Nutrition, Growth and Development

Classification System

Low Birth Weight (LBW) <2500 grams or 5.5 pounds

Very Low Birth Weight (VLBW) <1500 grams of 3.3 pounds

Extremely Low Birth Weight (ELVW <1000 grams or 2.2 pounds

Classification System

Small for gestational age (SGA) Birthweight less than the 10th %tile

Appropriate for gestational age (AGA) Birthweight between 10th and 90th %tile

Large for gestational age (LGA) Birthweight greater than the 90th %tile

Infant Growth

Occurs in genetically predetermined way Can be compromised by nutritional status calorie or nutrient undernutrition or

imbalance.Undernutrition:

First affects weight gainIf severe enough, affects linear growth

Growth

After birth genetic influences are target seeking

Catch Up Growth: Grow faster to get closer to genetically determined size Usually shift growth channels by 3 to 6

monthsLag Down Growth:

Usually shift growth channels by 13 months

Rules of Thumb

Weight: 4 months:Double birth weight 12 months: Triple birth weight then 2.3 kg/year until 9 or 10 then adolescent growth spurt

Growth: Height

1 year: 50% increase in height4 years: double birth length13 years: triple birth lengthAdolescence: rapid increase

Adolescent Growth Spurt

2 years later in males than femalesintensity, duration highly variableGrowth continues until after the

epiphysis closesGenerally by 4 years post onset of

puberty

Body Proportions

At birth: Head 1/4 of total length

Leg 3/8 of total lengthWhen growth ceases: Head 1/8 of total

length Leg 1/2 of total length

Collecting and Assessing Food Intake

24-hour recallDiet historyDiet Record 1, 3 and 7 day or moreFFQ

Who should be asked about Diet Intake?

If the subject is a boy < 13 or 14 years of age, the caregiver should be asked.

If a girl under 12 years of age, caregiver.

Why?

After diet has been taken accurately, then analysis is required

How?Food Guide PyramidNutrient analysis using food

composition table/ computer analysisMicaelsen room 104

Red Flags

Anthropometric: ht or wt less than 5th %tile

Infant formula under or over dilutedwhole cow’s milk before 1 yearreduced fat cow’s milk before 2 yearssemi-solid foods before 4 monthsbottle fed to go to sleep

Other Assessments Made

parent’s nutrition knowledgeadequacy of foods offeredparent’s knowledge of community

servicesdelays in feeding skillsbehavior patterns that affect intakemotivation of parent for change

Feeding problem: organic or inorganic

Organic: problem with muscle coordination, development

Inorganic: stress in family, emotionalOccupational therapists, speech

pathologists are trained to make these types of evaluations: if feeding problem exists, you may need to make a referral to determine cause.

Organic Feeding Problems

Stressors

MovingDeath, divorce,

separationMarriage,

pregnancySerious injury or

illnessLoss of workFamily fights

Money problemsDrinkingTrouble with the

lawOther serious

problems

Parents of Maladjusted Children

Often are:youngermore dependent on relativeunstable mentallyhave marital or other conflictshave a disturbed relationship with

their child

Infant Feeding Choice

Breast feeding best choice but approx. 80 % of infants receive

formula at sometime during first year

types of formulas available: ready to serve concentrated powdered

Formulas: types

Source of Formula and Use Cow’s milk based formulas. Soy based formulas. Specialized formulas.

Cow’s Milk Formulas

2 types: 1. Protein diluted to reach amount in

human milk add back CHO, Fat, vitamins and minerals

2. Casein diluted to reach amount in human milk add back lactalbumin, fat, vitamins and

minerals

Soy Based and Specialized Formulas

Soy protein used as the protein base add back CHO, fat, vitamins, minerals,

and methionine (limiting amino acid) e.g.: Prosobee

Specialized: For special needs e.g.: Lofenalac: used with PKU infants

Low in phenylalanine

Osmolality

Measure of solute in solvente.g.: particles in milkosmolality: osmoles of solute in 1 kg of

solvent osmole: solute that dissociates in solution

to form one mole (Avogadro’s number) of particles.

If too high: water sucked out and causes diarrhea

Osmolality & Renal Solute Load

Human milk: low, less than 300 mosmolar, gut can easily handle Creates Renal Solute Load of 13

mosmol/100kcalCow’s milk: Higher osmolality

Renal Solute Load of 46 mosmol/100kcal Skim milk: RSL of 86 mosmol/100kcal

Formulas: 18-27 mosmol/100kcal

Potential Problems:

Mixing formulas too strong (or weak)Skim milk to infants or children

under 2 yoWhole milk under 1 yo

Nutrient Needs of Children

Energy Needs based on: body size and composition physical activity rate of growth surface area to volume ratio

Infancy more surface area to volume then later in life

More loss of energy to surrounding environment

Energy

Age Energy< 6 months kg x 1086mo-1 year kg x 98

Consider range of intake of intake requirements

Protein

Infant requirements based on amount found in breast milk

Extrapolation from nitrogen balance studies

RDA’sAge Protein<6 mo 2.2 g/kg6-12 months 1.6 g/kg

Fat

No RDA but 40 to 50 % of infant KcalsFat energy spares protein from being

used as an energy source45 to 50 % of infant formulas kcals are

from fat55% of human milk kcals are from fatEssential fat recommendation > 1.2%

of kcals (linoleic and linolenic acid)

When to reduce fat intake in kids?

Fat shouldn’t be a concern until after 2 years of age. Then start incorporating lower fat food

items into the dietreduced fat milk and milk products are okIf these are accepted early, the risk of

chronic disease could be reduced

Controversy: Am Ac of Pediatrics says don’t worry until after puberty: too late

Water

Age Amount3 days 80-100 ml/kg/day10 days 125-150 ml/kg/day3 mo 140-160 ml/kg/day6 mo 130/155 ml/kg/day9 mo 125-145 ml/kg/dayWith BF and formula: none additionally

needed

Iron(Fe)

In the fetus, Fe stores are related to body size, therefore lbw and premature babies are at increased risk for iron deficiency

Human milk: 49% of iron is absorbed, only 1% of cow’s milk Human milk not a very good source of Fe so

after 4 to 6 months, baby may be deficient in Fe. Iron fortified cereals with vitamin C.

Fluoride(Fl)

Major role in tooth and bone development

Adequate intake reduces dental decay Becomes incorporated in tooth and resists

acid breakdown. Acid produced by cariogenic bacteria in mouth.

Supplementation dependent on Fl in water supply.

Fluoride Supplementation

Amount in Water age supplement< 0.3 ppm 2 wk-2 y 0.25 mg/day 2-3 years 0.5 mg/day after 3 y 1.0 mg/day0.3-0.7 ppm 2 to 3 y 0.25 mg/day 3-16 years 0.5 mg/dayover 0.7 no supplementation

Age of Introduction of Solid Foods

Developmental readiness, generally 4 to 6 months depends on oral skills: tongue thrust, munching

pattern, brings objects to mouth palmer grasp develops interest: if child reaches for food

First Foods: iron-fortified cereals for infants6-8 months: strained vegies, fruits, meats,

finger foods

Adding Foods

New foods should be added one at a time, no more than one every three days Check for tolerance

As infant approaches 9 to 12 months, increase in texture to mashed and finger foods can progress

Avoid potential choking foods hot dogs

Feeding Problems

Colic: gas production, and bloating Cause? Not always known: formula fed,

may change formula to casein hydrolysatebut not always successful

Breastfeeding?Foods in the mother’s dietCow’s milk, or items

Colic

Spitting up

Normal occurrenceUnless projectile vomiting:

Organic problem: pyloric sphincter closure

What You Should Know About Gastroesophageal Reflux (GER) in Infants and Children - December 1, 2001 - American Academy of Family Physicians

Screening Infants for special needs

Nursing Bottle Syndrome: feeding baby to go to sleep with bottle Increases tooth decay Treatment: don’t put baby to bed with a bottle

Infant Obesity:>95%tile wt for age, Wt for ht Not predictive of obesity in later life Adequate nutrition should be the key: don’t

restrict foods

Neonatal Care

Level 1: uncomplicated births and healthy infants

Level 2: normal infants and expertise in screening and referral of high risk infants care for moderately ill neonates and

convalescing neonatesLevel 3: equipped to cope with most

serious neonatal problems, illnesses, abnormalities

Role of Nutritionist in Neonatal Care

Should be able to screen for various nutrition problems, monitor and assess nutritional progress, develop and implement nutrition

management plans

Failure to Thrive

Failure to regain birth weight by 3 weeks

Wt. loss of >10% of birth weight by 2 wks

Wt dropping below the 3rf %tileDeceleration of growth velocityEvidence of malnutrition

Growth Retardation: 4 Types

1. Small for Gestational age but appropriate growth since intrauterine growth retardation, but

appropriate since then parental height small stature

Growth Retardation

2. Small or appropriate for gestational age but subnormal growth velocity ongoing growth insult examples: poor intake, overdiluting

formula, in appropriate breastfeeding schedule, family stress, poverty

Growth Retardation

3. Depression in growth velocity Some transient growth insult but has

since been alleviatedSeasonal low intake of nutrients due to low

income

Growth Retardation

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

Determination of Short Stature

Chronological age: actual ageHeight age: compared to 50%tile on

growth chartBone age: x-ray needed and radiologist

measures the width of growth plate to determine bone age. The thicker the growth plate, the younger the bone age and the longer the time for continued growth

Height Prediction: Is the child exhibiting appropriate growth?Female Childmother ht(cm) + (father ht-13) + 8.5 cm 2

Male Child(mother ht(cm)+13) + father ht + 8.5

cm 2

Height Prediction

Compare this height to age 18 on growth chart to determine % tile.

Compare this %tile to the current %tile of child and see if it compares favorably. If considerably below, cause for further

investigation e.g.: If prediction shows 75%tile and actual is

5%tile, most likely there is some environmental influence.

Development of Food Patterns in Young Children

First 5 or 6 years are important for developing food likes and dislikes

Goals for food pattern development: 1. Children eat in a matter-of -fact

manner 2. Independent eating 3. Introduction of new foods

Ellyn Satter Theory

Caregiver: Gatekeeper: decides what foods are offered

Child: Decides whether to eat, and how much to eat Child then develops their own regulation

of food intakeIf caregiver forces food or withholds food,

child isn’t able to develop their own satiety gauge

Guidance for introducing new foods

Have then explore food first Feel, smell, play with?

Use small portions. Why?

Decision to consume is left up to the childPositive reinforcement when consumption

happens. Guard against negative reinforcement, or

coercing.

New foods

Gradually intro new texturesAdd individual foods first before

mixturesAdd when child most receptive to food

Often in morning when well rested Often not late in the day when they are tired

Be patient with self-feeding efforts Self-esteem

Setting up the food environment

Physical environment spills, space, distractions

Emotional environment free from arguing, fighting

Role model Eat the foods you want your kids to eat