Pediatric Nutrition

1. Pediatric Nutrition Darwin Deen, MD, MS RPSM July 27,2001

2. Overview Newborn feeding Formulas Requirements Infant Feeding Beikost Nutrient sources Toddler Diet School-aged children Special Topics: Obesity Eating disorders Food Intolerance Healthy Eating Resources

3. Developmental Stages Infants: newborn, 1, 2, 4, 6, 9, 12 months Toddlers: 15, 18, 24, 36, and 48 months Children: 5, 6, 8, 10 y.o. Adolescents: 11-21 yrs.

4. Newborns Breastfeeding for 6-12 months Iron-supplemented formula as an alternative. Low iron formulas do not reduce GI symptoms. Soy-based formulas for intolerance symptoms but not for allergy. Breastfeeding reduces hospitalizations, reduces respiratory infections, otitis media, and diarrhea. May reduce allergy. 21-29 oz formula per day in 4-6 feedings or 6-8 nursings.Breastfeeding reduces hospitalizations, reduces respiratory infections, otitis media, and diarrhea. May reduce allergy. 21-29 oz formula per day in 4-6 feedings or 6-8 nursings.

5. Breast vs. Formulas Cow�s Milks-based formulas: SMA, Enfamil: Casein:Whey=40:60 Similac, Gerber: 82:18, Good Start: 0:100, All contain palm, soy, coconut, & sunflower oils Soy-based formulas: ProSobee: Soy Protein with L-Methionine, Corn Syrup solids, Palm, soy, coconut, & sunflower oils Isomil: Soy Protein with L-Methionine, Corn Syrup & sucrose, soy & coconut oils (Isomil SF is made with hydrolysed cornstarch)Cow�s Milks-based formulas: SMA, Enfamil: Casein:Whey=40:60 Similac, Gerber: 82:18, Good Start: 0:100, All contain palm, soy, coconut, & sunflower oils Soy-based formulas: ProSobee: Soy Protein with L-Methionine, Corn Syrup solids, Palm, soy, coconut, & sunflower oils Isomil: Soy Protein with L-Methionine, Corn Syrup & sucrose, soy & coconut oils (Isomil SF is made with hydrolysed cornstarch)

6. Requirements Calories Protein Iron Calcium Zinc

7. Requirements Calories: Infants: 105 kcal/kg/d Toddlers: 90-100 kcal/kg/d Children: 80-90 kcal/kg/d Adolescence: 2100-2200 cal/d for females and 2700-2800 cal/d for males

8. Infants Introduce solids at 4-6 months when neuromuscular development is adequate: head control, ability to sit up, extrusion reflex has disappeared, infant swallows solids. Early introduction of solids increases risk of food intolerance & overfeeding. Start with a cereal (rice or barley) & add new foods one at a time. There is no correlation between solids and sleep. Do not add solids to a bottle, when the child is ready, feed with a spoon. Wean from the bottle when the infant can drink four 4-oz cups of milk per day. Use whole milk until age 2. There is no correlation between solids and sleep. Do not add solids to a bottle, when the child is ready, feed with a spoon. Wean from the bottle when the infant can drink four 4-oz cups of milk per day. Use whole milk until age 2.

9. Infants* 1-4 months-breast or formula only 4-6 months-cereals added 6-7 months-vegetables added 8-9 months-start finger foods (banana) & chopped (junior foods) 9 months- add meat and juices from a cup 10 months- egg yolk (cooked) & bite-sized cooked food 12 months- whole egg, cows milk, table foods 4-6 months: 29-32 oz formula or 4-5 nursings per day, 1-2 tsp cereal 1-2 X per day, 1-2 tsp strained fruits or veges 1-2 X per day *Trusswell AS: ABC of Nutrition 3rd Ed. BMJ Books, London, 1999, P.28, Box 5.6 4-6 months: 29-32 oz formula or 4-5 nursings per day, 1-2 tsp cereal 1-2 X per day, 1-2 tsp strained fruits or veges 1-2 X per day *Trusswell AS: ABC of Nutrition 3rd Ed. BMJ Books, London, 1999, P.28, Box 5.6

10. Infants Alternative strategy: Cereals at 6 months, fruits at 7, veges at 8, meats at 9. Start with 1-2 teaspoons increase gradually to 9 teaspoons (1 jar). At 9 months: 6-12 t cereal, � oz. Meat, 9-18 T fruit & vege, breast PRN or 26-31 oz formula. 6-9 Months: 30-32 oz formula in 3-5 feedings or 3-5 nursings per day, 2-3 Tbsp 2X/d, fruit juice 3-4 oz/d, mashed veges: 2-3 Tbsp/d, strained meats 1-2 Tbsp/d, �-1 teething biscuit or toast slice per day. 9-12 months: 24-30 oz formula in 2-4 feedings per day or 3-4 nursings, 2-4 T cereal 2X/d, 3-4 oz juice, Chopped Veges: 3-4 T 2X/d Chopped Fruits: 3-4 T 2X/d Strained Meats: 2-3 T 2X/d Bread: � to 1 serving 6-9 Months: 30-32 oz formula in 3-5 feedings or 3-5 nursings per day, 2-3 Tbsp 2X/d, fruit juice 3-4 oz/d, mashed veges: 2-3 Tbsp/d, strained meats 1-2 Tbsp/d, �-1 teething biscuit or toast slice per day. 9-12 months: 24-30 oz formula in 2-4 feedings per day or 3-4 nursings, 2-4 T cereal 2X/d, 3-4 oz juice, Chopped Veges: 3-4 T 2X/d Chopped Fruits: 3-4 T 2X/d Strained Meats: 2-3 T 2X/d Bread: � to 1 serving

11. Nutrients in Baby Foods Cereals are fortified with iron. Juices are fortified with Vit C. Fruits and vegetables supply vitamins & minerals. Meats supply protein and iron. Deserts supply only sugar and starches. Avoid dinners, deserts, and pudding.

12. Macronutrients in Foods

13. Food Sources of Nutrients Iron: red meats, legumes, green leafy veges, fortified cereals, dried fruit, peanut butter Calcium: dairy, greens, broccoli, legumes, tofu, almonds, sesame seeds Zinc: meats, seafood, eggs, milk Vit A: dark yellow & green veges Folate: dark green leafy veges and fruit Vit B6: whole grain cereals, seeds, nuts, legumes, potatoes

14. Home-made Thoroughly wash fresh or thaw frozen fruits or vegetables. Trim meats well. Use canned goods without added salt or sugar & rinse. Steam or boil until tender. Stew meats. Puree in blender or grinder. Add water to adjust consistency. Will keep refrigerated for 48 hrs or can be frozen in ice cube tray.

15. Toddlers Between 1 and 3 appetite declines along with growth rates. Parents require reassurance. Suggestions: provide small portions of �finger foods� to consume frequently. Avoid appetite stimulants. Counsel parents to avoid foods that present a choking risk: nuts, raisins, brittle crackers, hot dogs, peanut butter on spoon, whole grapes, hard candy, popcorn, raw carrots, whole corn & peas, etc. Counsel parents to avoid foods that present a choking risk: nuts, raisins, brittle crackers, hot dogs, peanut butter on spoon, whole grapes, hard candy, popcorn, raw carrots, whole corn & peas, etc.

16. Toddler Diet Whole milk, yogurt, cheese, custard or pudding, cottage cheese, ice cream Meat, fish, poultry, cooked beans Bread, cereal, starches Fruits VegetablesWhole milk, yogurt, cheese, custard or pudding, cottage cheese, ice cream Meat, fish, poultry, cooked beans Bread, cereal, starches Fruits Vegetables

17. School Age Children Advise 2-3 glasses of low fat or skim milk per day. Encourage physical activity and limit TV hours. Don�t use food as a reward. Encourage nutritious snacks. Encourage healthy family eating patterns.

18. Adolescents Body Image issues Encourage physical activity Discourage dieting Watch intake of soda and junk Reinforce healthy attitudes toward food and nutrition See Adolescent Nutrition presentation

19. Special Topics Obesity Eating Disorders Vegetarianism Food Intolerance/Allergy Healthy Eating Habits Drinks/Snacks

20. Obesity Weight for Height or BMI > 85%ile is overweight and > 95%ile is obese. Increasing prevalence in children and adolescence. Associated with parental obesity and inactivity (hours of TV). Prevention is easier than treatment. Encourage activity and healthy eating. Once obese child is identified, get family commitment to address the problem. Refer to a nutrition professional.Once obese child is identified, get family commitment to address the problem. Refer to a nutrition professional.

21. Eating Disorders Common onset in adolescence Be alert for body image disturbances Screen for medical complications Treat with nutritional and psychiatric interventions See Eating Disorders presentation

22. Vegetarianism Protein: combine protein sources to maximize biological value. eggs, grains, seeds, nut butters, hummus, tofu, soy milk, tempeh, dairy products, legumes, bean soups & chili, vege burgers, vegetables. See Francis Lappe�s Diet for a Small Planet for more on protein complementarity.See Francis Lappe�s Diet for a Small Planet for more on protein complementarity.

23. Vegetarianism Non-dairy Calcium sources: Green leafy veges: bok choy, kale, broccoli, mustard, turnip, beet, and collard greens Tofu Dry beans Sesame seeds or tahini Figs, almonds, molasses Fortified orange juice or soy milk See Francis Lappe�s Diet for a Small Planet for more on protein complementarity.See Francis Lappe�s Diet for a Small Planet for more on protein complementarity.

24. Food Intolerance/Allergy Allergy: immunologic reaction to food Intolerance: non-immunologic Clinically respiratory, gastrointestinal, dermatologic or systemic symptoms Challenge testing

25. Food Allergy More common in families with atopy history. Allergy symptoms: respiratory distress, vomiting, diarrhea. Foods to avoid: cow�s milk, eggs, nuts, fish, wheat. Pulmonary hemosiderosis, eosinophilic proctocolitis, enterocolitis, esophagitisPulmonary hemosiderosis, eosinophilic proctocolitis, enterocolitis, esophagitis

26. Food Allergy Symptoms GI: abdominal pain, bloating, diarrhea, malabsorption, nausea, vomiting, constipation Respiratory: asthma, chronic cough, runny nose, wheezing Dermatologic: eczema, atopy, urticaria, angioedema, itching, rash Systemic: anaphylaxis, headache, behavioral changes

27. Common allergens Milk Wheat Soy Nuts (ground or tree) Shellfish Beef Watermelon Corn egg

28. Food Intolerance Skin rashes GI symptoms: vomiting, diarrhea, constipation Upper respiratory symptoms: cough, runny nose

29. Healthy Eating Habits Provide 3 meals and 2 snacks daily. Choose foods from each food group and proportions according to the pyramid. Choose whole grains when possible. Avoid fatty or sugary items except in small portions after a meal.

30. Food Groups for children: Bread: 6 servings Fruit: 2 servings Vegetables: 2 servings Meat: 2 servings Dairy: 2 servingsFood Groups for children: Bread: 6 servings Fruit: 2 servings Vegetables: 2 servings Meat: 2 servings Dairy: 2 servings

31. Healthy Snacks 100% juice not sugar water. Avoid too much soda, candy, cake, non-juice soft drinks. Low fat Milk and cheese, yogurt, fruit, vegetables, muffins. PB&J on whole wheat bread.

32. Healthy Carbohydrates Whole grain breads Whole grain cereals Tortillas (esp. corn) Rice cakes Pita bread Pop Corn Pretzels

33. Healthy Fruits Whatever the child likes, including: Apples Bananas Pears Berries Oranges Melon Grapes Canned fruits

34. Healthy Vegetables Cooked or raw: Carrots, green peppers, cucumbers, radishes, cauliflower, tomatoes (grape or cherry) Cooked: Broccoli, green beans, peas, etc.

35. Healthy Protein Sources Low fat milk Turkey or chicken Yogurt Cottage or other low fat cheese Nuts Tuna Eggs

36. Fruit Juice AAP recent position paper on juices: Americans spend $5 billion per year on fruit juices. Most are little more than sugar water (11-16% CHO). 6 oz. Juice = 1 fruit serving. Use cup not a bottle to avoid tooth decay. No more than 4-6 oz per day for infants and 8-12 oz per day for older children. Do not use as re-hydration formula. (Pedialyte is 2-3% CHO & much higher in Na & K). http://www.pediatrics.org/

37. Drinks/Snacks Apples wedges with peanut butter PB&J sandwiches (substitute apple butter Raw veges with yogurt-based dip Cottage cheese with canned fruit rice cakes with PB or low fat cheese Grilled cheese sandwich or Tortilla with melted cheese

38. Composition of Beverages*

39. Composition of Beverages*

40. Iron deficiency Very common in children. Risks include: poverty, minority groups, immigrants, premis and LBW, maternal diabetes. Associated with learning problems (even without anemia). Reduced risk by using only high iron formulas and by adding meat and fruit to the diet. No need for Vit C supplement unless you are adding iron supplement. Hgb < 11Hgb < 11

41. Current Controversies Addition of long-chain fatty acids to infant formula Why delay solids? Sugar and dental caries Avoid sugar except at mealtime. Avoid dried fruits or other foods that will stick to teeth. Eat fibrous foods. Don�t prop the bottle. Give only milk or formula by bottle, give juice and water by cup.Avoid sugar except at mealtime. Avoid dried fruits or other foods that will stick to teeth. Eat fibrous foods. Don�t prop the bottle. Give only milk or formula by bottle, give juice and water by cup.

42. Web resources in Pediatric Nutrition: Virginia Cooperative Extension: ABCs of Feeding preschoolers http://www.ext.vt.edu/pubs/preschoolnutr/348-009/348-009.html �USDA Food Guide Pyramid for Young Children http://www.usda.gov/cnpp/KidsPyra/index.htm� About.com information on healthy eating for children http://nutrition.about.com/library/blchildfoodguide.htm General Children�s Health Info http://www.kidshealth.org/

43. More Web Resources: Nutrition In Pediatric HIV Infection http://www.hivpositive.com/f-Nutrition/f-3-PediatricNeut/n-Zafonte.html Harvard Medical School�s Consumer Health Information http://www.intelihealth.com/IH/ihtIH/EMIHC000/20722/20722.html?k=tnavx3324x20722 American Dietetic Association Pediatric Practice Group http://www.eatright.org/dpg/dpg22.html International Food Information Council http://ific.org/ Children�s Hospital of Iowa http://www.vh.org/Patients/IHB/Peds/Diet/PedsDiet.html

44. References Kleinman RE. Pediatric Nutrition Handbook 4th Ed.: American Academy of Pediatrics, 1998 Tamborlane WV: The Yale Guide to Children�s Nutrition. New Haven 1997 Picciano MF et. Al: Nutritional Guidance is needed during the dietary transition in early childhood. Pediatrics 2000;106:109-114. Bogen DL Baker SS: Screening for iron deficiency anemia by dietary history in a high-risk population. Pediatrics 2000;105:1254-59. Deckelbaum RJ: Fat intake in children: is there a need for revised recommendations? J Pediatr 2000;136:7-9 Hall RF Carroll RE: Infant Feeding. Peds Rev 2000;21(6):191-9.

45. References Trusswell AS: ABC of Nutrition 3rd Ed. BMJ Books, London, 1999 Kreiter SR, et.al.: Nutritional Rickets in African American breastfed infants. J Pediatrics 2000;137:153-7. Klish WJ, Baker SS: Soy Protein-based infant formulas. Pediatrics 1999;104:119-23. Renfrew MJ, et. al.: Interventions for influencing sleep patterns in exclusively breastfed infants. Cochrane Database Syst Rev. 2000; 2: CD000113. Walker WA, Watkins JB: Nutrition in Pediatrics: Basic Science and Clinical Applications. 2nd Ed. BC Decker Inc 1997, Hamilton Hendricks KM, Duggan C, Walker, WA: Manual of Pediatric Nutrition 3rd Ed. BC Decker, 2000, Hamilton.