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Pediatric Nutrition. Gestational Age and Size. Low birth weight (LBW) – an infant who weighs less than 2500 g at birth Very low birth weight (VLBW) – an infant who weighs less than 1500 g at birth Extremely low birth weight (ELBW) – an infant weighing less than 1000 g at birth

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Pediatric Nutrition

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Pediatric nutrition

Pediatric Nutrition

Gestational age and size

Gestational Age and Size

  • Low birth weight (LBW)– an infant who weighs less than 2500 g at birth

  • Very low birth weight (VLBW)– an infant who weighs less than 1500 g at birth

  • Extremely low birth weight (ELBW)– an infant weighing less than 1000 g at birth

  • LBW may be attributable to a shortened period of gestation, prematurity, or a restricted intrauterine growth rate

Gestational age and size1

Gestational Age and Size

  • Term infant– born between 37th and 42nd weeks of gestation

  • Preterm infant (premature)– born before 37 weeks of gestation

  • Postterm infant– born after 42 weeks of gestation

Gestational age and size2

Gestational Age and Size

  • Small for gestational age (SGA)– infant with birth weight less than 10th percentile

  • Asymmetrical intrauterine growth restriction (IUGR)– infant with normal length and HC measures, but weight is below 10th percentile

  • Symmetrical intrauterine growth restriction – infant with weight, length, and HC <10th percentile

  • Appropriate for gestational age (AGA)– birth weight between 10th and 90th percentile

  • Large for gestational age (LGA)– birth weight >90th percentile

Premature infants

Premature Infants

  • Most nutrients are deposited during the last 3 months of gestation; therefore, premature infants begin life in a compromised state of nutrition

  • Fat constitutes 1% total body weight in preterm infant weighing 1000 g compared to a term infant weighing 3500 g with ~16%

  • Preterm infant will rapidly run out of fat and CHO fuels unless adequate nutrition support established

  • PN initiated immediately for VLBW infants

Premature infants1

Premature Infants

  • Common problems among premature infants:

    • Respiratory – RDS, CLD, BPD

    • Cardiovascular – patent ductusarteriosus (PDA)

    • Renal – fluid/electrolyte balance

    • Neurologic – intraventricular hemorrhage

    • Metabolic – hypoglycemia, hyperglycemia, hypocalcemia, metabolic acidosis

    • GI – hyperbilirubinemia, feeding intolerance, NEC

    • Hematologic – anemia

    • Immunologic – sepsis, pneumonia, meningitis

    • Other – bradycardia, apnea, cyanosis, osteopenia

Premature infants2

Premature Infants

  • May have difficulty progressing to full enteral feeding in first several days or weeks of life d/t small stomach capacity, immature GI tract and illness

  • PN becomes essential either as full nutrition support or in addition to EN

  • Important to initiate EN as soon as possible to stimulate GI enzymatic development and activity, promote bile flow, increase villous growth in the small intestine, and promote mature GI motility

Parenteral nutrition for preterm infant

Parenteral Nutrition for Preterm Infant

  • Energy:

    • 30-50 kcals/kg 1st 3 days of life

    • Increase gradually to 90-100 kcal/kg to support growth

  • Protein:

    • 1.5-3 g/kg/day initially

    • Some ELBW infants may need 3.5-4 g/kg/day

  • Lipids:

    • 1-2 g/kg/day initially

    • Advance to 3 g/kg/day

    • Premature infants have limited ability to produce carnitine, so carnitine is frequently added to PN to facilitate mechanism by which FA’s are transported across the mitochondrial membrane

Enteral nutrition for preterm infant

Enteral Nutrition for Preterm Infant

  • Energy:

    • 50 kcals/kg 1st 3 days of life

    • Gradually increase to 105-130 kcals/kg for growth

    • Some preterm infants may need >130 kcals/kg

  • Protein:

    • 3.5-4 g/kg/day

    • Whey-predominant formulas most appropriate

    • Too much casein can irritate infants GI tract causing GIB, anemia

  • Lipids:

    • 40-50% total kcals

    • Essential FA’s added to premature infant formulas since premature infant has less stores

    • MCTs more appropriate as premature infant has low levels of pancreatic lipase and bile salts



  • Standard infant formula is 20 kcals/oz

    • Ex/ Enfamil, Similac

  • Premature infant formulas RTF are 22 and 24 kcal/oz

    • Ex/ Enfamil Premature, SimilacNeosure

  • Additives to increase kcals to 26, 28 or 30 kcals/oz

    • MCT oil (7.7 kcals/ml)

    • Microlipid ( 4.5 kcals/ml)

    • Corn oil (8 kcals/ml)

    • Karo syrup (4 kcals/ml)

    • Polycose (8 kcals/ml)

    • Promod or protein supplement (5.5 kcals/1 g pro/tsp)



  • Formulas can come in 3 different forms:

    • Ready to feed (RTF)

      • No preparation

      • No mixing or adding water necessary

      • Most expensive

    • Concentrate liquid (12 oz can)

      • 40 kcal/oz undiluted

      • Must add 12 oz water to 12 oz formula (1:1 ratio) to make 20 kcal/oz formula

      • 1 can should last ¾-1 day

    • Powder

      • 1 scoop powder to 2 oz water to make 20 kcal/oz formula

      • Least expensive

      • 1 can should last 3-4 days

Special formulas

Special Formulas

  • Soy-based

  • Lactose free

  • Elemental

  • Metabolic formulas

  • Hypoallergenic

  • Human milk fortifier (HMF)

How to get a diet history for an infant

How to get a diet history for an infant?

  • Interview parent or caregiver and obtain the following information:

    • What type of formula does the infant receive?

    • How do you mix/prepare the formula?

    • How much formula is given and how often is it given?



  • Infants should stay on breast milk or formula for their first year of life

  • Transition to whole milk at 1 year

  • Then to 2% or skim milk at 2 years

Whey vs casein

Whey vs. Casein

  • Whey protein preferred for preemies

  • Whey is easier to digest

  • Casein can irritate GI tract and cause GIB or anemia

  • Too much casein causes hard rocks or curds in infant’s stomach and can lead to obstruction

  • Less allergies associated with whey

Whole milk vs breast milk formula

Whole milk vs. Breast milk/Formula

  • Breast milk (20 kcal/oz)

    • “gold standard”

    • Whey:casein is 70:30

  • Cow’s milk (18.6 kcal/oz)

    • Too high RSL – contains 3x protein and mineral content of breast milk renal failure, dehydration

    • Whey:casein is 20:80

    • Not enough vitamins/minerals (low Fe)

    • Not enough fat with 2% or skim; not enough EFA’s



  • Breast milk is 290 mOsm/kg

  • Infant formulas 180-300 mOsm/kg

  • Whole milk 288 mOsm/kg

  • Goat’s milk 339 mOsm/kg

  • Karo syrup 2198 mOsm/kg

  • Apple Juice 705 mOsm/kg

  • Cola 714 mOsm/kg

Pediatric disorders

Pediatric Disorders

  • Necrotizing Enterocolitis (NEC)

  • Gastroschesis

  • Hirschsprung’s Disease

  • Intestinal Atresia

  • Congenital Heart Disease

  • Bronchpulmonary Dysplasia (BPD)

  • Failure to Thrive

  • Cystic Fibrosis (CF)

  • Cerebral Palsy (CP)

  • Down Syndrome

  • Spina Bifida

  • Fetal Alcohol Syndrome (FAS)

  • Cleft Lip or Cleft Palate

  • PraderWilli Syndrome

  • Metabolic Disorders

Pediatric gi disorders necrotizing enterocolitis nec

Pediatric GI Disorders – Necrotizing Enterocolitis (NEC)

  • Definition: Acute inflammatory bowel disorder characterized by ischemic necrosis of GI mucosa

    • Primarily occurs in preterm or low birth weight neonates

    • Can result in peritonitis or perforation

    • Very serious and can be fatal

    • Leading cause of SBS in infants

Pediatric gi disorders necrotizing enterocolitis nec1

Pediatric GI Disorders – Necrotizing Enterocolitis (NEC)

  • Symptoms

    • Distended abdomen

    • Lethargy

    • Respiratory distress

    • Pallor

    • Hyperbilirubinemia

    • Vomiting

    • Diarrhea

    • Bloody stools

    • Sepsis

    • Decreased or absent bowel sounds

Pediatric gi disorders necrotizing enterocolitis nec2

Pediatric GI Disorders –Necrotizing Enterocolitis (NEC)

  • Diagnosis

    • X-ray

    • Presence of peritoneal fluid

  • Treatment

    • Surgery w/ possibility of ostomy

    • ABT

    • PN for 14-21 days s/p surgery

    • IVFs

    • Transition to aggressive enteral feeding; BM if possible

Pediatric gi disorders necrotizing enterocolitis nec3

Pediatric GI Disorders – Necrotizing Enterocolitis (NEC)

  • Nutrition Intervention

    • Acute:

      • PN for 14-21 days s/p surgery

      • Transition to aggressive enteral feeding; BM if possible

    • Recovery:

      • 2 x RDA for protein

      • 25% more kcals than normal for age

      • Frequent feedings

    • Elemental formulas may be best

      • Pregestimil, Nutramigen

    • Iron supplement

Pediatric gi disorders gastroschisis

Pediatric GI Disorders – Gastroschisis

  • Definition: congenital defect characterized by incomplete closure of the abdominal wall with protrusion of the intestines

    • Type of hernia

  • Symptoms (noticed before birth)

    • Lump in abdomen

    • Intestine sticks through the abdominal wall near the umbilical cord

Pediatric gi disorders gastroschisis1

Pediatric GI Disorders – Gastroschisis

  • Treatment

    • Careful delivery

    • Surgery to repair the defect

      • If possible, place bowel back into the abdomen and close the defect

      • If abdominal cavity is too small, a mesh sack is stitched around the borders of the defect and the edges of the defect are pulled up.

      • Over time, the herniated intestine falls back into the abdominal cavity, and the defect can be closed.

    • PN

    • Antibiotics

    • Keep body temperature controlled

Pediatric gi disorders

Pediatric GI Disorders

Pediatric gi disorders gastroschisis2

Pediatric GI Disorders – Gastroschisis

  • Even after surgery, infant may have problems with feeding, digestion, and absorption

    • CDC reports 1 in 1,871 births

    • CDC researching etiology; reports increased risk with:

      • Smoking

      • Young age of mother

      • Mother with genitourinary tract infection during pregnancy

Pediatric gi disorders hirschsprung s disease

Pediatric GI Disorders – Hirschsprung’sDisease

  • Definition: condition in which there is a congenital absence of ganglion cells in the smooth muscle wall of the colon, which causes poor or absent peristalsis

    • Also known as congenital megacolon

  • Symptoms

    • Segments of the bowel become obstructed

    • Abdominal distention

    • Vomiting

    • Constipation or diarrhea

    • Growth failure, anorexia, weight loss

Pediatric gi disorders hirschsprung s disease1

Pediatric GI Disorders – Hirschsprung’sDisease

  • Treatment

    • Surgical removal to alleviate obstruction

    • Temporary colostomy

    • Replace electrolytes and fluid

  • Complications of surgery

    • Stricture formation

    • Enterocolitis

    • Wound infections

  • Incidence: 1 in 5,000 births

  • Surgery usually occurs at 6 mos or older

Pediatric gi disorders hirschsprung s disease2

Pediatric GI Disorders – Hirschsprung’s Disease

  • Nutrition Therapy

    • High kcal/high pro diet

    • Supplements

    • May need EN

    • TPN if large sections of bowel are removed

    • Provide adequate fluid

    • Monitor electrolytes

    • May receive EN and TPN simultaneously

Pediatric gi disorders intestinal atresia

Pediatric GI Disorders –Intestinal Atresia

  • Definition: congenital defect of small or large intestine characterized by narrowing or absence of a portion of the intestine

  • Type based on location:

    • Duodenal atresia - malformation of the duodenum (most common)

    • Jejunal atresia - malformation of the jejunum

    • Ileal atresia - malformation of the ileum

    • Colon atresia - malformation of the colon

Pediatric gi disorders1

Pediatric GI Disorders

  • Duodenal Atresia

Pediatric gi disorders intestinal atresia1

Pediatric GI Disorders –Intestinal Atresia

  • Etiology

    • Vascular accident in utero

    • Superior mesenteric artery (SMA) occlusion

    • Problem with development of duodenum in utero; can affect other areas

  • Incidence

    • 1 in 2,500 duodenal atresia

    • 1 in 1,000 ileal or jejunal atresia

Pediatric gi disorders intestinal atresia2

Pediatric GI Disorders – Intestinal Atresia

  • Symptoms

    • No stool passed

    • Swollen belly from gas

    • Vomiting; vomit may be yellow or greenish in color

    • Lack of desire to eat

  • Treatment

    • Surgery to remove the damaged portion and join the intestine back together

    • May need ostomy

Pediatric disorders intestinal atresia

Pediatric Disorders – Intestinal Atresia

  • Nutrition Therapy

    • Enteral feedings are carefully started after signs peristalsis noted

    • PO intake if tolerated

      • Breast milk is preferable; formula w/ low osmolality

      • Increased concentration and volume as the patient tolerates the formula.

    • Achieving full enteral nutritional support takes average of 5-7 days, but may be weeks or even months later.

    • May need PN if anticipated prolonged return of intestinal function

Congenital heart disease

Congenital Heart Disease

  • Most common birth defect in U.S.

  • 12-14 of 1,000 births

  • Usually caused by a developmental defect that occurred b/w weeks 5 and 8 of pregnancy

  • Defects can involve the walls of the heart, the valves of the heart, and the arteries and veins near the heart

  • Increased energy expenditure

  • Feeding difficulties common

  • Surgical repair may be delayed to allow weight gain

  • Heart transplant

Congenital heart disease chd

Congenital Heart Disease (CHD)

Cerebral palsy cp

Cerebral Palsy (CP)

  • Condition not a disease

  • Results from brain damage to motor centers before, during, or after birth

  • 1 in 500 births may be affected

  • CP causes non-progressive physical and mental disabilities

  • Infants may present with abnormal rolling, stiffness, irritability, developmental delays

  • Also seizures, mental retardation, hyperactive gag reflex, tongue thrust, poor lip closure, inability to chew properly, and behavioral problems

Cerebral palsy cp1

Cerebral Palsy (CP)

  • Spastic CP – affects 75%

    • Uncontrolled shaking or difficult, stiff movement

  • Athetoid CP – affects 15%

    • Involuntary worm-like movement

  • Ataxic CP – affects about 10%

    • Impaired coordination and balance

  • Many individuals have a mixed form of CP

  • Wasting of voluntary muscles contributes to reduced resting energy needs

Cerebral palsy cp2

Cerebral Palsy (CP)

  • Energy requirements depend on functional capacity

  • Reduced energy intake for spastic CP or those with severely limited activity

    • 11 kcal/cm for ages 5-11

  • Moderately active

    • 14 kcal/cm ages 5-11

  • Over age 18 with athetoid CP

    • 45 kcals/kg

Cerebral palsy cp3

Cerebral Palsy (CP)

  • May need feeding tube

  • Soft, pureed foods

  • May need anti-emetic for frequent vomiting

  • Thicken foods and liquids for constant dribbling/drooling

  • High fiber or laxative for constipation

  • MVI supplement

  • High risk for pressure ulcers

  • May need adaptive feeding equipment

Down syndrome

Down Syndrome

  • Congenital defect

  • Patients carry altered chromosome

  • Trisomy patients have an altered chromosome 21

  • Characteristics include short stature, decreased muscle tone, constipation, intestinal defects, weight changes, mental retardation

  • Higher risk for congenital heart disease, celiac disease, Hirschsprung’s disease, hypothyroidism, leukemia, respiratory problems, GERD

  • Incidence often related to maternal age

Down syndrome1

Down Syndrome

  • Provide adequate energy and nutrients for growth

  • Use “Down Syndrome” growth charts

  • Introduction of solid food may be delayed

  • Treat obesity with balanced diet and increase in physical activity; do not restrict energy

  • Assist with feeding problems

  • Avoid overfeeding

  • Manage GI complications, constipation

Failure to thrive ftt

Failure to Thrive (FTT)

  • Term used to describe infants and children who fail to grow and develop at a normal rate

  • Protein, energy, vitamin and mineral insufficiency indicated

  • 1/3 of pediatric patients in acute care are malnourished

  • FTT can be caused by medical or social factors

  • Prompt diagnosis and treatment are important to prevent malnutrition and developmental delays

Failure to thrive ftt1

Failure to Thrive (FTT)

  • Weight is most reliable marker for FTT

  • Characteristics include small HC, muscular wasting, apathy, weight loss, poor weight gain

  • Primary FTT – originates from social/environmental deficits, inadequate feeding procedures, or caretaker behaviors

  • Secondary FTT – originates from disease states

    • Ex/ CF, cancer, cleft lip/palate

Failure to thrive ftt2

Failure to Thrive (FTT)

  • Nutritional Interventions:

    • Additional kcals for “catch-up” growth at ~150% of energy requirement for their expected age (not actual age)

    • Teach caregiver how to properly feed and prepare formula or meals

      • Provide schedule for feeding

      • May need higher kcal formula

    • Achieve daily weight gains of 30 g for infants

Fluid requirements

Fluid Requirements

Energy and protein requirements

Energy and Protein Requirements

Catch up growth

Catch-Up Growth

  • Involves rapid increase in weight, length, and head circumference and continues until the normal individual growth pattern is resumed

  • Commonly done w/ premature infants and infants with FTT

  • Goals:

    • Improve energy intake

    • Promote weight gain

    • Allow optimum growth

    • Correct nutritional deficiencies

Pediatric nutrition

  • Estimating Catch-Up Growth Requirements

  • 1. Plot the child's ht and wt on the NCHS growth chart

  • 2. Determine the child's recommended calories for age (RDA/RDI)

  • 3. Determine the IDEAL WT (50th %ile) for the child's HT

  • 4. Multiply the RDA calories by IDEAL BODY WT FOR HT (kg)

  • 5. Divide this value by the child's actual wt

  • Catch-up growth requirement:

  • RDA calories for age x ideal wt for ht (kg)

  • Actual wt

  • Protein requirements:

  • RDA for protein for age x ideal wt for ht (kg)

  • Actual wt



Age: 16 weeks

Weight: 4.2 kg (<2nd %)

Length: 58 cm (2-5th%)

IBW: 5.6 kg

Calculate catch-up growth:

= RDA calories for age x ideal wt for ht (kg)

Actual wt

= (108 kcals/kg x 5.6 kg) / 4.2 kg

= 144 kcals/kg for catch-up growth

Spina bifida

Spina Bifida

  • Serious birth defect of the spine and brain caused by neural tube defect during 3rd and 4th week of pregnancy

  • Caused primarily by folate deficiency

  • Pre-conceptional consumption of folic acid reduces occurrences of NTDs by 50-70% (CDC)

  • Genetic MTHFR polymorphisms in mother may cause congenital folate malabsorption, regardless of whether diet is deficient in folate or not

Spina bifida1

Spina Bifida

  • Spina bifida includes any congenital defect involving insufficient closing of the spine

  • Anencephaly forms when the brain does not close

  • Decreased energy needs d/t short stature and limited mobility; obesity is common

  • Manage feeding problems

  • May need tube feeding

Fetal alcohol syndrome fas

Fetal Alcohol Syndrome (FAS)

  • Mental and physical defects that develop in the fetus when a woman drinks alcohol during pregnancy

  • Effects include growth retardation, facial stigmata, damaged neurons and brain structures which can result in psychological or behavioral problems

  • 0.2-1.5 in every 1000 births

Fetal alcohol syndrome fas1

Fetal Alcohol Syndrome (FAS)

  • Criteria for FAS:

    • Growth deficiency

    • FAS facial features

      • Smooth filtrum (groove b/w upper lip and nose)

      • Thin upper lip

      • Small palpebral (b/w upper lip and lower eyelid)

    • Central nervous system damage

    • Prenatal alcohol exposure

Fetal alcohol syndrome fas2

Fetal Alcohol Syndrome (FAS)

Fetal alcohol syndrome fas3

Fetal Alcohol Syndrome (FAS)

  • Nutrition Assessment

    • Height and/or weight may be below 3rd percentile

    • Some infants have FTT

    • Feeding problems common

      • Weak suck

      • Oral motor problems

    • Energy and nutrient needs are same as for non-affected child

Cleft lip or cleft palate

Cleft Lip or Cleft Palate

  • Most common craniofacial birth defect

  • Cleft lip – opening of the upper lip

  • Cleft palate – roof of mouth has not joined completely

  • Result from incomplete merging and fusion of embryonic processes during formation of the face

  • 1 in 700 births

  • Risk factors include genetics, maternal folic acid deficiency, smoking, alcohol use, anticonvulsant use, and some maternal illnesses

Cleft lip and cleft palate

Cleft Lip and Cleft Palate

Prader willi syndrome


  • Disorder caused by DNA abnormalities of chromosome 15

  • Characteristics include infant hypotonia, hypogonadism, mental retardation, small hands/feet, atypical facial features and obesity d/t insatiable appetite in early childhood

  • 1 in 10,000-16,000 births in U.S.

  • Symptoms present at 1-4 years of age

    • Delayed motor development and hyperphagia w/ obesity

Prader willi syndrome1


  • Ghrelin levels are high in PWS

    • Ghrelin stimulates appetite and food intake

  • Patients w/ PWS are not able to control their food intake and often sneak or steal food; gorging behaviors

  • Nutrition therapy involves avoiding excessive weight gain

    • Promote exercise

    • Secure food

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