Nutri&on

5th year med. students

Dr. Dániel Szűcs
 Conception to birth 0-28 days 0-24 months

• Maternal morbidity
• Infant/child morbidity
and mortality
• Neonatal morbidity and mortality
• Adverse birth
and mortality • Developmental
outcomes: LBW,
delays
PTB, SGA, SB

Risk factors: Risk factors: Risk factors:

Low and high BMI, Delayed initiation Stunting, wasting,
short stature, and non-exclusivity micronutrient
inadequate weight of breast feeding, deficiency
gain during vitamin A (vitamin A, zinc,
pregnancy, low dietary deficiency, LBW, iron, iodine)
quality, micronutrient PTB, SGA
deficiency

Interventions during
Interventions in the neonate: Interventions in children:
pregnancy:
Breastfeeding counseling, Supplementation with
Supplementation with food
newborn supplementation with vitamin A, food (protein-
(protein-energy), iron-folic
vitamin A and vitamin K, and energy), iron, zinc, and
acid, calcium, vitamin A,
delayed cord clamping IYCF counseling
multiple micronutrients
Christian
Fig – Nutrition risk factors and interventions for P. Nutrition
maternal, neonatal,andand
maternal, neonatal,
child health andanddevelopment.
child health.
Semin Perinatol. 2015 Aug;39(5):361-72
 Energy, Protein, And Fluid Needs In
Pediatric Pa&ents
Average
Age (yrs) Protein Fluid
Energy (kcal/ Requirement (g/ Requirement (ml/
kg) kg) kg)

0.0– 0.5 108 2.2 120 - 150

1-3 102 1.2 114 - 115
7 – 10 70 1.0 70 - 85
11 – 14 (BOYS) 55 1.0 70 - 85
(GIRLS)
47 1.0 70 - 85
15 – 18 (BOYS) 45 0.9 50 - 60
(GIRLS)
40 0.8 50 - 60
 Protein+Micronutrients

(/bodyweight kg) 1-3 years adult

Protein 1,17 g 0,75 g
Ess. fatty acid n6: 0,32 g 0,08 g
n3: 0,06 g 0,02 g
Ca 32 mg 14 mg
Iron 0,6 mg 0,2 mg
Vitamin-D 0,8 µg 0-0,8 µg
 Delayed cord clamping
•  é blood volume, HgB, Fe (fototh.)

Premature:
•  ê 39% transfusion
•  ê 41% IVH
•  ê 38% NEC

Christian P. Nutrition and maternal, neonatal, and child health.

Semin Perinatol. 2015 Aug;39(5):361-72
Koletzko B (2007) (ed) Kinderheilkunde und. Jugendmedizin, ed 13. Berlin, Springer
 Newborn - Nutri&on

• Breast feeding
•  Recommenda&on as exclusive breast feeding for 4-6
months.

•  Formula feeding
Suckling Hormonal Reflex Arc

Source: Lacta'on Educa'on Program Nutri'on Policy and Educa'on

 Page 21

Figure 1.
Milk protein concentrations, comparing milk from mothers who delivered preterm and term,
by gestational age at delivery and weeks postpartum (adapted from Bauer & Gerss, 2011).
 Table 1
Macronutrient (g/dL) and energy (kcal/dL) composition of human milk from specified references
NIH-PA Author Manuscript

Author (year), n Protein Fat Lactose Energy

Mean (± 2 SD) Mean (± 2 SD) Mean (± 2 SD) Mean (± 2 SD)

Term infants, 24-hour collection, mature milk

Nommsen et al (1991), n=58 1.2 (0.9, 1.5) 3.6 (2.2, 5.0) 7.4 (7.2, 7.7) 70 (57, 83)

Donor human milk samples

Wojcik et al (2009), n=415 1.2 (0.7, 1.7) 3.2 (1.2, 5.2) 7.8 (6.0, 9.6) 65 (43, 87)

Michaelsen et al (1990), n=2553 a 0.9 (0.6, 1.4) a 3.6 (1.8, 8.9) a 7.2 (6.4, 7.6) a 67 (50,115)

Representative values of mature milk, term infants

Reference standard 0.9 3.5 6.7 65 to 70

Preterm, 24-hour collection, first 8 weeks of life

NIH-PA Author Manusc

Bauer & Gerss (2011)

Born <29 weeks, n=52 2.2 (1.3, 3.3) 4.4 (2.6, 6.2) 7.6 (6.4, 8.8) 78 (61, 94)
Born 32-33 weeks, n=20 1.9 (1.3, 2.5) 4.8 (2.8, 6.8) 7.5 (6.5, 8.5) 77 (64, 89)

Preterm donor milk

Hartmann (2012), n=47 1.4 (0.8, 1.9) 4.2 (2.4, 5.9) 6.7 (5.5, 7.9) 70 (53, 87)

a
Median (lower bound)
 Breast Milk - Composi&on
Carbohydrate
–  Lactose is primary carbohydrate in milk
•  higher in breast milk vs. cow’s milk

 Breast Milk - Composi&on
Protein
–  Total protein 0.7 - 0.9 g/100 ml breast milk vs 3.5g/ 100 ml in cow’s milk
–  casein:lactalbumin (whey)
•  Breast milk (40:60)
•  Cows milk (80:20)
–  Amino Acids (Breast milk)
•  low in phenylalanine and methionine
•  high in taurine and cys&ne
 Breast Milk - Composi&on
Fats
–  higher in breast milk overall.
–  breast milk has more:
•  cholesterol (CNS myelin, enzymes)
•  linoleic acid (essen&al fady acid)
•  carni&ne (important for fat metabolism)
•  lipases (enzyme for diges&on of fats)
 Breast Milk - Composi&on
Minerals
– Generally lower in breast milk
• 6x more P; 4x more Ca and 3x more total
ash in cow’s milk (higher renal solute load than breast milk).
• However, bioavailability of some minerals
higher in breast milk [e.g. Fe (5x higher
absorp&on than cow’s milk), Zinc]
Fe is however low in milk and infant needs
alterna&ve source ajer 6 months
 Breast Milk - Composi&on

Vitamins
–  variable in breast milk depending on diet
–  Vitamin E higher in breast milk than cow’s milk and
Vitamin K low in both
 Breast Feeding
Advantages to Infants
•  Immunologic benefits
–  An&-infec&ous agents (Bifidus factor, lactobifidus (GIT
infec&on)
–  lactoferrin (iron absorp&on)
–  Immunoglobulins
•  Convenient and ready to eat.
•  Least allergenic
•  SIDS reduced
•  Protects against some chronic diseases e.g. obesity
•  Mother-infant bonding.
 Breast Feeding
Advantages to Mothers

•  May delay return of ovula&on.

•  Loss of pregnancy-associated
adipose &ssue and weight gain.
•  Suppresses post-partum bleeding.
•  Decreased breast cancer rate.
 Breast Feeding -Nutri&on
•  Weight padern - consistent weight gain.
•  Voiding - wet diapers/day
•  Stooling - generally more stools than
formula.
•  Feed-on-demand - every 2-3 hours.
•  Dura&on of feedings - generally 10-20 min/
side.
 Are there any contraindica&ons?

•  HIV , HLTV 1 & 11 infec&ons (depending on

socio-economic status)
•  Ac&ve Tuberculosis.
•  Herpes lesions on mother’s breast.
•  Infant with inborn error of metabolism:
galactosemia, phenylketonuria.
•  Mothers on certain medica&ons ; an&cancer
therapy, radioac&ve isotope etc.
 Human Milk Subs&tutes
•  Wet nurses
•  Other mammalian milk (cow, goat, donkey, camel)
•  Pablum: bread/flour, mixed with water
–  bread, water, flour, sugar etc..
 Preterm
•  under 27 gw, below 1000g
•  IUGR
•  unstable, respirated
•  asphyxia, CPR

•  Necro&sing enterocoli&s
–  bilous/bloody gastric resid./ stool
–  coloured abdominal wall (lila, blue)
 MM
•  own/collated
•  for&fing

•  Formula: if nothing else available

 Feeding
•  1. day
–  cri&cal: 10ml/kg/day NG tube
–  28-31 gw: 20
–  32-34: 30

•  raise: 20 ml/kg/day
 Mother milk Formula
Composi6on physiological different
Sterility easy hard
Immunology IgA, complement, etc… none(?)
Protein physiological other species
Gut microbiom L. bifidus coliform (c. sec&on!!!)
Mother-child rela6on in&mate less
Taste varied fixed
Technic easy difficult (depends on
mothers IQ)
Component Function Chemokines
Reference

Cells G-CSF Trophic factor in intestines

Macrophages Protection against infection, T-cell Jarvinen, 2002, Yagi, 2010, Ichikawa, 2003

NIH-PA Author Manuscript

activation MIF Macrophage Migratory Inhibitory Factor:
Prevents macrophage movement, increases
Stem cells Regeneration and repair Indumathi, 2012 anti-pathogen activity of macrophages
Immunoglobulins Cytokine Inhibitors
IgA/sIgA Pathogen binding inhibition Van deTNFRI
Perre, 2003,
and IICianga, 1999; Brandtzaeg,
Inhibition 2010;
of TNFα, anti-inflammatory
Kadaoui, 2007; Corthësy, 2009; Hurley, 2011; Agarwal, 2010;
Castellote,
Growth2011Factors
IgG Anti-microbial, activation of phagocytosis Cianga,
EGF1999; Agarwal, 2010 Stimulation of cell proliferation and
(IgG1, IgG2, IgG3); anti-inflammatory, maturation
response to allergens (IgG4)
Ballard and Morrow
IgM Agglutination, complement activation Brandtzaeg, 2010; Van de Perre, 1993; Agarwal, 2010

Cytokines HB-EGF Protective against damage from hypoxia

and ischemia
IL-6 Stimulation of the acute phase response, B Ustundag, 2005; Meki, 2003; Mizuno, 2012; Agarwal, 2010;
cell activation, pro-inflammatory Component
VEGF
Castellote, 2011 Function
Promotion of angiogenesis and tissue repair

IL-7 Increased thymic size and output NGF2011; Ngom, 2004

Aspinall, Promotion of neuron growth and maturation
NIH-PA Author Manuscript

IL-8 Recruitment of neutrophils, pro- Claud, 2003; Ustundag, 2005; Meki, 2003; Maheshwari, 2002;
inflammatory IGF 2003; Maheshwari,
Maheshwari, Stimulation
Pediatr2004;
Clin Amof. Author
Hunt, 2012;
North growth and development,
manuscript; available
increased
Agarwal, 2010; Castellote, 2011; Mehta, 2011 RBCs and hemoglobin

IL-10 Repressing Th1-type inflammation, Meki, 2003; Agarwal, 2010; Castellote, 2011; Mehta, 2011
induction of antibody production,
facilitation of tolerance
Erythropoietin Erythropoiesis, intestinal development
IFNγ Pro-inflammatory, stimulates Th1 response Hrdý, 2012; Agarwal, 2010

TGFβ Anti-inflammatory, stimulation of T cell Penttila, 2010;

phenotype switch Kalliomäki, 1999; Saito, 1993; Nakamura, 2009;
Letterio,
Hormones1994; Ando, 2007; Ozawa, 2009;
Donnet-Hughes, 2000; Verhasselt, 2008; Verhasselt, 2010;
Penttila, 2003; Mosconi, 2010; Okamoto,
Calcitonin 2005;
Development of enteric neurons
Penttila, 2006; Peroni, 2009; McPherson, 2001;
Ewaschuk, 2011; Castellote, 2011 Regulation of gastric epithelial growth
Somatostatin
TNFα Stimulates inflammatory immune activation Rudloff, 1992; Ustundag, 2005; Erbağci, 2005; Meki, 2003;
Anti-microbial
Agarwal, 2010; Castellote, 2011
anuscript
Hormones
Calcitonin Development of enteric neurons Struck, 2002; Wookey, 2012

Somatostatin Regulation of gastric epithelial growth Chen, 1999; Rao, 1999; Gama,

Anti-microbial
Lactoferrin Acute phase protein, chelates iron, anti- Adamkin, 2012; Sherman, 2004
bacterial, anti-oxidant Hirotani, 2008; Buccigrossi, 20

Lactadherin/ Anti-viral, prevents inflammation by Stubbs, 1990; Kusunoki, 2012;

MFG E8 enhancing phagocytosis of apoptotic cells Chogle, 2011; Baghdadi, 2012;
Newburg, 1998; Shah, 2012; M
Miksa, 2009; Wu, 2012; Matsu
NIH-PA Author Manuscript

Metabolic hormones
Adiponectin Reduction of infant BMI and weight, anti- Martin, 2006; Newburg, 2010;
inflammatory Ley, 2011; Dundar 2010; Ozard
Weyerman, 2006

Leptin Regulation of energy conversion and infant Savino, 2008; Savino, 2012a; S
BMI, appetite regulation Weyermann, 2006

Ghrelin Regulation of energy conversion and infant Savino, 2008; Savino, 2012; Du
BMI

Oligosaccharides & glycans

HMOS Prebiotic, stimulating beneficial Newburg, 2005; Morrow, 2005

colonization and reducing colonization with 2012;
pathogens; reduced inflammation Kunz, 2012; Ruhaak, 2012; Bo

Gangliosides Brain development; anti-infectious Wang B, 2012

Glycosaminoglycans Anti-infectious Coppa, 2012; Coppa 2011

Mucins
MUC1 Block infection by viruses and bacteria Ruvoen-Clouet, 2006; Liu, 201
Yolken, 1992
NIH-P

MUC4 Block infection by viruses and bacteria Ruvoen-Clouet, 2006; Liu, 201
 Standard Formula – Nutriton
cow’s milk-based formula

•  Caloric density: 0.67 calories/cc.

•  Protein content: ra&o 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 fady acids.
•  Carbohydrate: lactose, beneficial effect on mineral
absorp&on (Ca, Zn, Mg), and on colonic flora.
•  Micronutrients: Higher vitamin and mineral content
than human milk to cover 97% of the popula&on.
 Higher protein intake in infancy is associated with a higher
weight in the first 2 years of life33

Koletzko et al. Lower protein in infant formula is associated with lower weight up to age 2 y:
a randomized clinical trial. Am J Clin Nutr. 2009 Jun;89(6):1836-45

33. Koletzko et al 2009

 Higher protein intake in young children is associated with the
risk of increased BMI and body fat at 7 years of age

A maintained high
protein in the
second year of life is
related to a more
than 2-fold risk of
increased BMI (body
mass index) and
percentage body fat
at 7 years

OBSERVATION STUDY
IN YOUNG CHILDREN

34. Adapted from: Günther et al. 2007

Günther et al. 2007
 Formula

CMP Soy

Intact
Hydrolyzed
(CMP)

Par&ally Extensively Aminoacid

(pHF) (eHF) (AA)

whey casein whey casein

(pHF-W) (pHF-C) (eHF-W) (eHF-C)
 Formula

CMP

Normal High
energy energy

Extensively
Intact
hydrolyzed

infant toddler adult infant special

62, Number 4, April 2016 ID, VDD Iron and Vitamin D Deficiency in Healthy

Diet
- Iron and vitamin D intake
Sun exposure
- Composition of the diet
(calcium, vitamin C, etc) - Season
- Type and amount of milk - Skin pigmentation
- Supplement use - Degree of altitude
- Time spent outdoors

?
Iron deficiency Vitamin D eficiency

Iron deficiency
Demographic factors
anaemia
- Sex
- Age
- Ethnicity
- Socioeconomic status
- Day care attendance

diagram for iron and vitamin D deficiency. Akkermans et al. JPGN 2016;62: 635–642
 When do you start solids?
Complementary feeding
•  4-6 months
–  fruits/vegetables/rice cereals
•  6 mo: sits, sweeps with lips
•  8 mo: chew, swallow more lumpy food
•  9-12 mo: developed manual skills
 When will you give possible
allergens?
•  There is no clear evidence.

•  So:
I don’t know. Not even gluten 😞
(Allergy vs. tolerance)

Cow’s milk: past 1 year (Na, iron, protein)

 Please
Do not put extra

•  SUGAR

or

•  SALT
 Energy Distribu&on

CARBOHYDRATE 50% - 60%

FAT 30%- 40%

PROTEIN 10% - 15%
 Obesity - E&ology and Treatment
•  E&ology:
–  Gene&c predisposi&on: 80% risk if both parents
obese
–  Environment
–  Dietary intake
–  Physical ac&vity / sedentary ac&vity
•  Treatment:
–  Mul&disciplinary and comprehensive
–  Formal behavior modifica&on
–  Family-based
Obesity - Consequences

•  Cardiovascular disease risk

•  Type 2 diabetes (epidemic)
•  Hypertension
•  Orthopedic
•  Sleep apnea
•  Gall bladder disease/steatohepa&&s
•  Psychosocial problems
 Case
•  Severe abdominal pain
•  Vomi&ng
•  poor general state

•  Jaundice
 Diagnosis?
•  Acute pancrea&&s
 Therapy?
•  Fluid balance/resuscita&on
•  AB?
•  Feeding
–  NG/enteral tube
–  con&nuos
–  which formula?
–  PN
Case 2.
 11-year old boy
Symptoms: Laboratory results
•  Abdominal pain —  CRP: 19.2 mg/mL
•  Diarrhoea —  ESR: 65 mm/hour
•  Weight loss —  HCT: 33%
•  Iron-deficiency anaemia —  seFe: 2.8 umol/L
•  Perianal fistula —  Albumin: 40 g/L

Body metrics
•  Percen&le body weight: 50–75%
•  Percen&le height: 90–97%
CRP = C-reac&ve protein
ESR = erythrocyte sedimenta&on rate
HCT = haematocrit
seFe = serum ferri&n
 Ac6ve Crohn’s disease

Severe growth retarda6on / Mild / Moderate Severe

Severe perianal fistulas /
Predictors of severe outcomes
EEN tolerated? In very severe, isolated
Crohn coli6s cases
To be considered No (mild/moderate) Yes No (severe)
in selected cases
EEN (for 6–8 W)
Budesonide (for 12 W)
No response po. Prednisolone
± 5-ASA or AB

Clinical remission No response

Biologic therapy
No response
No response iv. Me6lprednisolone

Other therapies
to be considered Maintenance therapy 5-ASA = 5-aminosalicylic acid
AB = an&bio&cs
Ruemmele F, et al. J Crohns Coli's 2014;8:1179–1207
EEN = exclusive enteral nutri&on
iv = intravenous
Po = per os