NUTRITION FOR INFANTS, CHILDREN AND ADOLESCENTS

1. NUTRITION FOR INFANTS, CHILDREN AND ADOLESCENTS Andrew Tershakovek, MD Associate Professor of Pediatrics University of Pennsylvania School of Medicine Director, Weight Management Program Children’s Hospital of Philadelphia Lisa Hark, PhD, RD Director, Nutrition Education and Prevention Program University of Pennsylvania School of Medicine

2. Objectives • To recognize the changing nutritional needs of developing children, from infancy to adolescence. • To understand that nutritional recommendations for children vary by age, stage of development,and gender. • To recognize that nutritional and dietary behaviors learned in children can have a significant impact on adult health concerns such as obesity, cardiovascular disease, and osteoporosis.

3. Why is Nutrition Important? • Energy of daily living • Maintenance of all body functions • Vital to growth and development • Therapeutic benefits • Healing • Prevention

4. Growth in Infants • Rapid body growth and brain development during the first year: • Weight increases 200% • Body length increases 55% • Head circumference increases 40% • Brain weight doubles

5. Major Determinants of Caloric Needs • Basal metabolic rate (BMR) • Activity level • Growth (2x BMR during first year) • Stress (infection, surgery, illness) • Misc. (thermic effect of food)

6. Monitoring Growth • Use updated growth charts • www.cdc.cov • Monitor trends in growth not one value using wt, ht, HC (< 2 yrs), BMI. • In general, normals fall within 5th-95th%ile. • Evaluate changes in %iles. • Malnutrition results in: • Decreased weight (acute), then height, then head circumference (chronic).

7. Feeding the Newborn • What are the options? • Breast feeding • The American Academy of Pediatrics recommends exclusive breast feeding for 6 months. • Formula feeding

8. Breast Feeding Questions • Why should I breast feed my baby? I thought formula was the identical alternative. • How often and for how long will my baby nurse? • How do I know if the baby is getting enough? • How many months can I breast feed the baby and when can I add formula?

9. Breast Feeding Advantages to Infants • Immunologic benefits (>100 components) • Decreased incidence of ear infections, UTI, gastroenteritis, respiratory illnesses, and bacteremia. • Convenient and ready to eat. • Reduced chance of overfeeding? • Fosters mother-infant bonding.

10. Breast Feeding Advantages to Mothers • May delay return of ovulation. • Loss of pregnancy-associated adipose tissue and weight gain. • Suppresses post-partum bleeding. • Decreased breast cancer rate.

11. Assessment of Breast Feeding • Weight pattern - consistent weight gain. • Voiding - # wet diapers/day, soaked? • Stooling - generally more stools than formula. • Feed-on-demand ~ every 2-3 hours. • Duration of feedings - generally 10-20 min/side. • Need for high fat hind milk. • Activity and vigor of infant.

12. Breast Fed Infants • My 8 week old breast fed baby has not had a bowel movement in 6 days. He gets 1 or 2, 4 oz bottles of iron fortified formula at night as well. He is happy and active. His appetite is good. He is not vomiting. His abdomen is soft and nontender. What should I do?

13. What should I do? - cont. • Discontinue the iron formula, it may be constipating. • Give 1 tsp of mineral oil per day until he goes. • Give a suppository each day until he goes. • Add cereal to the bottle to help his bowels and to sleep. • Dilute the formula to give more water. • Give 1 oz apple juice per day until he goes. • Do nothing, breast fed infants may not have a bowel movement for up to 7 days.

14. Supporting Breast Feeding • Ask patients if they plan to breast feed. • Give prenatal guidance, materials and support numbers. • Support hospital initiatives to encourage breast feeding, such as lactation counselors. • Ask about breast feeding support available to mother. • Become familiar with how to manage common problems such as mastitis and inverted nipples. • Understand issues related to pumping and helping moms return to work or wean the infant.

15. Infant Formula • 3 Forms: • Ready to feed - most expensive, does not require water. • Concentrate - requires mixing with water in equal parts. • Powder - requires mixing with water.

16. Composition of Standard Infant Formula • Caloric density: standard formulas contain 20 calories/oz (0.67 calories/cc). • Protein content: ratio of whey to casein varies-most are 60:40 similar to human milk. • Fat: most provide ~50% of calories from fat from saturated and polyunsaturated fatty acids. • Carbohydrate: lactose, beneficial effect on mineral absorption (Ca, Zn, Mg), and on colonic flora. • Micronutrients: Higher vitamin and mineral content than human milk to cover 97% of the population.

17. Special Formulas • Soy: used for vegetarians, lactase deficiency, galactosemia. • Lactose free: cow’s milk-based formula. • Protein hydrolysate: infants who can not digest or are allergic to intact protein. • Free amino acids. • Pre-term infant: unique for premies, predominant whey protein, cow’s milk based, higher protein and calcium, 20-50% MCT. • Pre-term follow up

18. Assessing Readiness to Feed • At what age it is best to introduce solid foods? How do I know if he is ready to eat? • What food should I give the baby first? • Should I put cereal in the bottle? It seems to help the baby sleep at night. • My baby likes to go to sleep in the crib with a bottle. Is that OK?

19. Feeding Skills Development • 4-6 mos - experience new tastes. • Give rice cereal with iron. • 6-7 mos - sits with minimal support. • Add fruits and vegetables. • 8-9 mos - improved pincer grasp. • Add protein foods and finger foods. • 10-12 mos - pulls to stand, reaches for food. • Add soft table food, allow to self-feed.

20. Feeding Skills Development • 12-18 mos - increased independence. • Stop bottle, practice eating from a spoon. • 18 mos -2 yrs - growth slows, less interest in eating. • Encourage self-feeding with utensils. • 2-3 yrs - intake varies, exerts control.

21. Pre-school (1 to 6 Years) • 1-2 years: on average, grows 12 cm, gains 3.5 kg. • Rate of growth slows by 4 years. • 6-8 cm/year • 2-4 kg/year • Brain growth triples by 6 years.

22. Common Complaints • My 2 year old is such a picky eater. I am worried about his diet. • My 3 year old eats noodles for dinner every night. Is that ok? • I think my 4 year old is anorexic. She won’t eat when we have meal time.

23. Cow’s Milk • My son is 9 mos and formula is so expensive. Can I start giving him whole milk now? • My daughter is 14 mos and we drink skim milk. Can I give her skim milk so I only have to buy one type of milk for the family?

24. Developing Healthy Habits • Offer a variety of healthy foods and snacks. • Encourage fruit and vegetable intake. • No junk food snacking. • Limit intake of juices ( 4 oz per day). • Increase intake of water (no soda). • Encourage low fat dairy products (3-4 servings/ day). • Make fun physical activity a habit. • Limit TV to no more than 1 to 2 hours per day. • Track growth and development carefully. • Be a good role model.

25. Nutritional Concerns in Childhood and Adolescents • Malnutrition and poverty. • Growth spurt-onset of menses for girls-changes in body size/image. • Food fads, vitamins, athletes. • Eating disorders: anorexia and bulimia nervosa. • Overweight and obesity. • Hyperlipidemia and heart disease. • Bone mineralization and osteoporosis.

26. Poverty and Malnutrition • 18 million (22.7%) of children under 18 in the US live in poverty. • Income <$14,306/year for family of 2 adults and 2 children. • Iron deficiency anemia most problematic. • Low vitamin C intake. • Exposure to lead.

27. Poverty and Malnutrition • Poor nutrition and cognitive function: • Decreased brain growth and or CNS development. • Poor performance on measures of cognitive ability. • Malnourished children are unprepared to benefit from age-appropriate educational experiences.

28. Adolescent Growth Spurt • Physiological growth stage (Tanner staging) rather than chronological age, is the best indicator for establishing requirements or evaluating intake. • Females: 11-14 years: • Grow 8.4 - 9.0 cm/year. • Girls deposit more total body fat. • Males: 13-16 years: • Grow 9.5 - 10.3 cm/year. • Boys deposit more muscle mass. • Boys tend to gain more weight at a faster rate and skeletal growth continues longer than girls.

29. Eating Disorders in Adolescents • An estimated 20% of teens engage in some type of abnormal eating. • 5% of high schools girls have been diagnosed with an eating disorder. • Adolescents are frequent users of OTC diet pills. • Multiple factors contribute: thin “ideal” , family pressure, exhibiting body control.

30. Diagnostic Criteria for Anorexia Nervosa (DSMIV) • Refusal to maintain body weight over a minimal normal weight. • Intense fear of gaining weight or becoming fat, even though underweight. • Denial of low body weight. • In females, absence of at least 3 consecutive menstrual cycles. • Specific types: restricting or binge purging.

31. Diagnostic Criteria for Bulimia Nervosa (DSMIV) • Recurrent episodes of binge eating characterized by: • Eating a larger amount of food than most people would eat in a specific period of time. • A sense of lack of control over eating at this time. • Recurrent inappropriate compensatory behavior to prevent weight gain (vomiting, laxatives, exercise). • Binge eating and other behaviors occur, on average, at least twice a week for three mos. • Self-evaluation is unduly influenced by body shape / weight. • Specify type: Purging type or non-purging type.

32. Eating Disorders Physician’s Role • Know the diagnostic criteria and ask questions. • Look for warning signs. • Convey your concerns to the patient without focusing on weight. • Expect denial, anger, or defensive reaction. • Know your limits and refer to an experienced eating disorder team.

33. Obesity in Childhood and Adolescents • >20% of children/adolescents are overweight. • Increased by 50-100% over last 20-30 years: • More sedentary lifestyle and behavior (TV/video games). • Prevalence increasing more rapidly among African-Americans. • Obese children and adolescents become obese adults. • Recent reports indicate 8-45% of newly diagnosed pediatric pts with diabetes are diagnosed with type 2.

34. Obesity:Health Consequences • Cardiovascular disease risk • Type 2 diabetes (epidemic) • Hypertension • Orthopedic • Sleep apnea • Gall bladder disease/steatohepatitis • Psychosocial problems

35. Pediatric ObesityEtiology and Treatment • Etiology: • Genetic predisposition: 80% risk if both parents obese • Environment • Dietary intake • Physical activity / sedentary activity • Treatment: • Multidisciplinary and comprehensive • Formal behavior modification • Family-based

36. Prevention of Cardiovascular Disease • Atherosclerotic process begins in childhood. • Childhood cholesterol levels associated with degree of early atherosclerotic changes. • Cholesterol levels track. • Behavior tracking?

37. Prevention of CVDCurrent Recommendations • NCEP guidelines apply to children over 2 yrs. • Diet: <30% fat, <10% sat. fat, <300 mg cholesterol/day. • Check fasting lipid profile when there is a positive family history of early CVD, or elevated cholesterol (hyperlipidemia) in a 1st degree relative. • Combine dietary intervention with healthy lifestyle for maximum benefits.

38. Osteoporosis • Bone mineralization peaks in teenage-young adult years. • Maximizing peak bone mineralization may decrease the risk of adult osteoporosis. • Maximizing bone mineralization: • Diet • Calcium • Sodium, protein, phosphorus • Weight bearing exercise.

39. Dental Health • Cariogenic Bacteria • Food • Adherence • Frequency of eating • Sugar • Fluoride

40. Disease Prevention Developing Healthy Eating Habits • Discourage dieting and obsession with weight. • Pack healthy lunch at least twice a week. • Limit fast food eating out. • Encourage a balanced diet. • 5 servings of fruits/vegetables a day. • Encourage low fat dairy products (3-4 / day). • Prepare meals that kids and teens enjoy. • Encourage teens to learn to cook healthy food. • Teach kids and teens label reading. • Be a role model.