nestl Nutrition Institute.

Disclaimer:All rights reserved. No part of the publication may be translated into any other language, reproduced orutilized in any form or by any means, electronic or mechanical including photocopying, recording, micro copying, or by

any information storage and retrieval system, without written permission from Nestl Nutrition Institute, India.

Great care has been taken to maintain the accuracy of the information contained in this booklet. However, Nestl

Nutrition Institute, the authors and their assistants or agents cannot be responsible for any errors, omissions or

inaccuracies in this publication whether arising from negligence or otherwise, however or for any consequences arising

from the use of the information contained herein.

Information for healthcare professionals only


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Preface

Section 1: Nursing PracticesTackling Errors in Hospital Setting .........................................................................................................................................................................................................................1Types of Errors ..........................................................................................................................................................................................................................................................................1Human Factors that Increase Error Rates .........................................................................................................................................................................................................1Factors that Help Identify Errors...............................................................................................................................................................................................................................1Prevention of Errors .............................................................................................................................................................................................................................................................2Infections in Hospital Setting ......................................................................................................................................... 4Sites of Infection in ICU ..................................................................................................................................................................................................................................................4Pathogens Commonly Encountered in ICU ...................................................................................................................................................................................................4

Links in Chain of Transmission of Infections ................................................................................................................................................................................................5Breaking the Chain of Infection: Routine Infection Control Practices ..................................................................................................................................6References ..................................................................................................................................................................... 9

Section 2: Maternal NutritionNutrition during Pregnancy and Lactation ..................................................................................................................... 10Energy Requirement during Pregnancy and Lactation ........................................................................................................................................................................10Micronutrient Requirements during Pregnancy and Lactation ....................................................................................................................................................10Other Important Micronutrients...............................................................................................................................................................................................................................13References ..................................................................................................................................................................... 13

Section 3: Pediatric Nutrition

Nutritional Requirements............................................................................................................................................... 14Carbohydrates...........................................................................................................................................................................................................................................................................14Proteins ...........................................................................................................................................................................................................................................................................................14Lipids ................................................................................................................................................................................................................................................................................................15Vitamins .........................................................................................................................................................................................................................................................................................16Minerals .........................................................................................................................................................................................................................................................................................19Feeding Infants and Young Children ............................................................................................................................... 20Breastfeeding .............................................................................................................................................................................................................................................................................20Complementary Feeding.................................................................................................................................................................................................................................................22References ..................................................................................................................................................................... 23

Section 4: Adult NutritionNutrition........................................................................................................................................................................ 24Nutrients and Their Functions ....................................................................................................................................................................................................................................24Macronutrients versus Micronutrients ................................................................................................................................................................................................................24Food Energy ................................................................................................................................................................................................................................................................................24Proteins, Carbohydrates and Fats ................................................................................................................................... 26Proteins ...........................................................................................................................................................................................................................................................................................26Carbohydrate .............................................................................................................................................................................................................................................................................28Fats ......................................................................................................................................................................................................................................................................................................29Vitamins and Minerals .................................................................................................................................................. 29Vitamins .........................................................................................................................................................................................................................................................................................29Minerals .........................................................................................................................................................................................................................................................................................31References ..................................................................................................................................................................... 33

Contents


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The Nestl Nutrition Institute (NNI) fosters Science for Better Nutrition. It was created to provide healthcare

professionals with up-to-date information on nutrition and nutrition-related disorders in order to enable them

to continuously improve patient care based on the latest medical and scientific breakthroughs.

At Nestl Nutrition Institute (NNI), we are working with a focused goal of enhancing the nutrition knowledge

of the healthcare community. Our global vision to empower the healthcare community with the latest

scientific knowledge in an unbiased manner finds resonance in South Asia where we have been a positive

enabler for spreading science based nutritional messages.

This pre-read module is intended as a guide for nurses taking part in the NNI National Nurses Quiz 2014. This

module covers various aspects of nursing practices mainly the medical errors in hospital setting and the role

of a nurse in preventing these errors. It also contains information about nutrition across different stages of lifecategorized into maternal, pediatric and adult nutrition. The focus of this module is to provide a summary of

the topics that will be a part of the quiz competition.

We firmly believe that the pre-read module will further strengthen the commitment of Nestl Nutrition Institute

towards nutritional education of the nursing fraternity in the South Asia Region.

Dr. Sanjeev GangulyHead Medical & Scientific Affairs,

Nestl Nutrition Institute South Asia.

Preface


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SECTION 1

Nursing Practices

Tackling Errors in Hospital Setting

Medical errors can be responsible for patient suffering, loss of life and considerable healthcare costs. In this section, types

of errors that occur in a hospital setting, role of a nurse and their prevention will be discussed.

Types of Errors

A medical error can be defined as a mistake, inadvertent

occurrence, or unintended event in healthcare delivery, which

may, or may not, result in patient injury.1

Human Factors that Increase Error Rates

Several human factors increase error rates. These include: fatigue,2

emotional state,2

illness,2

unfamiliar situations or problems,2

inadequate labeling or instructions on medications,2poor ICU

working system,3high staff workload,3low nurse-to-patient staffing

ratio,4communication gaps between physicians and nurses,2and hard-to-read handwriting.2

Poor ICU work system can be caused by ineffective communication between staff, equipment problems, etc. 3Decreasing

nurse-to-patient staffing ratios may be associated with an increased risk of medical errors. Nurse-to-patient ratios of 1:1

or 1:2 appear to be the safest in the ICU4and nurses with a heavy workload may not have sufficient time to perform tasks

safely, or apply safe practices, or monitor patients. Owing to heavy workload, the nurses fail to double check medications

and may have decreased communication with physicians and other healthcare providers. Risks of errors (slips and lapses

or mistakes) are higher in such situations. Furthermore, those with heavy workload can have difficulty in following the

rules and guidelines thus compromising quality and safety of patients.

5

Factors that Help Identify Errors

In order to identify errors, healthcare providers use the following strategies:

Knowing all aspects of the patient (medical and medication history).6

Knowing and reviewing the plan of care. For example, reviewing the plan at the change of shift or during

rounds can help nurses find errors in the current plan.6

Surveillance of the patient and his or her environment.6

Types of Errors

Different types of errors that can be

encountered in a hospital setting are:

Medication errors

Mechanical errors

Surgical errors

Other errors

Infections


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Knowing policies/procedures of the particular unit.6

Double-checking physicians orders/interventions with other nurses.6

Use of systematic processes such as multidisciplinary rounds, use of structured report forms, 24-hour chart

checks, medication reconciliation, and bedside checks at change of shifts.6

Prevention of Errors

Prevention of Medication Errors

Medication error is any preventable event that may cause or lead to inappropriate medication use that may harm a

patient.7

Types of Medication Errors

Based on the stage of their occurrence in the medication use cycle, medication errors may be classified as: Prescribing

errors, dispensing errors, or administration errors. Prescribing errors may occur due to lack of knowledge about the

prescribed drug, its recommended dose, lack of patient details, poor handwriting, improper medication history, confusion

with the drug or generic name, use of abbreviations, inappropriate use of decimal points, use of verbal orders, etc.

Dispensing errors may occur due to selection of the wrong product (especially with drugs having similar names), wrong

dose, wrong patient, etc. Administration errors may occur due to incorrect administration technique or the administration

of incorrect or expired preparations.8

Preventing Medication Errors

When medication orders are given verbally or over the telephone, nurses should read back and verify all medication

orders. Following a few simple strategies during this process prevents medication errors. These include:9

Having the patients chart available and writing down the order while on the phone.

Verifying the patients name.

Reading back and confirming the medication and its dosage by stating each number individually.

Asking the prescriber to spell the drug name in case of unfamiliar medications.

Verifying with the prescriber for what condition that the medication is being used to treat. (For example,

Actosis is used for treating diabetes mellitus, whereas the similar-sounding whereas Actonel is used for

treating osteoporosis).

Steps to Reduce Medication Errors (6 RIGHTS)

Nurses administering medication should always observe the following six rights to reduce medication errors: Right

person to the Right patient, Right drug, Right dose, Right route and Right time.2Additional RIGHTS that have been

proposed recently include Right reason for the drug, Right documentation, Right to refuse medication, and Right

evaluation and monitoring.9

Section 1:Nursing Practices


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Preventing Mechanical Errors (Tubing Misconnections)

Mechanical errors such as tubing misconnections are potentially serious occurrence and can have life-threatening

consequences. They can be prevented by employing the following steps:2

Training nonclinical staff and visitors not to reconnect lines but to seek clinical assistance

Avoiding modification or adaptation of I.V. or feeding devices

Rechecking connections and tracing all tubes on arriving at a new setting or as part of a hand-off process

Routing tubes and catheters that have different purposes in unique and standardized directions

Packing together all parts needed for enteral feeding and reducing the availability of additional adapters and

connectors

Labeling or color-coding feeding tubes/connectors and educating other staff about the labeling

Identifying and minimizing conditions that may cause healthcare worker fatigue

Preventing Surgical Errors

Surgical errors can be attributed to failure in communication, lack of competence, experience, excessive workload,

errors in judgment, lack of supervision etc. They can be prevented by checking for retained foreign objects and preventing

surgery at the wrong site. Nurses should count the number of sponges, sharps, and instruments before surgery, before

wound closure, and at skin closure. Surgery at the wrong site can be prevented by10

Preoperative patient identification

Site verification

Marking the operative site

Time-out by the surgical team immediately prior to incision

Improving Communication (SBAR Tool)

Communication plays a crucial role in preventing errors in a hospital setting. The situation, background, assessment,and recommendation (SBAR) tool is a useful communication tool that aids in the hand-offs between shifts and between

caregivers.2

SituationWhats happening right now?2

BackgroundWhat are the circumstances that led up to this situation?2

AssessmentWhat do I think about the problem is with this patient?2

RecommendationWhat should be done to correct the situation?2



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Steps to Prevent Nosocomial Infections10

Nosocomial infection or hospital-acquired infection is an infection that was not present at the time of admission but is

contracted while the patient is hospitalized. Nosocomial infections lead to deaths, substantial financial burden and use of

resources for extended care. Some of the important nosocomial infections and steps to prevent them have been given as

follows:

Prevention ofcatheter-associated

urinary tractinfections

Prevention ofsurgical site

infections

Prevention ofventilator-associated

pneumonia

Prevention of centralline-associated

blood-stream infections

Washing hands

before catheter

insertion

Loosely positioning

the catheter to

prevent compression

by the patients legs

Avoiding

unnecessary

catheterizations

Timely removal ofcatheters

Preoperative hair

removal

Adequate

glycemic control

Hand and

forearm

preparation

Antimicrobial

prophylaxis

Use of noninvasive ventilation

when possible

Semi-recumbent positioning

Proper hand hygiene

Subglottal suctioning

Oral decontamination

Use of antimicrobial-coated

endotracheal tubes

Proper antibiotic use

Maintaining proper

hand hygiene while

placing or maintaining

central lines

Use of sterile

precautions and skin

preparation

Coagulase-negative staphylococci Pseudomonas aeruginosa Enterobacterspp. Escherichia coli

Staphylococcus aureus Klebsiella pneumoniae Enterococci spp. Candida albicans

Infections in Hospital Setting

Sites of Infection in ICU

According to the European Prevalence of Infection in Intensive Care (EPIC) Study, which included 10,038 patients from

1,147 European ICUs, the most common sites of infection in the ICU were lungs (pneumonia, 46.9%); other respiratory

tract (17.8%); urinary tract (17.6%); and bloodstream (12%).11

Pathogens Commonly Encountered in ICU

The eight most common pathogens associated with nosocomial infections among ICU patients are:11



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Links in Chain of Transmission of Infections

The chain of infection transmission is a model that describes the components required for transmission of organisms.

The links in this chain of transmission are as follows:11

Infectiousagent

Microorganism capable of colonizing individuals or causing disease. This may include viruses,bacteria, fungi and moulds, or parasites.

Reservoir Place where an infectious agent lives and reproduces so that it can be transmitted. It can be aperson, animal, insect, plant, soil, water, or a combination of these.

Portal of entry

Portal of exit

Path by which an infectious agent enters or exits a susceptible host.

For example, blood, respiratory tract, gastrointestinal tract, genitourinary tract, skin and mucusmembranes, placenta

Susceptible

host

Individual who is lacking an effective resistance to a particular agent.

For example, persons with reduced immunity, very young and the elderly, non-immunizedpeople, cancer patients, diabetics, people on certain drugs, those with underlying medicalconditions that may affect their immune system

Mode oftransmission

Mechanism by which an infectious agent is transferred from its reservoir to a susceptible host.The different modes of transmission are:

Contact Transmission

Direct contact: Occurs when there is a direct contact between an infected or colonizedindividual and a susceptible host. Transmission may occur, depending upon the type ofinfectious agent, through biting, touching, or sexual activity.

Indirect contact: Occurs when there is passive transfer of an infectious agent to a susceptiblehost through a contaminated intermediate object (contaminated hands or patient careequipments).

Droplet Transmission

This refers to large droplets (5 m) from the respiratory tract of the patient when he or shecoughs or sneezes or during intubation or suctioning being propelled and deposited on themucus membranes of the susceptible host.

Air-Borne Transmission

This refers to spread of infectious agents through the airborne route. Diseases transmitted via thisroute include varicella (chicken pox), measles (rubella) and tuberculosis.

Common Vehicle Transmission

This refers to spread of agents by a single contaminated source to multiple hosts and can resultin explosive outbreaks. Examples: contaminated food (Salmonella), water sources (E. coli),contaminated medication and intravenous fluids or equipment.

Vector-Borne Transmission

This refers to spread of agents by means of an infected insect or animal (vector).

For example, West Nile virus is transmitted by mosquitoes and rabies by an infected animal.



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Breaking the Chain of Infection: Routine Infection Control Practices

Routine infection control practices are vital to break the chain of infections, and must include:12

Adequate assessment of patient to identify any risks or symptoms of communicable diseases

Adequate hand hygiene

Use of personal protective equipment (PPE)

Routine cleaning, disinfecting and sterilization of equipment

Ensuring adequate infection control during patient accommodation and transport

Hand Hygiene

Following good hand hygiene prevents the chain of transmission and reduces transient flora on the hand thereby reducing

the risk of nosocomial infections.12

Proper Handwashing Techniques

Adequate hand hygiene includes handwashing using an alcohol-based hand rub or soap and water.12

Alcohol-based hand rub Soap and water

Should contain 6090% alcohol (isopropanol or ethanol)

Work by denaturing proteins and killing microorganisms present on the skin

More effective in reducing bacterial counts on hands than soap- or

detergent-based antimicrobial substances

Should not be used when hands are visibly soiled

Effective option to remove

microorganisms from the

hands

Suspends easily removable

organisms from the skin

During handwashing:12

Remove all hand and wrist jewelry

Use warm water and adequate

amounts of hand rub or soap

Rub hands vigorously to create

friction

Wash for at least 15 seconds,

including all parts of the hands and

wrists

Best practices for performing hand hygiene include:12

At the beginning and end of shift

Before and after patient contact, handling food, smoking

During and after PPE removal

Before invasive procedures

After cleaning/disinfecting equipment and the vehicle

Before leaving the emergency department, after using the

bathroom or other personal body functions (sneezing, coughing)

Whenever the hands are visibly soiled



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Eyewear/Mask Gloves Caps, boots,

shoe covers

Gowns and

plastic aprons

While conducting

procedures that may

generate splashes of blood,

body fluids, secretions, or

excretions

When touching

blood, body fluids,

secretions, excretions

or mucus membranes

When the patients blood,

body fluids, secretions or

excretions may splash,

spill or leak onto the hair

or shoes

During procedures that can

possibly cause splashing

of blood, body fluids

secretions, or excretions

Personal Protective Equipment

These equipments protect staff from contamination with body fluids and reduce the risk of transmission of infection

between patients and staff and from one patient to another. The various personal protective equipments (PPEs) include:

eye wear, gloves, mask, cap, gowns, plastic aprons, boots and shoe covers.12

Principles to Use PPE

The principles to be followed while using PPE are:12

Select PPE based on the risk of exposure to the healthcare worker

Avoid any contact between contaminated PPE and surfaces, clothing or individual outside the patient care

area

Discard used PPE in proper disposal bags, while abiding with hospital safety regulations

Do not share PPE

Each time a patient is attended, PPE should be completely changed and stringent hand hygiene should be

maintained

Disposable PPEs should not be reused. They should be disposed according to the healthcare facility protocol.

Indications for the Use of PPE12



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Donning of PPE

Always don the PPE before coming in contact with patients. The sequence for donning PPE is as follows: perform hand

hygiene, wear gown (if applicable), wear mask, eyewear, and gloves (if applicable).12

Gown12 Mask12 Eyewear12 Gloves12

Fully cover torso from

neck to knees, arms to

end of wrists, and wrap

around the back.

Secure at neck and

waist.

If gown is too small, use

two gowns: the first ties

in front, the second ties

in back

Secure on head

with ear loops

Place over nose,

mouth and chin

Fit flexible nose

piece over bridge

Adjust fit-snug to

face and below

chin

Position eyewear over

eyes and secure to

head using ear pieces

Don gloves last

Insert hands into gloves

Extend gloves over gown

cuffs (if wearing gown)

Removal of PPE

All items must be removed and discarded carefully. Perform hand hygiene after gloves/gown removal before removing

masks and eyewear. The sequence of removal is as follows: remove gloves and gown, perform hand hygiene, remove eye

wear and mask, and again perform hand hygiene.12

Sharps Safety

Handling of sharps poses risk of occupational exposure to blood-borne infectious agents. Safe handling of sharps

includes12

Ensuring immediate and proper disposal of sharps

Avoiding recapping of needles

Disposing sharps containers in proper biohazard container when the full line is reached

Avoiding leaving behind of sharps to be disposed by other personnel

Avoiding uncapped sharps in pockets, passing exposed sharps from person to person, and bending or

breaking a needle

Using needleless systems, safety intravenous catheters, and needles where possible

Hospital Waste Management

Hospital waste is a potential reservoir of pathogenic microorganisms. The various steps in the management of hospital

waste are: generation, segregation/separation, collection, transportation, storage, treatment, and final disposal.12



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Methods of Disposal13

Sharps

Autoclave, shred and land-fill or microwave, shred and land-fill, or treat by plasma pyrolysis (a method

used dispose medical wastes safely) of puncture-proof containers storing discarded sharps

Deep burial in a secure area. Burial should be 23 meters deep and at least 1.5 meters above the

groundwater table.

Anatomical parts and animal carcasses, cytotoxic drugs and toxic laboratory chemicals other than mercury

require incineration.

Patient-contaminated non-plastics and non-chlorinated plastics may require incineration.

Radioactive waste: Adhere to national laws.

References

1. Rosenbloom M, Ramsde EC. Personal digital assistants and the reduction of medical error.Harvard Health Policy Review. 2004;5:3846.

2. Evans N. Prevention of Medical Errors. 2011 Wild Iris Medical Education, Inc. Available at: http://www.nursingceu.com/courses/380/index_ot.html.Accessed on: 22 May 2013.

3. Gurses P. Impact of Performance Obstacles on Intensive Care Nurses Workload, Perceived Quality and Safety of Care, and Quality of WorkingLife. Health Services Research. 44:2, Part I (April 2009).

4. Moyen E, Camir E, Stelfox HT. Clinical review: Medication errors in critical care. Critical Care. 2008;12:208.

5. Carayon P, Gurses AP. Nursing Workload and Patient SafetyA Human Factors Engineering Perspective patient Safety and Quality:An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.

6. Henneman EA, Gawlinski A, Blank FS. Strategies used by critical care nurses to identify, interrupt, and correct medical errors.Am J Critical Care.2010;19:500509.

7. Hughes R, Blegen M Medication administration safety. Hughes R Patient Safety and Quality An Evidence-based Handbook for Nurses. Rockville,MD Agency for Healthcare Research and Quality 2008.

8. DJP Williams. Medication errors.J R Coll Physicians Edinb. 2007;37:343346.

9. Anderson P, Townsend T. Medication errors: Dont let them happen to you.American Nurse Today. 2010;1:2328.

10. Pham JC, Aswani M, Rosen M, et al. Reducing medical errors and adverse events.Annu Rev Med. 2012;63:447463.

11. Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalenceof Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee.JAMA. 1995 Aug 2330;274(8):639644.

12. Bates M. Infection Prevention and Control Best Practices Manual for Land Ambulance Paramedics. In: Emergency Health Services Branch Ministryof Health and Long-Term Care. Ontorio. 2007, pp.154.

13. World Health Organization. Practical Guidelines for Infection Control in Health Care Facilities.[Internet][cited 2014 Feb 17]. Available at: http://www.searo.who.int/LinkFiles/Publications_PracticalguidelinSEAROpub-41.pdf.



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SECTION 2

Maternal Nutrition

Nutrition during Pregnancy and Lactation

A womans body undergoes several physiologic changes during pregnancy, which result in increased plasma volume and

red blood cells and a decreased concentration of circulating nutrient-binding proteins and micronutrients. Undernutrition

can aggravate these physiologic changes leading to deficiency states such as anemia, which can be life-threatening forboth the mother and the newborn.1In developing countries, maternal undernutrition affects a large proportion of women,

but has not received adequate attention. Maternal undernutrition is an important determinant of poor maternal, newborn,

and child health outcomes such as intrauterine growth restriction, preterm birth, and maternal and infant morbidity and

mortality.2

Energy Requirement during Pregnancy and Lactation

The energy requirement during pregnancy in these women is calculated based on the assumption of gestational weight

gain during pregnancy (normally 12 kg) and optimal pregnancy outcome. During lactation, energy is spent in two ways:

Energy in the secreted milk, and energy spent in secreting milk. Additional energy requirements during pregnancy and

lactation have been mentioned in Table 1.3,4

Table 1: Additional energy requirements during pregnancy and lactation

DGI3 ICMR4

Pregnant +350 Kcal/day +300 Kcal/day

Lactating (06 months) +600 Kcal/day +600 Kcal/day

Lactating (612 months) +520 Kcal/day +520 Kcal/day

DGI: Dietary Guidelines for Indians; ICMR: Indian Council of Medical Research

Micronutrient Requirements during Pregnancy and Lactation

Table 2 lists the RDA of different micronutrients for pregnant and lactating women, their sources and deficiency

outcomes.


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Table 2: Nutrient requirements during pregnancy and lactation

Nutrient Deficiency

outcomes

RDA3 Sources3,5

Pregnant

women

Lactating women

(06 months)

Lactating women

(612 months)

Protein Malnutrition 82.2g/day 77.9 g/day 70.2 g/day Pulses, milk, eggs

Visible fat Malnutrition 30 g/day 30 g/day 30 g/day Cooking oils,

ghee, whole milk

Iron Anemia 35 mg/day 25 mg/day 25 mg/day Amaranth leaves,Bengal gram and

radish leaves

Calcium Bone problems 1200 mg/day 1200 mg/day 1200 mg/day Bengalgram,

rajmah, almonds,

gingelly

Iodine Goiter, still births,

abortions,

cretinism

RDA not mentioned Iodized common

salt, seafood,

water

Magnesium Neuromusculardysfunction5

310 mg/day 310 mg/day 310 mg/day Green leafyvegetables such

as spinach, whole

grains, legumes,

nuts, seeds5

Zinc Growth retardation,

loss of appetite,

impaired

cell-mediated

immunity, hair loss5

12 mg/day 12 mg/day 12 mg/day Oysters, meat,

pulses, nuts, outer

layer of grains,

milk and milk

products5

Vitamin A Rickets, night

blindnessRetinol:800 g/day

-carotene:6400 g/day

Retinol:950 g/day


Retinol:950 g/day


Spinach, fenugreek

leaves, carrot

Thiamin Glossitis, angular

stomatitis

1.3 mg/day 1.4 mg/day 1.3 mg/day Whole cereals,

pulses nuts, eggs5

contd...

Section 2:Maternal Nutrition


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Riboflavin Glossitis,

cheilosis51.6 mg/day 1.7 mg/day 1.6 mg/day Fenugreek leaves,

spinach, gingelly

seeds, almonds,

walnuts

Niacin Pellagra5 16 mg/day 18 mg/day 17 mg/day Milk and milkproducts, whole

cereals and pulses,

nuts, prawn, lean

meat5

Pyridoxine Anemia, cheilosis,

glossitis52.5 mg/day 2.5 mg/day 2.5 mg/day Wheat, pulses,

nuts, chicken,

meat, fish5

Folate Anemia,

weight loss5500 g/day 300 g/day 300 g/day Spinach,

bengalgram,

greengram,

gingelly

Vitamin B12

Pernicious

anemia51.2 g/day 1.5 g/day 1.5 g/day Liver, fish,

mutton, beef,

eggs, milk and

milk products5

Ascorbic

acid

Scurvy, fatigue,

inflammation of

gums, red/blue

spots, bone, jointand muscle pain5

60 mg/day 80 mg/day 80 mg/day Capsicum, amla,

guava

Vitamin D Osteomalacia RDA not mentioned Sunlight exposure

Table 2: Continued...

Nutrient Deficiency

outcomes

RDA3 Sources3,5

Pregnant

women

Lactating women

(06 months)

Lactating women

(612 months)



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Other Important Micronutrients

Essential Fatty Acids

The fatty acids are collectively known as essential polyunsaturated fatty acids (PUFAs) and comprise the parent essential

fatty acids (EFAs) and their longer-chain, more unsaturated derivatives known as the long-chain polyenes (LCPs). Essential

fatty acids and LCPs are important elements of cell membranes and thus an essential component for the formation of new

tissues that occurs during pregnancy and fetal development. Essential fatty acids have to be consumed in diet as they are

not synthesized in humans. Pregnancy is associated with a reduction in the functional status of PUFA, particularly that of

DHA. After delivery, it tends to normalize but recovery of the functional (DHA) status is still incomplete even after

6 months.6

DHA

Since DHA cannot be synthesized in body, it must be obtained from diet. DHA ensures integrity of the brain and vision

development during second trimester, third trimester and lactation. Low DHA levels lower brain growth factors. For

supplementation, 300 mg/day dose of DHA is recommended. Dietary sources of DHA include fish oils and shell fish.5

Probiotics

Research suggests that the gut microbiota plays a vital role in the microbial, metabolic and immunological programming

of the child. Any disturbance in the compositional development of the gut microbiota may increase the risk of obesity and

allergies. Modification of the gut microbiota with probiotics early in life has gained scientific significance in the recentpast. Probiotics are found to be associated with immune regulation, improved function of the gut barrier and reduced risk

of intestinal infections and allergic diseases.7Studies suggest that perinatal probiotics may have positive effects on blood

glucose control, reducing the risk of genital infection, reduction in respiratory infections and reduction in gastrointestinal

symptoms in infants.8

References

1. Ladipo OA. Nutrition in pregnancy: Mineral and vitamin supplements. 2000;72(suppl):280S290S.

2. Ramakrishnan U, Imhoff-Kunsch B, Martorell R. Maternal nutrition interventions to improve maternal, newborn, and child health outcomes. NestleNutr Inst Workshop Ser. 2014;78:7180.

3. Dietary Guidelines for Indians. Available at: http://ninindia.org/DietaryguidelinesforIndians-Finaldraft.pdf.

4. A Report of the Expert Group of the Indian Council of Medical Research 2009. Dietary guidelines. Available at: http://icmr.nic.in/final/RDA-2010.pdf.

5. Shrilakshmi B. Nutrition Science. New Age International Publisher, Fourth Revised Edition-2012.

6. Hornstra G. Essential fatty acids in mothers and their neonates.Am J Clin Nutr. 2000;71(5):1262s1269s.

7. Luoto R, Laitinen K, Nermes M, et al. Impact of maternal probiotic-supplemented dietary counseling on pregnancy outcome and prenatal andpostnatal growth: A double-blind, placebo-controlled study. Brit J Nutr. 2010;103:17921799.

8. Sanz Y. Gut microbiota and probiotics in maternal and infant health.Am J Clin Nutr. 2001;94(6 Suppl), 2000S2005S.



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SECTION 3

Pediatric Nutrition

Nutritional Requirements

Good nutrition is vital for the growth and development that occur during the first year of an infants life. Consumption of

appropriate quantities and types of foods provides adequate amount of essential nutrients. Several factors influence the

energy or caloric requirements of an infant. They are body size and composition, metabolic rate (the energy the bodyexpends at rest), physical activity, size at birth, age, sex, genetic factors, energy intake, medical conditions, ambient

temperature and growth rate. The birth-weight of healthy infants doubles by 6 months of age, and triples by 12 months of

age.1The essential nutrients, their functions and important sources have been discussed in the following topics.

Carbohydrates

Carbohydrates are classified into monosaccharides (e.g., glucose, galactose, fructose and mannose), disaccharides

(e.g., sucrose, lactose, and maltose), and polysaccharides (e.g., starch, dextrins and glycogen). Indigestible complex

carbohydrates of plant origin are also referred to as dietary fibers. 1

Functions of Carbohydrates in Infants Diet

Functions of carbohydrates in infants diet are as follows:1

They supply food energy for growth, activity, and body functions.

They enable the protein in the diet to be efficiently utilized for building new tissue.

They allow normal use of fats in the body.

They provide building blocks for some essential body compounds.

Sources of Carbohydrates in Infants Diet

Lactose is a major type of carbohydrate normally consumed by young infants. It is present in breast milk and cows milk-

based infant formula. Additional sources of carbohydrates in later infancy include cereal and other grain products, fruits,

and vegetables. Legumes, whole-grain foods, fruits, and vegetables are a good source of dietary fiber. Breast milk does not

contain dietary fiber. Infants generally do not consume fiber in the first 6 months of life.1

Proteins

All proteins, whether in the body or in the food we eat, are made up of individual units known as amino acids. Twenty

amino acids which make up proteins are classified into two basic groupsessential (or indispensable) and non-essential


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(or dispensable). Essential amino acids cannot be synthesized by the body and must be

obtained from the diet.1

Functions of Proteins

They build, maintain, and repair tissues (e.g., tissues of the eyes, skin, muscles,

heart, lungs, and also help manufacture important enzymes, hormones,

antibodies, etc.1

They serve as a potential source of energy, if sufficient energy is not obtained

from carbohydrates or fats in the diet.1

They perform very specialized functions in regulating body processes.1

Sources of Proteins

Breast milk and infant formulas provide sufficient protein to meet a young infants needs if consumed in adequate

amounts. During later infancy, in addition to breast milk and infant formula, sources of protein include meat, poultry, fish,

egg yolks, cheese, yogurt, legumes, and cereals and other grain products.1

Lipids

Lipids include fats, oils and fat-like substances, such as cholesterol. Fatty acids form the major constituents of many lipids.

Fatty acids that cannot be synthesized by the body are referred to as essential fatty acids. For example, linoleic acid and-linolenic acid. The fatty acids arachidonic acid (ARA) and docosahexaenoic acid (DHA) are derived from linoleic acid

and -linolenic acid, respectively. They are referred to as long-chain polyunsaturated fatty acids (LC-PUFAs).1

Functions of Fats

They serve as a major source of energy (approximately 50% of the energy consumed in breast milk and infant

formula).1

They promote accumulation of fat in the body. The stored fat exhibits insulation effects to reduce body heat

loss and also act as a cushion to protect body organs.1

They facilitate the absorption of the fat-soluble vitamins A, D, E, and K.1

They provide essential fatty acids required for normal development of brain, healthy skin, hair and eyes.1

They help resist infections and diseases.1

Sources of Fats

During infancy, breast milk and infant formula are vital sources of lipids, including essential fatty acids. Although the

lipid content of breast milk varies, after about the first 2 weeks postpartum, breast milk provides approximately 50% of

its calories from lipids. Infant formula also provides nearly 50% of its calories from lipids. Breast milk provides about

5.6 g/L of linoleic acid and approximately 0.63 g/L of n-3 polyunsaturated fatty acids (-linolenic acid and DHA).

On the contrary, infant formula provides 3.38.6 g/L of linoleic acid and 00.67 g/L of -linolenic acid and DHA.1

Essential Amino Acids

Isoleucine

Threonine

Leucine

Tryptophan

Lysine

Valine

Methionine

Histidine

Phenylalanine

Section 3:Pediatric Nutrition


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In the older infants diet, food sources of lipids other than breast milk and infant formula are meats, cheese and other

dairy products, egg yolks, and any fats or oils added to home-prepared foods.1

Vitamins

Infants diet should not be supplemented with vitamins or minerals during the first year of life, unless prescribed by a

healthcare provider. Excessive amounts of certain vitamins and minerals can be toxic or even fatal to infants.1

Functions and Sources of Vitamins in Infants Diet

Main functions and sources of water-soluble and fat-soluble vitamins are discussed as follows:

Water-soluble vitamins1

Vitamin Functions Sources

B1

(thiamin)

Helps the body to release energy from

carbohydrates during metabolism and plays

a crucial role in the normal functioning of

the nervous system

Breast milk, infant formula, whole-grain breads,

cereals, and other fortified or enriched grain

products, legumes, and potatoes

B2

(riboflavin)

Helps the body to release energy from

protein, fat, and carbohydrates duringmetabolism

Breast milk, infant formula, dairy products, egg

yolks, green vegetables and whole-grain breads,cereals, and fortified grain products

B12 Proper functioning of the nervous system

and healthy blood cellsMajor sources:Breast milk and infant formulas

Other sources:Complementary foods, such as

meat, egg yolks, and dairy products provide this

vitamin later in infancy as well

Folate Cell division, growth and development

of healthy blood, cells and formation of

genetic material within every cell

Breast milk, infant formula, green leafy vegetables,

oranges, whole-grain breads, cereals, and fortified

or enriched grain products, legumes, egg yolks and

liver

B6

(pyridoxine)

Helps the body to use protein to build

tissues and aids in fat metabolism

Breast milk, infant formula, liver, meat, whole-grain

breads, cereals, and other fortified or enriched grain

products, legumes, and potatoes

Niacin Helps the body to release energy from

protein, fat, and carbohydrates during

metabolism

Breast milk, infant formula, egg yolks, poultry, meat,

fish, and whole-grain breads, cereals, and fortified

or enriched grain products. Niacin can be formed

in the body from tryptophan present in foods (meat,

poultry, cheese, yogurt, fish, and eggs)

contd...



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Manifestations of Vitamin Deficiencies in Infants1

Deficiency of vitamins can give rise to a variety of disorders in infants. Each of the vitamin deficiencies have been

discussed further.

Fat-soluble vitamins1


A Formation and maintenance of healthy skin,

hair, and mucus membranes, proper vision,

growth and development, healthy immune and

reproductive systems

Major sources:Breast milk and infant formula.

Other sources:Egg yolks, yellow and dark

green leafy vegetables and fruits (e.g., spinach,

greens, sweet potatoes, apricots, cantaloupe,

peaches), and liver

D Proper formation of bones, proper utilization of

calcium and phosphorus in the body

Sunlight, fish, liver, egg yolk, and breast milk

(minor amounts)

E Protects vitamin A and essential fatty acids in

the body, prevents the breakdown of tissuesInfants:Breast milk and infant formula

Older infants: Green leafy vegetables,vegetable oils and their products, wheat germ,

whole-grain breads, cereals, and other fortified

or enriched grain products, butter, liver, and

egg yolks

K Helps in blood clotting Infant formula, green leafy vegetables, pork and

liver

Water-soluble vitamins1: Contd...


C Forms collagen (a protein that gives structure

to bones, cartilage, muscle, blood vessels,

and other connective tissue), helps maintain

capillaries, bones, and teeth, heals wounds,

plays a role in the bodys ability to resist

infections, and enhances the absorption of

iron

Major sources:Breast milk and infant formulas.

Additional sources:Vegetables (e.g., tomatoes,

cabbage, potatoes), fruits (e.g., citrus fruits, papaya,

and strawberries), and infant and regular fruit and

vegetable juices naturally high in or fortified with

vitamin C



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Recommended Average Intake of Vitamins in Infants

The recommended dietary intake (RDA) is the average daily dietary intake level sufficient to meet the nutrient

requirements of nearly all (9798%) healthy individuals in a group. It is calculated from an estimated average requirement

(EAR). If sufficient scientific evidence is not available to establish an EAR, and thus calculate an RDA, an adequate intake

Vitamin Deficiency in infants

A Poor growth, damage of varying intensity to the eyes (night blindness), loss of appetite, increased

susceptibility to infections, and skin change

D Inadequate intestinal absorption of calcium and phosphorus resulting in improper bone formation and

tooth mineralization. Rickets (characterized by swollen joints, poor growth, and bow legs or knock

knees) can result from vitamin D deficiency

K Breast milk has low vitamin K levels. Hence, exclusively breastfed infants are at an increased risk of

bleeding including cerebral hemorrhage due to vitamin K deficiency

C Scurvy, characterized by poor bone growth, bleeding, and anemia

B12

Failure to thrive, movement disorders, delayed development, and megaloblastic anemia

(anemia characterized by large red blood cells)

B2

Growth inhibition, skin changes and dermatitis, anemia, and lesions in the mouth

Age 06 months 712 months

Vitamin A 400 g retinol active equivalent/day 500 g retinol active equivalent/day

Vitamin D 10 g/day* 10 g/day*

Vitamin E 4 mg/day 5 mg/day

Vitamin K 2 g/day 2.5 g/day

Vitamin C 40 mg/day 50 mg/day

Vitamin B1

0.2 mg/day 0.3 mg/day

Vitamin B6


Vitamin B2


Folate 65 g/day 80 g/day

Vitamin B12

0.4 g/day 0.5 g/day

Niacin 2 mg/day of preformed niacin 4 mg/day of niacin equivalents

*Recommended dietary intake



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(AI) is usually developed. For healthy breastfed infants, an AI is the mean intake. The average intake of vitamins in infants

is presented in the below Table.2

Minerals1

Some of the important minerals include calcium, iron, zinc, sodium and fluoride. Their functions, source and

recommended RDA/AI are as follows:

Mineral Functions Sources Recommended RDA/AI

Calcium Plays an important role in bone

and tooth development, bloodclotting, and maintenance of

healthy nerves and muscles

Breast milk, infant formula, yogurt,

cheese, fortified or enrichedgrain products, some green leafy

vegetables (turnip greens)

AI for infants

06 months: 210 mg/day712 months: 270 mg/day

Iron Helps in the proper growth

and formation of healthy blood

cells. It is a vital component

of hemoglobin, which carries

oxygen throughout the body;

myoglobin, which stores oxygen;

and many enzymes in the body

Breast milk, infant formula,

whole-grain breads, cereals, and

fortified grain products, dark green

vegetables, legumes

AI for infants06 months: 0.27 mg/day

RDA for Infants712 months: 11 mg/day

Zinc Helps in the formation ofprotein, and thus aids in wound

healing. Required for formation

of blood, general growth and

maintenance of all tissues,

taste perception, and a healthy

immune system

Breast milk and infant formula,meat, egg yolks, and cereals,

legumes, cheese, yogurt

AI for infants06 months: 2 mg/day

RDA for infants712 months: 3 mg/day

Sodium Maintains water balance in the

body, regulates blood volume,

and ensures proper functioning

of cell membranes and other

body tissues

Breast milk contains a relatively

small, but adequate amount of

sodium for growth

Estimated minimumrequirement for infantsis 100200 mg/day

Fluoride Reduces susceptibility of the

teeth to decay

Fluoridated water, infant formulas

prepared with fluoridated water,

some marine fish

AI for infants06 months: 0.01 mg/day

712 months: 0.5 mg/day



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Feeding Infants and Young ChildrenBreastfeeding

Breastfeeding is the most ideal and safest form of nourishment for an infant. Breast milk is the best source of nutrients for

young infants.3

Colostrum, Transitional and Mature Breast Milk

Lactation progresses through three stages: Colostrum, transitional milk, and mature milk.3

Colostrum:It is the first fluid secreted by the mothers breasts postpartum.4 It is yellowish in color with a high protein

and mineral content, low fat and lactose concentrations and provides 67 kcal/dL according to the needs of the newborn

during the first week of life.3Colostrum is rich in immunologic components (secretory IgA, lactoferrin and leukocytes) and

developmental factors (epidermal growth factor). Concentrations of sodium, chloride, and magnesium are higher and the

concentrations of calcium and potassium are lower in colostrum than in the milk produced later. 4Colostrum facilitates

the growth of Lactobacillus bifidusin the gastrointestinal tract of the newborn and the elimination of meconium.3

Transitional milk:The transitional phase of lactation lasts from the seventh day or the tenth day, up to 2 weekspostpartum. The composition of colostrum changes during this stage. The concentration of immunoglobulins and proteins

decreases and the levels of lactose, fat and energy content also increase to maintain the characteristics of mature milk.3

Mature breast milk: Mature breast milk is a homogenous mixture containing three fractions: Emulsion (fat droplets),

suspension (casein micelles) and solution (water-soluble components). Maternal milk contains 88% of water with an

osmolarity similar to that of plasma. Hence, exclusive breastfeeding on demand, without supplementation with water, is

crucial to keep the nursing infant well hydrated.3

Benefits of Breast Milk for the Baby and Mother

Breast milk has anti-infectious, anti-inflammatory, and immunomodulatory properties and offers protection against diverse

pathologies.3

Benefits for the Baby

Protects the infant against gastrointestinal and respiratory infections.3

Reduces the incidence of acute otitis media, urinary tract infection, and meningitis caused by Haemophilus

influenzae.3

Decreases the incidence of allergic diseases in breastfed infants.3

Exerts a beneficial effect on the development of the infants oral cavityLeads to adequate tooth alignment

and rare cases of malocclusion, and reduces the risk of sleep apnea during adulthood.3

Enhances the development of the motherchild bond.3



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Apart from nutrients, breast milk also contains flavors derived from foods, beverages and spices ingested orinhaled by the mother.

Breast milk functions as a bridge between the in uteroexperiences (e.g. flavors in amniotic fluid) and the

solid foods introduced during complementary feeding and beyond.5

Benefits for the Mother

Breastfeeding offers a series of physiological benefits for the mother.3

In the immediate postpartum period, breastfeeding is associated with uterine contractions, which reduce the risk of

postpartum bleeding.

Adequate involution of the uterus accompanied by a decrease in postpartum bleeding protects the maternal

iron reserves, and thus reduces the risk of anemia.

Breastfeeding leads to a rapid weight loss in the mother, particularly during the first month postpartum.

Breastfeeding confers protection against breast cancer.

Breastfeeding exerts a contraceptive effect, with a consequent increase in the interval between gestations.

Repeated and closely spaced pregnancies are a major cause of maternal morbidity and mortality in

developing countries.

Protective Factors in Breast Milk

Breast milk exerts several non-nutrient beneficial effects.6

Leukocytes are present in high numbers in breast milk and are found to exert activity in the gastrointestinal

tract of the infant and induce a local and systemic immune response.

Secretory immunoglobulin A (sIgA) is present in large quantities in breast milk. These antigens bind to

potential pathogens and prevent their attachment to the infants cells. They neutralize infectious agents and

also limit the damaging effects of tissue inflammation that can occur with other antibody types.

Breast milk contains the enzyme lysozyme. This enzyme disrupts the proteoglycan layer of the bacterial cell

wall and thus inhibits the growth of several bacterial species. Lactoferrin, which is one of the most abundant proteins present in breast milk, removes essential iron and

thus deprives the microorganisms of iron and prevent their growth in the infant.

Nucleotides present in breast milk enhance immune function in infants.

Breast Milk vs. Whole Cows Milk

Protein Content and Quality

Protein in breast milk provides about 7% of calories, while that in whole cows milk provides about 20% of calories.

The average whey/casein ratio in breast milk is 35:65 and in whole cows milk, it is 19:81. The greater casein content in



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whole cows milk is undesirable as casein forms a tough curd, which is hard for infants to digest. The concentration of the

essential amino acids, cystine and taurine is higher in breast milk than in whole cows milk.7

Fatty Acids

Lipids in breast milk as well as whole cows milk provide 50% of calories. The concentration of linoleic acid and

polyunsaturated fatty acids is greater, in breast milk than in whole cows milk. Linoleic acid present in breast milk

provides 4% of calories while in whole cows milk, it provides only 1.8% of calories.7

Mineral Content

Compared to breast milk, whole cows milk contains low concentrations of zinc, niacin, vitamin C and vitamin E.

The sodium and potassium content of whole cows milk is approximately three times higher than those in breastmilk. Furthermore, the concentrations of calcium and phosphorus in whole cows milk are four and six times higher,

respectively, when compared to those in breast milk. The high phosphate load has been implicated as a causative factor

of late hypocalcemic tetany of the neonate.7

Complementary Feeding

Complementary feeding is defined as the process starting when breast milk alone is no longer sufficient to meet the

nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk.8

After a certain age, breast milk alone cannot meet the nutritional requirements of the child. Increasing need for energy

and proteins is the main factor for introducing complimentary foods. But, levels of micronutrients are more likely todiminish sooner than macronutrients in breast milk.9

According to the World Health Organization, exclusive breastfeeding should be practiced from birth to 6 months of age.

Complementary foods should be introduced at 6 months of age, while continuing breastfeeding. Frequent, on-demand

breastfeeding should be continued until 2 years of age or beyond.10

The Infant and Young Child Feeding Guidelines (2010) by Indian Academy of Pediatrics stipulate that appropriately thick

homogenous complementary foods made from locally available foods should be introduced at six completed months

to all babies while continuing breastfeeding ad libidum. Complementary food should be a balanced food consisting

of various (as diverse as possible) food groups/components in different combinations. As the child shows interest in

complementary feeds, the variety should be increased by adding new foods in the staple food one by one. 11



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References

1. Chapter 1: Nutritional needs of infants. [Internet][cited 2014 Feb 18]. Available at: http://www.nal.usda.gov/wicworks/Topics/FG/Chapter1_NutritionalNeeds.pdf.

2. Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Vitamins.[Internet][cited 2014 Feb 18]. Availableat: http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/RDA%20and%20AIs_Vitamin%20and%20Elements.pdf.

3. do Nascimento MB, Issler H. Breastfeeding: Making the difference in the development, health and nutrition of term and preterm newborns.Rev Hosp Clin Fac Med Sao Paulo. 2003;58(1):4960.

4. Ballard O, Morrow AL. Human milk composition. Nutrients and bioactive factors. Pediatr Clin N Am. 2013;60:4974.5. Beauchamp GK, Mennella JA. Flavour perception in human infants: Development and functional significance. Digestion. 2011;83(Suppl. 1):16.

6. Jackson KM, Nazar AM. Breastfeeding, the immune response, and long-term health.J Am Osteopath Assoc. 2006;106(4):203207.

7. Leung AK, Sauve RS. Whole cows milk in infancy. Paediatr Child Health. 2003;8(7):419421.

8. World Health Organization. Guiding principles for complementary feeding of the breastfed child. [Internet][cited 2014 Feb 18].Available at: http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf.

9. Dewey KG. Nutrition, growth, and complementary feeding of the brestfed infant. Ped Clin North Am. 2001;48(1):87104.

10. World Health Organization. Complementary feeding. Report of the global consultation. Summary of guiding principles. [Internet][cited 2014 Feb 18]. Available at: http://www.who.int/nutrition/publications/Complementary_Feeding.pdf.

11. Infant and Young Child Feeding Chapter, Indian Academy of Pediatrics, Rajeshwari K, Bang A, Chaturvedi P, et al. Infant and young child feedingguidelines: 2010. Indian Pediatr. 2010;47(12):9951004.

Amount of food to offer at different ages11

Age Food texture Frequency Average amount of each meal

68 months Start with thick porridge,

well mashed foods

23 meals/day plus frequent

breastfeeding

Start with 23 tablespoonfuls

911 months Finely chopped or mashed

foods, and foods that baby

can pick up

34 meals plus breastfeed.

Depending on appetite offer

12 snacks

Half of a 250 mL cup/bowl

1223 months Family foods, chopped or

mashed if necessary

34 meals plus breastfeed.

Depending on appetite offer12 snacks

Three-fourths to one 250 mL cup/

bowl



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SECTION 4

Adult Nutrition

Nutrition

Nutrients and Their Functions

Substances in food that provide energy for activity, growth, and all body functions are referred to as nutrients. Nutrientsare classified into macronutrients and micronutrients.1

Macronutrients versus Micronutrients

Essential nutrients are those which are indispensable to life processes and that the body cannot make for itself. They can

only be obtained from food.2

Macronutrients2 Micronutrients2

Required by the body in relatively large amounts Required only in small amounts daily

Fats, carbohydrates, proteins Vitamins, minerals

Nutrient in Food Energy provided

One gram of protein 4 kcal

One gram of carbohydrate 4 kcal

One gram of fat 9 kcal

Food Energy

Proteins, carbohydrates, and fats present in food provide energy.3The energy released by carbohydrates, fats, and proteins

is measured in calories. Energy is expressed in 1000-calorie metric units [kilocalories (kcal)].2


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Basal Metabolic Rate

The basal metabolic rate (BMR) is usually defined as the amount of energy expended [expressed in kcal or megajoules

(MJ) per day] when an individual is at complete rest (physical and psychological). It can also be expressed as kilocalories

per hour or per kilogram of weight. Basal metabolic rate provides the energy required for the working of the body (see

Table 1). It is influenced by the composition (amount of protein and fat) of an individuals body. Women usually have

lower BMR than men.3

Table 1: Basal metabolic rate in adult men and women in relation to height and median acceptable weight

for height3

Height(m)

Weight(kg)a

Age: 1830 years Age: 3060 years Age: Over 60 years

kcal (kJ)b/

kg/day

kcal (kJ)/

day

kcal (kJ)/

kg/day

kcal (kJ)/

day

kcal (kJ)/

kg/day

kcal (kJ)/

day

Men

1.5 49.5 29.0 (121) 1440 (6.03) 29.4 (123) 1450 (6.07) 23.3 (98) 1150 (4.81)

1.6 56.5 27.4 (115) 1540 (6.44) 27.2 (114) 1530 (6.40) 22.2 (93) 1250 (5.23)

1.7 63.5 26.0 (109) 1650 (6.90) 25.4 (106) 1620 (6.78) 21.2 (89) 1350 (5.65)

1.8 71.5 24.8 (104) 1770 (7.41) 23.9 (99) 1710 (7.15) 20.3 (85) 1450 (6.07)

1.9 79.5 23.9 (100) 1890 (7.91) 22.7 (95) 1800 (7.53) 19.6 (82) 1560 (6.53)

2.0 88.0 23.0 (96) 2030 (8.49) 21.6 (90) 1900 (7.95) 19.0 (80) 1670 (6.99)

Women

1.4 41 26.7 (112) 1100 (4.60) 28.8 (120) 1190 (4.98) 25.0 (105) 1030 (4.31)

1.5 47 25.2 (105) 1190 (4.98) 26.3 (110) 1240 (5.19) 23.1 (97) 1090 (4.56)

1.6 54 23.9 (100) 1290 (5.40) 24.1 (101) 1300 (5.44) 21.6 (90) 1160 (4.85)

1.7 61 22.9 (96) 1390 (5.82) 22.4 (94) 1360 (5.69) 20.3 (85) 1230 (5.15)

1.8 68 22.0 (92) 1500 (6.28) 20.9 (87) 1420 (5.94) 19.3 (81) 1310 (5.48)

Section 4:Adult Nutrition


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Average Daily Energy Requirements

Several factors influence the energy requirements of an individual. These include:3

Body size:A small individual requires less energy than a large individual.

Basal metabolic rate:BMR varies among individuals and can be affected by factors such as disease of the

thyroid gland.

Activity:The greater the physical activity, the more the energy needed.

Pregnancy and lactation:Pregnant and lactating women need extra energy to cater to the needs of thegrowing fetus and infant, respectively.

Age:Infants and children need more energy for growth and activity than adults. Elderly individuals usuallyrequire less energy because their BMR is lower and the amount of physical activity they perform is lesser.

The mean daily energy requirements (expressed as multiples of BMR) of men and women doing light, moderate and

heavy work are presented in Table 2.3

Table 2: Mean daily energy requirements (in multiples of BMR)3

Nature of work Men Women

Light 1.55 1.56

Moderate 1.78 1.64

Heavy 2.10 1.82

Proteins, Carbohydrates and Fats

Proteins

Proteins are the main structural constituents of

all the cells and tissues of the body. They containcarbon, hydrogen, and oxygen. Proteins constitute

a greater portion of the substance of muscles and

organs, apart from water. All proteins are made

up of individual units known as amino acids,

which are joined together like links in a chain.

The chemical linkage by which amino acids join

together is called a peptide linkage. Twenty amino

acids which occur in protein are classified into

two basic groupsessential (or indispensable) and

non-essential (or dispensable).3

Non-Essential Amino Acids

Aspartate

Asparagine

Alanine

Arginine

Glutamate

Glutamine

Glycine

Cysteine

Proline

Serine

Tyrosine

Essential Amino Acids

Isoleucine

Threonine

Leucine

Tryptophan

Lysine

Valine

Methionine

Histidine

Phenylalanine



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Box 1: Complementary food combinations4

Beans and rice

Beans and corn or wheat tortillas

Rice and lentils

Rice and black-eyed peas

Pea soup with bread or crackers

Chickpeas with sesame paste

Pasta with beans

Peanut butter on bread

Functions

They are required for the growth and development of the body, for maintenance, repair and replacement of damaged

tissues, and to produce metabolic and digestive enzymes. They serve as an essential constituent of certain hormones

(thyroxine and insulin).3

Protein Quality in Human Diet

The quality of protein in food depends mainly on the composition

and digestibility of its amino acid. The protein quality of a food

is considered to be lower if a protein is deficient in one or

more essential amino acids. The essential amino acid which is

most deficient in a protein is called the limiting amino acid.

The efficacy of utilization of a protein present in a food or in a

combination of foods is determined by the limiting amino acid.3

Animal foods usually provide complete protein, that is, all the

essential amino acids in nearly the right proportions (e.g., red meat,

poultry, fish, eggs, milk, and milk products). Plant foods provide

incomplete protein, that is, they lack one or more essential amino

acids. Although the protein provided from one plant food may lack

certain amino acids, the protein provided by another plant food may serve as a complementary protein that completes the

amino acid pattern. Some examples of complementary food combinations are provided in Box 1.4

Recommended Dietary Allowance for Protein

Recommended dietary allowance for protein for a healthy adult is 0.8 g per kg body weight per day. 5

Nitrogen Balance

The nitrogen balance of an individual can be determined by measuring the amount of nitrogen in the urine and feces,

and comparing it with the amount of nitrogen ingested in the form of dietary protein. Nitrogen balance occurs when

the amount of nitrogen excreted is equal to the amount of nitrogen consumed. It is a good indication of the adequacy ofprotein intake and the ability of the body to utilize and retain dietary protein. Nitrogen balance can be either positive or

negative.

Positive nitrogen balance exists when the body takes in more nitrogen than it excretes. The difference is

accounted for by the synthesis of additional protein. Positive nitrogen balance is observed in growing infants

and children, during pregnancy, when recovering from illness or starvation, or in body builders.

Negative nitrogen balance exists when the amount of nitrogen excreted is higher than the amount consumed.

This occurs when dietary protein or energy intake is insufficient or after severe injury (e.g., burns) or

infection.4



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Carbohydrate

Classification

Carbohydrates are composed of carbon, hydrogen and oxygen. They are classified into:3

MonosaccharidesThese are simple sugars. For example, glucose, fructose and galactose.

DisaccharidesExamples: Lactose, sucrose (table sugar), and maltose.

PolysaccharidesExamples: Starch, glycogen, and cellulose. They are chemically the most complicated

carbohydrates.

Sources of Carbohydrates

Monosaccharides:The important monosaccharides are glucose, fructose and galactose.3

Glucose is the endproduct of digestion of more complex carbohydrates in the diet. It is also the form in which

sugar is found in the blood. It is found in fruits, sweet potatoes, onions, etc.3It provides energy for body

cells.6

Fructose is found in some fruit juices and honey. It can be manufactured from starch and is used

commercially as a sweetener.

Galactose is not found free in nature but is produced when milk sugar is digested.3

Disaccharides: The important disaccharides are sucrose, lactose and maltose.3

Sucrose (or ordinary table sugar) is found mainly in sugar cane and sugar beet. It is also present in carrots and

pineapple.

Lactose (milk sugar) is the principal sugar found in the milk of mammals. It is less sweet than sucrose.

Maltose (malt sugar) is found in germinating seeds.

Polysaccharides:The three important polysaccharides are starch, glycogen and dietary fiber.3

Starch, the major polysaccharide in our diet, is the storage form of carbohydrate in plants. Major food sources

of starch include cereals and potatoes.3

Glycogen is found primarily in liver and muscle.3

Relative Sweetness of Sugars

Lactose is the least sweet of all natural sugars and fructose is the sweetest. Natural sugars vary in sweetness.6



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Dietary Guidelines for Carbohydrate Intake

The WHO/FAO Dietary Intake Goals recommend a carbohydrate intake of 5575% of total energy intake.1

Fats

Fats (also known as lipids) are an essential source of energy. Like carbohydrates, fats are composed of the elements

carbon, hydrogen and oxygen.3Lipids are a group of substances that comprise fats, oils, and fat-like substances. Fatty

acids that cannot be synthesized by the body are referred to as essential fatty acids (e.g., linoleic acid, -linolenic acid).

These fatty acids must be provided by the diet.1

Fats in Foods

Dietary fatty acids are classified into saturated and unsaturated fatty acids. Unsaturated fatty acids include

polyunsaturated (PUFA) and mono-unsaturated fatty acids (MUFA).3Polyunsaturated fatty acids are further classified

into:7

Omega-6 polyunsaturated fatty acid

Omega-3 polyunsaturated fatty acid

The sources of different types of fatty acids are presented below:7

MUFA Omega-6 PUFA Omega-3 PUFA

Nuts

Vegetable oils

Canola oil

Olive oil

Sunflower oil

Avocado

Soybean oil

Corn oil

Safflower oil

Soybean oil

Canola oil

Walnuts

Flaxseed

Fish: trout, herring, and salmon

Vitamins and Minerals

Vitamins

Vitamins: Sources and RDA for Adults

The sources of vitamins and the U.S. RDA of vitamins are discussed as follows.



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Fat-soluble vitamins

Vitamin RDA Sources Deficiency

A 750 g of

retinol per

day3

Dairy products (butter, milk), meat,

eggs, liver, red and green vegetables,

yellow or orange fruits3,1

Pathologic drying of the eye, resulting in

xerophthalmia, keratomalacia, and blindness.

Follicular keratosis3

D 5 g7 Fat in certain animal products, eggs,

cheese, milk, butter, meat, fish, fish

liver oils (vitamin D is also synthesized

in the skin on exposure to sunlight)3

Rickets in children and osteomalacia in adults,

reduced development of teeth and bone8

E 410 mg7 Vegetable oils, wheat germ, eggs7 Hemolytic anemia, muscle wasting,

reproductive failure, nerve damage7

K 80 g7 Green leafy vegetables, fruits,

dairy and grain products7Prolonged blood clotting time7



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Water-soluble Vitamins

Vitamin RDA Sources Deficiency

C 4060 mg7 Fruits (plantains and bananas),

vegetables (e.g., root

vegetables, potatoes), and

leaves (amaranth, spinach)3,7

Scurvy, bleeding gums, slow

healing wounds7

B1(thiamin) For moderately active

Men: 1 mgWomen: 0.8 mg3

Whole grains, pulses, green

vegetables, fish, meat, fruit,

yeast, and milk3

Beriberi (in advanced forms,

it produces paralysis of the

limbs), Wernicke-Korsakoff

syndrome (in alcoholics)3

B2(riboflavin) 1.5 mg3 Milk and its non-fat products,

green vegetables, meat (liver),

fish, eggs, cereals, pulses3

Ariboflavinosis (painful

cracking of the lip and corner

of the mouth)3

Niacin

(nicotinamide)

20 mg3 Meat (liver), groundnuts,

cereal bran or germ3Pellagra3

B6(pyridoxine) 1.42.0 mg7 Meat, whole grains, fish, nuts,

pulses7Glossitis, dermatitis,

convulsions, muscle weakness,

anemia7

B12

(cobalamine) 3.0 g3 Foods of animal origin,

fermented vegetable products3Pernicious anemia due to

inability of an individual to

utilize vitamin B12

in the diet.3

Folic acid 200 g7 Dark green leafy vegetables,

liver, and kidney7Macrocytic anemia,

gastrointestinal disorders7

Minerals

Main Health Aspects of Minerals

Iron deficiency anemia:Deficiency of iron causes iron-deficiency anemia. Iron-deficiency anemia is most frequently

noted in young children, women of child-bearing age, and in people with chronic blood loss.3

Iodine deficiency:Iodine deficiency in adults manifests as goiter (enlargement of the thyroid gland). Babies born to

women with inadequate iodine intake during the early months of pregnancy may show cretinism and mental retardation.3

Osteoporosis:Calcium deficiency in adults leads to the development of osteoporosis. It is an age-related skeletal

disease, characterized by fragile bones which consequently lead to fractures of the hip, vertebrae, and other bones,

especially in older women.3



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Major minerals

Mineral RDA Sources

Calcium 400500 mg3 Cows milk, milk and milk products (cheese and yogurt), pulses, vegetables,

small saltwater and freshwater fish (with bones)3

Phosphorus 800 mg Meat, poultry fish, milk products, whole grain cereals, dried fruit

Potassium 2000 mg Meat, vegetables and fruits (dates, apricots, bananas and citrus)

Chloride 700 mg Table salt and salty foods

Sodium 500 mg Cured meats (ham, bacon), cheese, soups, table salt

Magnesium Men:350 mg

Women:280 mg

Whole grain cereals, nuts and green vegetables

Trace elements

Element RDA Sources

Iron 8.710 mg7 Meat (especially liver), fish, eggs, legumes, cereal grains (rice, wheat and maize)

and green leafy vegetables3

Fluorine 1.54 mg7 Fluoridated water, tea, seafood7

Zinc 9.515 mg7 Red meat, unrefined cereals7

Copper 1.13 mg7 Nuts, oysters, vegetables7

Selenium 5575 g7 Whole grain cereals, meat, fish7

Manganese 110 mg7 Cereals, nuts, pulses, green vegetables7

Iodine 140 g7 Ocean fish, seafood, cod liver oil3

Molybdenum 50400 g7 Milk, legumes, cereals, kidney7

Chromium 50200 g7 Brewers yeast, whole grain nuts, vegetables7

Recommended Dietary Allowances for Major Minerals and Trace Elements for Adults



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References

1. Food and agriculture organization of the United Nations. Family Nutrition Guide. [Internet][cited 2014 Feb 19]. Available at: ftp://ftp.fao.org/docrep/fao/007/y5740e/y5740e00.pdf.

2. Whitney E. Rolfes SR. An Overview of Nutrition. Cengage Learning, 2012.

3. Food and Agriculture Organization of the United Nations. Basic Nutrition. [Internet][cited 2014 Feb 19]. Available at: http://www.fao.org/docrep/w0073e/w0073e04.htm.

4. Insel P, Ross D, McMahon K, et al. Nutrition. In: Proteins in the Diet. 4th edn. Jones & Bartlett Publishers, 2010, pp. 225266.

5. Surdykowski AK, Kenny AM, Insogna KL, et al. Optimizing bone health in older adults: The importance of dietary protein.Aging health. 20101;6(3):345357.

6. Dudek, SG. Nutrition Essentials for Nursing Practice. Lippincott Williams & Wilkins, 2010, pp. 1843.

7. Centers for Disease Control and Prevention. Polyunsaturated Fats and Monounsaturated Fats. [Internet] [cited 2014 Feb 20].Available at: http://www.cdc.gov/nutrition/everyone/basics/fat/unsaturatedfat.html.

8. Bowling T. Nutritional Support for Adults and Children: A Handbook for Hospital Practice. Radcliffe Publishing, 2004, 17162.



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