Nutrition in the Preterm and SGA Infants, Nutrition in Children

Nutrition in the Preterm and SGA Infants o Phosphorous 100 mg/kg

o Mg 8 mg/kg
- Caloric requirements: 60-150 cal/kg/day o Na 2.5-3.5 meq/kg; if
- Water: 80-200 ml/kg/day <1.5kg: 4-8 meq/kg
- CHO o K 2-3 meq/kg
o Fetal life – D glucose (dextrose) o Fe 2 mg/kg (after 6-8 weeks)
o Breastmilk and formula milk – lactose (glucose and o Cu 100-120 mcg/kg
galactose) o Zn 1200-1500 mcg/kg
o Formula of preter: polymers of gluucose – better o Mn 10-20 mcg/kg
absorption and digestion

- Fats: 30-55% total caloric requirement Nutrition in Term Neonates

o 3.3-6 g/100 calories - Energy requirement: 95-120 cal/kg/day
o 28 weeks or 1 kg fetus 1% of total body fat - Water req’t: 120-150 ml/kg/day
o Term: 15-16% body fat - Fluid req’t computed per day or per hr age of neonate
o Insensible water loss: 1ml/kg/hr or 20
- CHON: 2.5-4 g/kg/day ml/kg/day
o Taurine: soft hydroxyl-beta amino acid found in o Stools: <5ml/kg/day
large amounts in the breast; critical in the o Renal solute: 8-10 mOsm/100 cal/day
development of the CNS
- CHO: 39-43% of calories in breastfed or formula fed
- Essential amino acids in preterms infants
o Leucine o Lactose: main CHO in breastmilk
o Methionine  7 g/dl
o Isoleucine o Oligosaccharides, glycoproteins, glucose polymers
o Phenylalanine  1.3 g/dl
o Valine
o Tryptophan - CHON req’ts: 2-2.5 g/kg/day
o Threonine o Essential amino acids : lesserare needed in term
o Lysine neonates
 Isoleucine
o Possible essential amino acids: nutrients normally
 Leucine
synthesized by humans, but prematures have
 Methionine
reduced synthetic capability to produce
 Isoleucine
o Cystine
 Phenylalanine
o Tyrosine
 Valine
o Taurine
 Tryptophan
o Histidine
 Threonine
o Inositol  Lysine
o Choline  Histidine
- Inositol & cholione- for pre-terms
- Fat requirement: 50-55% of energy
- Vitamins o Fat intake: 0.5-6 g/kg/day or 30-55% of total daily
o A: 1400 IU calories
o D: 500-600 IU o Linoleic acid or linolenic acid
o E: 6-25 IU –has vital role for preterm
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milks,much needed; expensive; for the maturity of - Nucleotides :simulated in pre-term formulas
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the lungs; alleviate retinopathy o NPN content in breastmilk

o K: 15 mcg o Derived from the bases of purines and pyrimidines
o C: 50-60 mg o Biologic functions
o Thiamine/B1: 0.2 mg  Increase natural killer cell activity
o Riboflavin: 0.4 mg  Lymphocytic proliferation
o Niacin: 5 mg  Exert an effect on the type of bacterial flora in
o B6/pyridoxine: 0.4 mg the gut
o B12/cycobalamin: 1.5 mcg
- Bifidobacteria
- Folic acid: 50-100 mcg o Protective by competing for substrate with other
- Biotin: 6 mcg more pathogenic microorganism
- Minerals o Found in breastmilk, increase immune system
o Calcium 200mg/kg
Nutrition in the Preterm and SGA Infants, Nutrition in Children
- Advantages
- Inosine - Differentiate from cow’s milk and modified milk
o Facilitates iron absorption in breastmilk - Storage:
o Frozen at -20 ‘C up to 6 months; refrigerated at 4’C
- Positive relationship of nucleotide intake with improved for up to 24 hours
growth
- Breastmilk fortifies (supplements)
- Vitamins o Supplements for breastmilk for rapidly growing
o A: 500 IU prematures
o D: 400 IU o Increased somatic growth related to increased in
o E: 5 IU CHON and energy intake
o K: 15 mcg o Ie: Enfamil human fortifiers or Similac natural care
o C: 20 mg
o Thiamine/B1: 0.2 mg Complementary Feeding
o Riboflavin: 0.4 mg - WHO: term in which food and liquids are provided in
o Niacin: 5 mg addition to breastmilk
o B6/pyridoxine: 0.4 mg - Pincer grasps, ???
o B12/cycobalamin: 1.5 mcg - Milk formula is not enough food
- Weaning
- Folic acid: 50 mcg o Addition of supplemental foods when breastmilk
- Biotin: 5 mcg become inadequate in CHON or energy for
- Minerals adequate growth
o Calcium 60 mg/kg o Complete discontinuance of breast or bottle
o Phosphorous 40 mg/kg feeding
o Mg 8 mg/kg - Transitional foods
o Na 1-2 meq/kg o Complementary foods specifically designed to
oK 2-3 meq/kg meet the particular nutritional or physiological
o Fe 6-10 mg needs of the young child
o Cu 30-40 mcg/kg
Weaning
o Zn 500 mcg/kg
- Nursing Phase: 1st 4-6 months
o Mn 5 mcg/kg
o Breastmilk or formula milk
- Weaning Stages:
o Stage 1: 1-4 months, single nutrient (milk)
Principles of Infant Feeding: Parameters when to start
o Stage 2: transitional period
feeding
 6 months; milk and increased amount of
- Criteria for initiating infant feeding
other foods
o Most are fed within the first 4 hours
o Stage 3: 12-36 months
o No history of excessive or oral secretions
 Decreased amount of breastfeeding
o Non distended, soft abdomen
 Increased amount of family food
o Clinically stable
o Extubation (controversial): feed at least 6 hours
after extubation
Early vs. Delayed Complementary Feeding
o Respiratory rate: <60 bpm for oral feeding
- Early
o <80 bpm for gavage feeding o Introduction of semi-solid food before 4
o NGTPD – complications: months
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o May result to less frequent breastfeeding and less

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Infant Feeding
- For prematures:
o The earlier the feeding, the better
o Enteral feeding can be started in the 1st 3 days with
the objective of reaching full enteral feeding in 2-3
weeks
o For stable, larger prematures >500g: 1st feeding
may be given in the 1st 24 hours of life
o Early feeding allows release of enteric hormones
that exert a trophic effect on the intestinal tract
Breastfeeding : review!
milk production
o May increase risk of allergies-esp to atopy,
bronchial asthma—cough coryza
o May increase the risk of iron depletion and anemia
– b/c milk high quantity of Iron
- Delayed
o Growth faltering (wasting and stunting) – milk
formula not enough to sustain growth of the child
o Nutrient deficiencies – milk formula is insuffecient
o Critical period – time after which it is no longer
possible for that behavior to be mastered – baby’s
are learning to sit or major development motor
Nutrition in the Preterm and SGA Infants, Nutrition in Children
skills, not enough food, retardation of the development of the kidneys) are generally
development of motor skills suitable for infants
o Limit use of fruit juices to avoid interfering with
intake of nutrients containing food or fluids
- Factors of early & delayed complementary o Herbal teas and other beverages are of no known
o Nutritional needs of the infants benefits and may be harmful
 After 4-6 months of exclusive breastfeeding
or milk formula, transitional foods can be - Food safety and feeding safely
given to meet energy, iron and zinc needs o Don’t use honey to prevent botulism
 Caloric needs are not sufficiently provided by o Eggs- cooked well, egg white – not traditionally
breastmilk and infant is always hungry given until one year of age if the patient has
 Weight cues: doubling of birthweight history of atopy..eggyolk is 1st introduced
o Hard, small and round, smooth, sticky solid foods
o Physiologic maturation – not recommended as they can cause choking
 Adequate intestinal and renal maturity by 4-6 and aspiration
months o Introduce single foods
 Starches and some foods containing fats and o Combination of foods are done once single foods
CHON can’t be well tolerated by very young are tolerated
infants
Milk CHO CHON FATS
o Developmental and behavioral readiness NAN Lactose Whey, whole Milk fat,
 Coordination with chewing and swallowing milk corn oil
occurs Nestogen Lactose, Whey, Milk fat,
 Developmental maturity: sucrose skimmed milk vegetable
 Able to sit with support oil
 Head held up when placed on stomach S26 Lactose Reduced whey Vegetable,
 Intentionally places hands and toys in soy or
the mouth lecithin
Bonna Lactose, Milk CHON Vegetable
o Cultural practices sucrose oil
 Foods influenced by the availability in some Dulac Lactose Whey: casein Milk fat,
regions and by local traditions as the choice of veg. oil
their first foods Enfalac Lactose Whey Veg. oil
Nan2 Lactose Casein Milk fat,
o Guidelines corn oil
 Choose easily consumable and digestible food Dupro Lactose Whey, casein Milk fat,
according to increase sensory satiety in veg. oil
children
Promil Lactose, Milk CHON, Veg. oil,
 Aim at energy dense food rather than milk –
sucrose whey soya
cereal based food with milk and soya should
Gain Sucrose Skimmed milk Veg. oil
be well balanced and supplemented by
Enfapro Lactose, Non fat milk Veg. oil
micronutrients
sucrose
Neslac Sucrose Partial Corn, milk
skimmed fat, lecithin
Pre NAN Lactose, Whey, casein, MCT, corn,
maltodextrin lactoglobulin milk fat
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Rules in Weaning
- Introduce food at quantities one at a time and at
interval of 4-7 days Specific considerations in young children
- New concepts (mixed at the same time)-feeding is - Breastfeeding or milkf feeding is the main foos, the
better due to color, variety weaning food is only an additional food item
- Milk should be given in between feedings - 1-3 years old – breast milk or milk formula can be given
- Whole cow’s milk (fresh milk) should not be given at night but cannot replace other foods
before 1 year old - Caloric requirements
o 500-600 cal: 6-12 months
Issues surrounding complementary feedings o 800 cal: 12-24 mos
- Non milk fluids in infant feedings o 1300 cal: 24-36 mos
o Tap water, Well water (meets established o >/=1350 cal: after 3rd year of
standard of safety) and commercial bottled water life
(except mineral and carbonated – can impinge
Nutrition in the Preterm and SGA Infants, Nutrition in Children
o Failure to maintain a normal weight
 Obesity: more frequent in girls
 Underweight: more frequent in boys
o Stress of various kinds have adverse effects on
nutrition
Nutritional Requirement NUTRITION IN ATHLETES
- Fe – 6 mg/kg body weight - Needs more requirements than normal teenagers
- CHON requirements: - Need about 3000-6000cal/d
o 14 g: 6-12 mos - CHON intake may increase up to 100mg
o 23 g: 12-24 mos - Fluid needs are more
o 44 g: 24-36 mos - Electrolytes
- Weight control
- CHO loading
Nutrition in Toddlers, Preschoolers and School - Pre-game meal
- Ergogenic properties
Age Children - CHO may need up to 100g
- Fluids
NUTRITION IN CHILDREN
o 2h before: 500ml water
- Slowed and increased growth
o 10-15mins prior: another 500ml
- Energy demands are less
o During competition: 100-200ml every 10-15 mins
- Require well balance diet for continued growth and
health
- Athletes continues to drink for the next 24-36h until
- Social and culture aspects influence their developing
original weight is achieved
habits
- Toddler and preschooler feeding made simple
- CHO loading
o Children are not growing as fast as they did during
o About a week prior to competition → athlee
the first year, thus they need less food
exercise vigorously to deplete stores
o A child’s energy needs are irregular
o Diet high in protein and fat, restricted to 100g of
o Offer a variety of food
CHO
o Serve small portions. Let them ask for seconds if
o After 2-3d of glycogen depleting diet → a diet low
they are hungry
in fat, moderate protein and high in CHO 250-500
o Guide them in serving themselves small portions
grams is consumed for 3-4d
o Avoid over seasoning
o CHO loading not recommended fro short time
o Don’t force foods that children dislike
competition, but good in marathon
o Don’t put away the main meal before serving
dessert - Pre-game meal
o Keep quick-fix nutritious foods around for off o A rapidly digested meal low in fat, moderately low
hours meals in CHON , high in CHO, high in complex CHO should
o Children enjoy colorful meals like adults be eaten 3-5h prior to competition
o New foods should be given during the beginning of o 250-500ml beverages
a meal when the child is hungry o Individual preferences
o Be patient
- Ergogenic properties
COMMON DIETARY ERRORS o Substances that increase ability to work?
- Poor breakfast or none at all o Wheat germ, honey, bee pollen, protein
- Poor lunch
supplement, gelatin, Vitamin E or C
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- Snacks
- Overuse of milk especially in younger children
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JUNK FOODS
- Self-imposed dieting especially female teenagers
- Packaged commercial foods
- Irregular eating habits
- Low nutrient value consumed in excessive amounts due
- Food dislikes: don’t force children to eat what they
to convenience, appeal and cost
don’t want
- Layman’s perception
o Dry, extruded cereal based snacks
DIET FOR SCHOOL CHILDREN AND TEENEAGERS
o Carbonated beverages
- Diets for school children
o Sold in fast food chains
o Characteristics of food appearance
o Processed foods high in salt and sugar
o Choice of foods
o Food habits
NUTRITIOUSLLY ADEQUATE SNACKS
- Diet for teenager, problems
- Pancit bihon
o They may succumb to bizarre and unbalanced
- Arroz caldo
diets
Nutrition in the Preterm and SGA Infants, Nutrition in Children
- Peanut crackers
- Champorado
- Roasted peanuts
- Goto
- Banana Q
- Bibingka
- Nilupak
- Kamoteng kahoy Additional notes lang po…ung
SNACKS OF LIMITED OR LOW NUTRITIONAL VALUE pinapareview ni Dra.
- Soft drinks
- Sago
- Banana chips
- Suman sa lihiya Age Feeding skill Food
- Turon 0-4 months Sucking and Milk
- Artificial fruit juices swallowing
- Camote Q coordination,
- Buko tongue extrusion
4 months Lip muscle Cereals
STREET FOODS control, tongue
- Low nutritional value moves backward
- Health hazards and forward
- Ready to eat 5 months Teething,chewing Crackers,
- Hazards processs, can vegetables, fruits,
o Chemicals: additive and ingredients open mouth to introduce cup,
o Microbial accept food, egg yolk
o Processing and preparations moves head from
o Economics side to side
6-7 months Grasp, hand to Introduce spoon,
FAST FOODS mouth fish and meat
- French fries, hamburgers, milk shakes flakes
- Half of the caloric requirement 8 months Proper chewing Meat strips, soft
- 40% or more of protein allowances coordination, eye cooked
- Up to 1/3 of thiamine, riboflavin and niacin head control, vegetables
- Significant allowances of Ca and Fe cup/spoon skill
- If coffee is substituted for milk shake, Ca content is very 9-12 months Pincer grasp, Regular table
low attempt self food
- Low in fibers, vitamin A and C, folic acid, trace minerals feeding
12 months and Spit, sticks out his Whole egg, whole
AGE 0-6 6mos- 1-3y 4-6y 7-10y 11- above tongue, milk, start
mos 1yr 14y interested in weaning
Kcal 117* 108* 1300 1800 2400 2800 feeding himself

CHON 2.2* 2.0* 23 30 36 44 BREASTFEEDING

Water 150 150 125 100 75 75 - Breast and anatomical considerations
Vit A 1400 2000 2000 2500 3300 5000 o Areola
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o Morgagni
Riboflavin 0.4 0.6 0.8 1.1 1.2 1.5
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o Lactiferous sinuses
thiamine 0.3 0.4 0.6 0.9 1.2 1.4 o Fibroalveolar tissues
Niacin 5 8 9 12 16 18 o Cooper’s ligament
Pyridoxine 0.3 0.4 0.6 0.9 1.2 1.6 o Myoepithelial cells
Vit C 35 35 40 40 40 45 o Nipple

Fe 10 15 15 10 10 18 Anatomy
Calcium 360 540 800 800 800 1200 - 15-20 lobes (glands)

Ductus

Lactiferous sinuses
Nutrition in the Preterm and SGA Infants, Nutrition in Children
Nipple o RA 7600
- Milk code executive order no. 51
- Breast size is not equal to volume
Techniques of breastfeeding
- 4 reflexes
o Rooting
o Sucking
Physiology o Swallowing
- Sucking and milking o Satiety
o Lactiferous sinuses should be between upper and - Mature milk
lower jaw o 5% fat: dependent on maternal milk
o Chewing action of the jaw squeezes the milk out o 1.1% CHON
o Breastmilk production depends on how well breast o 7% lactose
are emptied o In poorly nourished women, nutrient
o Facilitated by early onset breastfeeding within 12 concentration not altered but mild yield is
hours decreased

Reflexes
Foremilk Hindmilk
- Prolactin
1st milk expressed Last milk
o Sucking  afferent  hypothalamus  pituitary
Thin Thick
prolactin secretion
Bluish Very white
- Oxytocin
o Ejection Decreased fat Increased fat
o Let down reflex Inceased water Decreased water
- Breastfeeding speeds up uterine involution
Full term Preterm
CHO 6 +/- 0.2 lactose 5.6 +/- 0.05
Advantages of breastfeeding Llactose
- Best deficiency,
- Reduce allergy suppress glucose
- Economical polymers
- Antibodies CHON 1.7 +/- 0.1 1.0 +/- 0.01
- Spaced birth hydrolysed whey
- Temperature controlled Fats MCT (median
- Fresh chain
- Emotional bond triglycerides)
- Easy to give
- Digestible Stools
- Immediately available Breastfed Cow’s milk
- Nutritionally complete Soft Hard
- Gastroenteritis prevention Increased frequency Decreased frequency
No constipation Constipation
Breast Milk
- Ideal food Kinds of Stools
- Complete - Meconium stools
- Digestible - Transitional stools
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- High energy (CHO & FATS) - Milk stools

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- 20 calories/ounce or .65 calories/ml

- Decreased in renal load (proteins & minerals) <300 Colustrum
mOsm/L - 2-4 ddays
- Yellow
Breastfeeding - Alkaline reaction
- Types - Specific gravity: 1.040-1.060
o Pure - Total: 10-40 ml
o Mixed - Increased protein
 Complementar: immediately after - Increased vitamin A
 Supplementary: alternate - Low fat and sugar
- Schedule - Unique immunologic factors
o Per demand o IgA
o Per schedule o 95% immunoglobulin
- Rooming in and breastfeeding Act of 1992
Nutrition in the Preterm and SGA Infants, Nutrition in Children
o 80-90% macrophages Pyridoxine B6,ug 93-205 470
o Lymphocytes B&T Niacin, mg 1.5 0.8
o Complement system Folic acid, ug 24-50 50
B12,ug 0.5-1 4

 Bifidus – produces acetic and lactic acid which can

prevent colonization of E.coli, shigella and yeast

Breastmilk Cow’s milk Protective Functions of human milk

Water 87-87.5% 87-87.5% - Lactoferrin
pH 7 7 o Antiviral activity (HIV,CMV,HSV), anti-adhesive for
Specific gravity 1.026-1.036 1.026-1.036 E. coli, anit-invasive for Shigella
Caloric density 20 cal/oz or 0.67 20 cal/oz or 0.67 o Reduced intestinal infection
cal/ml cal/ml - Lysozyme
Protein 1.1 3-.5 o Bacterial lysis, reduce endotoxic effect
Fat 3-5% 3.25-4% - Casein
Lactose 7 4.8-4.9 o Anti-adhesive against helicobacter, strep, H.
Minerals 0.2 0.7 influenza
Protein content - Oligosaccharides
Whey: casein 70:30 20:80 o Protective against E. coli, enetrotoxins, H.
Whey content Lactalbumin B lactoglobulin influenza, S. pneumonia, V. cholera
Caseins 0.2g/dl 2.6g/dl - Human milk lipids (FFA, monoglycerides)
Alpha lactalbumin 0.2g/dl 0.2g/dl o Anti-protozoal (Giardia lamblia), antimicrobial
Lactoferrin 0.2g/dl Trace against H. influenza, Grp. B strep, staph, antiviral
Secretory IgA 0.2g/dl Trace (RSV,HSV)
B lactoglobulin 0 0.5g/dl
Lactoferrin Positive Negative Content Human Cow Modified
Lysozyme Positive Positive Water same same same
Fat LCT Saturated milk Caloric Same same same
PUFA Lactose 6.8 4.8 6.9
Linoleic Acid l. bifidus positive negative +/-
increased CHON 1.1 3.5 1.5
Bile salt stimulated Positive Negative Whey:casein 70/30 20/80 60/40
lipase 80/20
Triglycerides 4% 4% Lactoferrrin positive negative negative
Phospholipids .04% .04% Lactoglobulin positive positive Negative
Carbohydrates Allergic
Lactose 7% 4.8% reaction
Bifidus Positive Negative Fats 4.5 3.7 3.3-4.0
Oligosaccharides 1.2g/dl 0.1g/dl Lipase positive negative Negative
Minerals predigested
Sodium 5mM 15mM Ash content
Potassium 15mM 43mM Ca:P 2:1 1140/920 Follow 2:1
mother’s milk
Chloride 15mM 24mM
Calcium 7.5mM 30mM
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Magnesium 1.4mM 5mM Procedure of Breastfeeding

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Phosphate 1.8mM 11mM - Latch on procedure

Bicarbonate 6mM 5mM - Madonna fold
Zinc 3-5 3-5 - Football hold
Iron 0.5 0.5
Milk formulas
Fluoride less More
- Raw milk pasteurized milk
Vitamins
- Homogenized milk evaporated milk
A, IU 2230 1000
- Prepared milk condensed milk
D, IU <20 24 - dried whole milk dried skim milk
E, IU 3 0.9 - Acid/fermented goat’s milk
K, ug 2.1 4.9 - Milk protein milk substitutes
C, mg 40 17 - Hypoallergenic milk filled/limitation
Thiamine B1, ug 210 300 - Elementary dietary substitutes for milk
Riboflavin B2, ug 350 1750
Nutrition in the Preterm and SGA Infants, Nutrition in Children
First year feeding problems
- Underfeeding
- Overfeeding
- Regurgitation and vomiting
- Loose stools or diarrhea
- Constipation
- Colic
- Weaning

Feeding during the second year of life

- Reduced caloric intake
- Self selection of diet
- Self feeding by infants
- Daily basic diet
- Eating habits
- snacks between meals

Malnutrition
- Classification
- Gomez classification
o does not distinguish between the clinical forms of
malnutrition
Weight for age Status
91-100 Normal
76-90 1st degree
61-75 2nd degree
<60 3rd degree

Classification of malnutrition
-Wellcome classification
Wt as % edema No edema
60-80 Kwashiorkor Undernutrition
<60 Marasmic- Marasmus
Kwashiorkor

Revised Waterlow Classification

Weight for height: Height for age:
Wasting Stunting
Normal >95% >95%
Mild 90-95% 90-95%
Moderate 85-90% 85-90%
Severe <85% <85%
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