INET dat aCey a) eee Nutritional Requirements ry ic Ala Shaikhkhalil, Veroni Pel aameretel ta ieee mee atts VEY [Nutritional intakes for infants, chldsen, and adolescents should provide for maintenance of current weight and support normal growth snd development, Ihe infancy growth period i rapid, critical for new- rocognitive development, and has the highest energy and nutrient requitements relative to body size compared with other periode of growth, Iis followed by the childhood period of growth, during which 60% of total growth occurs, and is finally followed by the puberty phase, Nutrition and growth during the fst 3 yeats of life predict adult ature and some health outcomes, The major risk period for growth stunting (impaired lincar growth) is between 4 and 24 months of age is ental to identify nutzient deficiencies promply and to address ‘hem aggressively early in life, because they can impart lating averse eiflects on growth and development. Dietary intake not only meets energy requirements but also provides macronutrients and micron ents essential for sustaining the functioning of multiple vial pro cesses. Nutrient deficiencies can limit growth. impairimmune function, ‘nd increase morbidity and mortality. The significant global burden of ‘malnstrition and undernutrition i the leading worldwide cause of scquired immunodeficiency and the major underiyng factor for mor bidity and mortality globally for childzen zTaS Yau a9vis-3an Err peony ered PnreryChapter 44 ¢ Nutritional Requirements _275 ponunues anewguts 0 ‘Ssensip Ip pue Buysny spnpul ues swwawejddns Buu ewes “ube way sireye essary 700} ur woe Burs Ageanieu Butwneuo> wo ‘ayo a5s0n9e jo 92490N9 ON sp09) sve sepa owns ge 0) n petueues 99 feu. 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ool on oN on oN on Gn GN on GN ON on oN on ON cont een coe aha p,m) vouese ou 982 ffep/6 KovevBoug coe ize foc Karn 009 AES ep/ Br) sojeuiog coe ice 008A. aL 9 hee (ep/6m) 31671 cor Aer 008, KEL ep) wore sg Ow ZI Tor ow 90 tepyém sue, nm Aire wees (fep/6u) voneey ve Tet * Gs dep Koveubeorg so KEL (frou) uore49 wo cu eee wo ow 90 epi) ss9ju, ogous una pue wousdojonan Suuotique ‘vononpoidas spor ou wrews-papuesg pue saeiphyoaies je usjoasion 4) suhaue05, 428) pus suawapedne 10 poo, ty unwean pewojard so ha 53x 04: eI "poo, u Sprouoreie y uueyoad 40 524 Woy sayy sre OIE OL, oa gwen eye uienas278 Part VI_¢ Nutrition ON on Nn on GN GN pewueuem ag feu uonnes oy ue wey jo on spaye avionpe uo Siep 227008 ON ‘Syn yey GN yrses aye osserpe jod ou salou, ueous on eso g umen y 19) 3989), 3 s20p sun “nuauajaans oN enoue Butunruoo fa fares yely #4 De pee) ul pune hyeunu pier warps anseyqoreboue 20ui 0 pare oi 1h Oge PFO fig uurein fo sunowe ey oN so ow Zi uenaid nig uwea punoe-poo} esqefeu Jo vonsuinsuo> iim paiebesse Anjpod"ysy eo = GN V0 OW 9) wsyoqesul poe. idoed repip Jo ot-0l eeneseg wee ancy sdeye staonpe ON cole pay Mep/6m swweju)safanuru) auAtven) useage cg uMvenA ool oz Aizen oz akais i co 6 iret St Aas hep bu) foveuboig cole izel zt Agia suo, Ob ket josey (fep/Buy sejewo} potinose rey Kaiedoine hoses cole ead peturaes 99 fue EL 2 Lonnes ‘poy ave "g wuseyn Jo % ot eve ‘spoyo osioqpe uo Eyep osneog SoH re oye ye, or UNa ha) seyasoue nso: si arionpe of soreg ploBunuss oe euurexopuld Joy euusied ov si sioqi ues searasqns wows pur "uabo>K ‘aulvopuka poo ik 20U S00p sia pavodesuseq —pasee-Aos poysicy GN “poe outwe spunaduo> pareja: seney poo} wow, "9 uMwena ain “eau ues.o GN us jogeiow 9 je deo.6 e se5sdu03 evo" paleaosse Saye ononpe oN ‘seaiea payuog ai u ourouoes SNOLVBOISNOD TWID3dS __NOILAINNSNOD SAISSIOXG ‘S3OUNOS: an Wuo _ anowD NOWDNAd “INSRILAN, 40 $193443 aSU3AGV aoos aa13a135 va 39ViSain 0} S0e0u Ser S-yy elseChapter 44 ¢ Nutritional Requirements _279 asp J voneuiquios eo 9089), ayo, ‘uouotddns wo aurea [eisydoser 9 wo} 2eous s949ei080n any an sue yeate> passezoiaun 3360) -quauiaydane 3 wien ayy vay posoy wow 2a pyrous ‘deo, wuepSeeaque uo siuoseg pede beage> 5 ae se} Yo o¥p 004) ‘oawens ‘Kain auneuo pyro oyouss 222690) 200g ‘1 paroaha fies! 2y0UNVON 13 Sind ‘iayourruou Sjessnig seoseiea fq popacu rey 4200 3 user jo “eoinf eeu fup/Bus €¢ feuonippe oinbos sioyous § 88 RB $88 $88 82 8 si a5 fap. foveuborg size St Asa ty AEG {iop/6u)coesieg sa hize Sh Sra it “ 5 wet ep uy wore s ew ere > 09 hepyby sce oe Kien Ste kai (fep/6u) vour3e Bhat oF Gs ftp/6. foveuborg size 9 sr hep Bu) soeuieg 8 se sh se st top 8u9 wore 5 ewe or ous hep) sep, _usprronve Suxyeniqetey> peu seg ot ou sey onaunyayqerou y ueproaue spoioud ese suuowayddns pue Jo Sule) uowosteasais¢ 04) epnpul sou S09 3 Sopnpu pproyson Beg uwen,280_Part VI_¢ Nutrition ge00\=p"pisoisdue ooquedeyrpe du nn Ysqaw) su pus tune 3 pr psoas aud soagssdoynpasesssisolega mrousass pur artusor seounB ts "Jo supe sadde> “wrens uosea susee wise y uh 0 0 uesnjeshareg sop b-plossyayeyoaduedo nbs atau fo fama vcore pbson cs yoosrndampa seu vn yeaa) Spon puro aucen saute toby a sander Sp ‘sovenoye lip pepouusoas yoy aiyeayd S2sop fa sinqacaga ute 01 p02) toy 26 pyre ays jo ainag ssurouse stone appuey 0 4 [pp tunuopaious GN 06 Hira aN se {hep wo oN 06 eet ON se aK hep) oueudsg on aN eauedeN og feu a ‘te 9 wai jo a ‘aaye seiaape uo erep aeneo9g oN ON on ay usyoqu sue, jo sweunyu pouedss ussq —spssNB YC pue Bunop pooyy vet vauaydans 20 poo, 101, usa on ul povjenu! Suoierd fue zoyuous ains409 9 speuids ‘sp ON fuedr 30 ssouquts vweyrdeooy poyesoute sina faigeieson wool, Hep) sie, Suunp ouloso0> semen SNOLVEROISNOD WID3dS __NOILAINNSNOD SAISSIOXG ‘SaDunOS: an uo anowD NOUDNAE “INSRILAN, ‘40 $193443 3SU3ACY GOs Ga193135 va 39ViSa4n teal rerChapter 44 ¢ Nutritional Requirements _ 281 hhae been successfully implemented to prevent iodine and folate deficiency Breast mak provides optimal intake of most nutrients including iron and zine. Although they present in lower amounts than in infant {ormula, they are more bioavailable and suficient to meet infant needs ‘until ~1-6 mo of age After 4-6 mo af age, ton and zine ate required rom complementary foods, sich at iron fortified cereal and pureed Tron requirements are higher during infancy and childhood as com pared to late life stages, and are higher for menstruating females as ‘compared to males of similar age groups (see Chapter 54). Tron present {in animal protein is more bioavailable than that found in vegetablee and other foods because itis aleady incorporated into heme moieties in blood and muscle. Iron deficiency isthe most common micronulti- ‘ent deficieney and ie associated with ion-deficieney anemia and ne- rocognitive defiitz Zine deficiency affects millions of children ane ‘ssociated with increased risk for impaired linear growth (stenting), ‘mpsired immune function, and increased risk for respiratory and diartheal diseases. Breast milk sa poor source of vitamin D (see Chapter 51). Vitamin 1D insufficiency is more common than previously thought in infants and children, Vitamin D is central to calcium and bone metabolisn, Dut is also an important determinant of various nonosseous health ‘outcomes, Vitamin D is absorbed in the skin from sunlight and is also present naturally in some foods and fortified i all cow mk products, regardless of fat content, soy milk, almond milk, and orange juice Sunlight exposure varies by season, Therefore, for populations residing in northern latudes andior who have datker skin, sunlight exposure is unlikely to meet the vitamin D needs aver the year; in these groups additional sunlight exposure and/or vitamin D supplementation may bbe requited to achieve optimal statu, Children with darker skin and those who do not consume fortified products should be screened for vitamin D deficiency. The DRI for ‘itamin D ie based on ss effects on ealeium statue and bone health, ‘he goal isto achieve serum levels of 25(OH) D evels above 50 nmol (G0 nga), which often achieved using vitamin D supplementation. 4p 2016, the American Academy of Pediatrics increased total vita ' inake recommendations to 600 IUiday fr infants and children, A supplement was recommended forall breast-fed infants to ensure sof ficken intake (Calcium adequacy is determined in part a a function ofbone health as measured by bone mineral content and density, The main storage ‘organs for calcium are the bones and teeth, Bone mineral accretion ‘occurs primarily inthe pediatric age range, with peak bone mass being achieved by the 2nd to 3rd decade of life. Calcium recommendations vary by age and were also increased from Alto RDA, and the UL was inctested in 9-18 yr olds (Table 1-6) ‘Vitamin K is an important determinant of bone health, but is aso an important cofactor for coagulation factors (factors Tl, VIL. IX, and X protein C: and protein $) (see Chapter 53). Status can be assessed bby prothrombin time, protein in the absence of vitamin K (PIVEA-1) and the vitamin K-dependent coagulation factor levels. Neonates are ft risk for suboptimal vitamin K status leading to an increased sk for hemorrhagic disease of the newborn. Vitamin K prophylaxis at birth is recommended forall newborn infants. Potassium and sodium are the main itra- and extracellular cations, respectively, and are involved in transport of fuids and nutrients across the cellular membrane. Thee is an AI set for potassium related to its ‘ellects in maintaining a healt blood preesure, reducing risk for neph- Tolithiass, and supporting bone health. Moderate potassium defi- ‘leney can occur even in the absence of hypokalemia and can result increased Blood preseute, stroke, and other cardiovascular disease, ‘Most American children have potassium intake below the current ree ‘ommendations. African-American in particular are at increased risk for potassium deficiency For people at increased risk for hypertension and who are salt sensitive, reducing sodium intake and increasing ‘potassium intake is advised. Leafy geeen vegetables, vine fruit (such as tomatoes) and root vegetables are good food sources of potassium (see “Table 44-6). People with impaired renal function may need to reduce potassium intake as hyperkalemia can increase risk for fatal cardiac seehythmias among these patients. Sodium has an Al. but given the risk of hypertension, an UL has also been set, The UL threshold may be even lower in Afican- “Americans, who, on average, are more salt sensitive, and for those with hypertension or preexisting renal disease, Dietary sodium intake also displaces potassium intake, Elevated sodium: potassium ratios can increase the risk for nephrolithiasis. Intakes of <2,300 mg (approxi- imately 1 tp) per day are recommended, The average diy elt intake {for most people inthe United States and Canade exceed: both the Al and UL. Most dietary salt in the United States is found in processed foods, breads, condiments, and as a food preservative, and to enhance palatability. For populations with or at risk for hypertension and renal disease, sodium intake should be decreased to <1,500 mg/day and potas ‘sm intake increased to >4,700 mg/day. For persone with hypertension, additional dietary guidelines are availabe fom the Dielary Approachet to Stop Hypertension (DASH) eating plan WATER ‘The water requirement and content asa proportion of body weight are highest in infants and decrease with age. Water intake is achieved with Higuid and food intake, and losses include excretion in the urine and stool as well asinsensible and evaporative losses through the skin and respiratory tact. An AT has been established for water (sce Table 1-5) Special considerations are required by Ife stages and by basal meta- bolic rte, physical activity, body proportions (eurface area to volume), ‘environment, and underlying medical conditions. Breast milk and infant formula provide adequate vvater, and additional water intake ie not required until complementary foods are introduced, Although ‘water containe no calories, the concern i that wate intake might acti- ally decrease breast milk intake and displace the intake of essential utente during this metabolically very active life stage. Ihe increased fluid needs of infants and young chldven can be explained in patt by the high ratio of body surface area to volume in infancy and igh respiratory rate The consequences of inadequate fuid intake include dehydration {impaired thermoregulation and heat dissipation, reduced activity tol ‘rane and performance, and reduced intravascular fluid, These def cite can result in an increased compensatory heart rate, hypotension and syncope, and, if uncortected, renal injury or nephrolithiass. Excess free water intake is usually beter tolerated by heathy ade than by younger children, who may be at increased risk for water intoxication. Hyponatremia can resul from excess free water intake coupled with inadequate sodium intake. Fluid intake requirements and reszitions are also influenced by underlying renal and hormonal dis, orders, including diabetes, the syndrome of inappropriate antidiuretic hormone secretion, and diabetes insipidus MEASURING NUTRITIONAL ADEQUACY Growth according to expected patcrns can be tracked using the 2000 Centers for Disease Control and Prevention (CDC) and 2006 WHO growth charts (see Chapters 6 and 15). The WHO growth charts are derived from longitudinal and cross-sectional date cbtained from a sample of healthy breast-fed infants and children (0-5 ye) who were receiving adequate nvtrtional intake and medical care from Braz, Ghana, India, Norway, Onan, and the United States, Consequenty the WHO growth charts are not only descriptive of population average and distribution, but ace also prescriptive regarding how adequately nour ished healthy children ner besteeare practices should grow. The CDC and American Academy of Pediatrics recommend the ute of the WHO charts to moniter grow ofall nfants and children (breast and bottle or infant formula fed) from bith to 2 yr of age, and the use of the CDC 2000 growth charts for children 2 to 20 yr of age ‘Although the WHO and CDC growth chart are recommended for ‘growch and nutritional assessment, a number of disease-specific charts te avilable, It x noteworlay that many other disease- or syndrome- specific growth charts are based on small samples of childzen, and include children with saboptimal nutsitioal status For these patient Text continued on p. 286282 Part VI_¢ Nutrition oot's Kye ssoqep uonese7 10 (ereenp foupy) cor’ souors Koups yess ouonys coy Taxoum au03 jo Shue suosied oos's siosveu eseanoe a pounsucs ue aye oocy Lanpor s03%9 ons or su098 ainteand po9}a jo 0.3 ue 550] uinsue> 2} poo ooa's pue Linsiejod Bulueiues uewoldns TneN BOE ‘Suunsuo> 01164 pyove> 2 susuleysan soy wor nous sein Susedeunreriod 10 wanisseiea ng sna “sieaw “sonpoid aoe ow cic Sey ‘uouqiuu 39Y se uans aseesIp —‘2uafe pod, wos ep ‘sead paup 25su0N DOF ewer) uejrosenoipies vo} Sep Bune suesiog —pawaursop oven) “SojgeiaBon put su ‘sua cove ove'z Aye Goneise7 pue Soveus cove ane’e Kreeh _ core avez Ee 60% fa 9poj 09-51 85 cove oce'z cove o0e'z Ayes spuoyo umpos se sow0> apes ising ou ons ove! uorun, sap ul uiipar jo stow aonedeq winpor ‘Bn joo "anu ‘eats Sore ooe't t fohsunoue Ui vejouinbo aie 7 pue fy nes wep eoquep osuoyoahy eomea os ow ety pur Bunion use yom se eons Ul nypea) tunpor —epuolyp unipor GN oom one 1 ap fim uesues uM S00) passeD018 sore) anor uo ssajoid sy yo cote ons Kye 109 oy 49pun ave eu 0 uolsUeyedty Goueizey pue Aoveuboig oney fpeaye out suosiod 10} YBuy oo} coz st Aish 9 feu sr ky nau coe aos KEES suotad fuieay svaredse 9) rosde 6.0m ow Aq winpos oy 51385 coz st ey a1ous paou 146s reoMs onssonee ges 24 oz 00s! Sos Seveup puny ul 10 Soro] Spe; : poppe es Zu ye hynsae Ut pobeBu suing ooe's Aunsne paiekys jo ri a onan ayons pur aseanip fovenorose> weomuea ‘e3) an oot \/peseoiou] 9puejio unpes poppe aN oo ueuedly Im 396) passed sacha) impos “SNOUVURGISNOD TwIDzaS NOLLWnSNOD Sz5un0s (ep/suhan ep/Bwh iy —anoUD Noung ANSRLLAN BAISSIOXa 40. GOO Gal93135 aovis3an sivada3 35u3AGV eet Serene rentChapter 44 ¢ Nutritional Requirements 283 pono uojidiosge unije> jou peorpas anew (eaanpul-ssonau txe.0u8 fo -ae3/849) uauow 2ayuoveuiy Jen yeuosipee aurbor Jfovatoyyreu euas yosse.q ‘Beqges ore no} Yowsspeeoly —eeunofe> sequel ‘seuss Keuppy 09 "unBok 25934> IW steers peysuo, ‘aanpoid ys poyives’g wien ees yeedy poy woog oney veh Busnes suay wioy 5869 "009 uonenvasues eo wos} goose sy Ae eusejspeversyy je dpoy ‘sfouon| uals cose 000'8 cos'z 00'8 00's cos'z 00 oosz oos'z cos't oot roy 0e't 00" oe" ooe't 00't oe't 00" 00 092 st st st st st st st o a foueiboig Kz. av% sous Kz. 1% seen ker KEL veep ower ou 90 nt Aro kas (fep/6m wowesse7 ais pj foueboug rr «lfep/61 sao} ee 699/60) 1671 ker WEL «ffop/61) wospyi ou eke ou 90 (p76 susju) voneunoy «001 put 9409 Enea wopsenue3 ‘spent Bune pooja spn piney unp9 wens oi ainsoaie Srenbope jo sunege uo pose, isa ‘josaynp284 Part VI © Nutrition » 2 EL oo a th kgs oo 8 sms sedde> m6 peonpo, pue Can o” “ou z ¢ \yytei8 1204 posed 0 6 aos sewfave ayoeds sj poiersorse 9a ue> Sv) te ‘ot paieBBeis 09 roys sWoKp ‘aupepeeu weyodiu ve se10p ap psen Gureg ave swuawe|dane put venta sok soudojanep J} Biajaiog esi08 03: ove vonatosqe joys - 2 ue yivons os: yi a0) suousojsdns 9417 satan)" sede 10) ues aug » 6 Arve pateB6ey 29 pjnoys OL was sosop ayy ;posn 6uleg ove siuowsans tet eon pu unaoege o 2 our wa aioe ura svausapddn Uo 9 *sp2919 19 fen sasso] vou seeasau veo se oa SL » 8 » 8 oo 8 UUooq aneu s13jap anhuBa20inoN, sp00) wejyea10 op on pie ak [> were} 4> 10} pepusuwosas ‘sates spe 90) o uoiGowou eu st pue vos sigeyeneora eseg-ivejd S660 pue "ugoyborus jocsuings sood e #3 303 ‘Kyep se2unoe SuUauuoN oon owoupex fovos yop 0} yu paseo ye oq Keus ey Sapos ozo ‘ultue Jo upie auireb poseanop yi uotieg soap 9 __deeutfoninor Sw waved e209 vo ‘SNOUVUBGISNOD TWIDzaS NolLaWnsNoD sspunos ep/Bub in Kep/Bw iy NUD NouDNng {INSRILAN PAISSEOXG 40 GOOd GalDa1as aoviszan sivadaa 3SugAgv errant estnntn ye] Pera iChapter 44 ¢ Nutritional Requirements _ 285 0 2u2ppoy jo orusu preog wowany pve poe, woy pardeny ‘Bo yonuorsuorssue sy sus ue gay eres oterdope youl ipapineid sty au, mojeq 10 snoge 3 usnerpty ueuieu 0: exenbape ove sfeous ye saBeionaa jo uonluraus put yuh ‘yeu seme 49 02 ~ 20} swnos.e poo, U saMSIOWN p00) ut puro} uy pue Yoven Bunjuup pue "epes ‘saya ‘ea satiotoq spaou em jeu6s 0) 374.2409 UD FOP.NOS IY srewp srevod Us asven fen se; ave popinosd sty 1 paieply Apienbope 2a ue suosiog paiepiy Ayaenbope a1 oys suesiod Knjeoy -Aysouab jo soye ui uspous uo posed ‘ove vaje 10, soyeu papuouluescy ‘epnpu ssyem jo swords nol 104 pin Jo (0 92) 1L0< ‘aypuey ued shou, Buuosran, yee ‘esne22q 70 N senos se0u ‘uojouusien sonpul spe0) amisoury6ins speoju! simsion, upnpuy“e6es0n04 IY 125 Su0N Aig (tepp fovea Kee Karn ev opr soetiog mele Karn shes epson ey vel een ow zie ou90 (ep sje uusyoqeisu: jo sonpe.d assem jo vonsin put enous, pus Sys2 9) sou jevootuen siomy fog et ua ssesoauoy sueuen somgroups, disease-specific charts may be helpful to use in conjunction with the WHO or CDC growth charts for comparison to children of ‘malar age and sex from the general poptdation. The goal chould be to use this information to approximate growth as closely to that of the general population as possible in these subsets of children, where and ‘when possible. In addition to anthropometry other nuttient biomark- ‘af be used to asses statue For infants and children with specific ietary or health concerns, consultation with lactation consultants registered dieticians, and/or physician nutetion specialists may alzo be indicated, Bibliography is wvalable at Expert ConsulChapter 44 ¢ Nutritional Requirements _ 28 Bibliography ‘huta ZA, Stam RA: Gaba auton epidemiology and tends, Am Nut Meta (Guding S,Dennion BA Bich Lt dk Amerian Heat Asodaton Geary ‘ecoramendaton fr chlsen and wslecnts» gid ar protons Pedic 17544859, 208, ‘Grammer Staen LM, Reino C Kebe NE: Use of Weld Heath Ogaaton ‘bd CDC growth charts for den aged 0-59 months in Use United States, [MMR Resor Rep 81-15,200 Insite of Medine (10M): Dietary Reference ker for Cl and Vtari ‘Washington, DC 2011, The National Academie Presa Insite of Medicine (OR): Dietary Reference Isak. The Beil Gade > ‘Nation Requiem’, Washington,DC. 2006, Naonal Academies Press ‘east DR, Flgo! VL 3d das TA, ta ood sures energy abd auets ‘song crea ia the Used Sate: National Health and Nuon rumination Survey 200-2006, ure S()}285-301, 2013 ‘enman BF, ecitor Perc ntrtonhondbok, Fk Grove ile, 2009, American Academy of Penis, ‘Neon Center for Health Stasis CDC growth charts. ce gov) Growth ‘sited Stats Departmen of Agree: Dicey ulin fo Americas 2010 Ipinccap ua go dietary: ‘United tater Deparment of Agriculture MjPlite wr chorea gv.286 Part VI_¢ Nutrition 45 Feeding Healthy Infants, Children, and Adolescents Parks, Ala Shaikhkhalil, Tea nae ERA Early nutrition plays an important role inthe origin of adult diseases such as type 2 diabetes, hypertension, obesity and the metabolic sya ‘rome; therefore, appropriate feeding practices should be established {nthe neonatal period and continued throughout childhood and ado- Teseence to adulthood. Healthy feeding in children requires partner ships between family members, the healtheare system, schools, t ‘community, and the government. FEEDING DURING THE FIRST YEAR OF LIFE Breastfeeding “The Ametican Academy of Pediatrics (AAP) and World Health Orgs: ization (WHO) have declared breastfeeding and the administration (of human milk to be the normative practice for infant feeding and nutrition, Breast(eding has documented shor and long term medieal and neurodevelopmental advantages (Tables 45-1 and-15-2) and rare contzaindeation (Zable 453), Thus the decision to breastfeed should be considered a public health issue and not onlyalifessyl choice. The [AAP and the WHO recommend that infants should be exclusively breastfed or given breastmilk for 6 months. Breastfeeding should be contied with the introduction of complementary foods for Lyear of Tonge, as mutually desired by mother and infant ‘The sucess of breast feeding initiation and continuation depends on multiple factors, such as education about breastfeeding, hospital breastfeeding practices and policies, routine and timely follow-up eare, and family and societal support (Table 45-2, ‘Feeding should be initiated soon afer birth unless medical con tions prec them. Mothers should be encourage ta nse teach breast at each feeding tating withthe breast offered second at the lst feeding. Tis not unusual for an infant to fal aleep ater the fst breast and refuse the second. Itis preferable to empty the Est breast belore oflering the second in order to allow complete empiying ofboth breasts and therefore better milk production, “able 45-5 summarizes patterns of mil supply inthe Ist week. ‘New mothers shouldbe instructed about infant hunger cues, correct sipple latch, positioning ofthe infant on the breat. and feeding fe- «quency. Tis also suggested that someone trained in laetaion observe 2 feeding to evaluate positioning, latch, milk transfer and maternal fesponses, and infant sitity. tention to these isues during the birth hospitalization allows dialogue with the mother and family and can prevent problems that could occur with improper technique of Table 45-1 Secretory laA. Specific antigan-targeted antinfoctve Lactoferin Immunomadilation, tan chelation, Srtimierobal action. antshesive, trophic for ntatinal growth ¥7% of birth weight, hypematremie dehydration, incon” solable erying and increased hunger. Insufficient milk intake may be caused by insufficient milk production, falure of established breast- {eeding, nd health conditions in the infant that prevent proper breast stimilation, Parents shovld be counseled that breasted neonates feed 8-12 times a day with a minimum of 8 times per day, Careful attention to prenatal history can identify maternal factore that may be associ ated with this problem (Lalu of breasts to enlarge during pregnancy for within the first few days alter delivery). Direct observation of breastfeeding can hep identity improper technique. Ifa large volume fof milk is expressed mancally after breastleeding. then the infant tight not be extracting enough malk, eventually leading to decreased alk outpot. Late preterm infants (34-36 wh) areal risk for insu ‘ent milk syndrome because of poor suck and swallow patterne oF medical issues Jaundice Breastfeeding jaundice is common reaton for hospital readmission, ‘of healthy breastfed infants and is largely related to insuficient fluid288 Part VI_¢ Nutrition Table 45-5 | Patterns of Mik DAY OF LIFE MILK SUPPLY Day? “Some mik (3 ml) may be expressed Days 244 Lactoganesis, mik production increases Days: Mik present, fullness, leaking felt, Day 6 onward Breasts should feel “ernoty” after feesing bresstioeding sucess, Cn Perinat {intake during the fist week of life (sce Chapter 102.3). It may also be stsocited with dehydration and hypernatremia, Breast mill jaundice {sa different disorder that causes persistenly high serum indirect bil, rubin in a thriving healthy baby that becomes evident later than breast feeding jaundice, but which generally declines in the 2nd to 3rd wh of |e Infante with severe or persistent jaundice chould be evaluated for other medical causes (see Chapter 1023) before asribing the jaundice to breast milk that might contain inhibitors of glacuronyl transferase ‘of enhanced absonption of bilirubin from the gut. Persistently high bulirubin levels may requise changing from breast mille to infant formula for 24-18 hr and/or treatment with phototherapy without ces sation of breastfeeding Breastfeeding should resume afer the decline in serum bilirubin, Parents should be reassured and encouraged to continue collecting breastmilk during the period when the infantis ing formula Collecting Breast Milk “The pumping of breast mill is a common practice when the mother and baby are separated for work, lines, or hospitalization of meter oF infant, Good hand washing and hygiene should be emphasized Flectrie breast pumps are more efcient and better tolerated by smothers than mechanical pumps or manual expression. Collection kits should be cleaned wit hot soapy water. rinsed, and air dried afer cach use. Glass or plastic containers should be used to collet the fnilk, and ml should be refrigerated and then used within 48 he Expressed breast milk can be frozen and used for up to 6 mo. Milk should be thawed rapidly by holding under running tepid water and used completely within 24hr afer thawing. Mik should never be microwaved Growth of the Breastfed Infant ‘The rate of weight gan ofthe breastfed infant dies from that of the formula-fed infant, and the infants risk for excess weight gain during late infancy may be associated with bottle feeding. The WHO growth charte are Based on the growth of heathy breastfed infants through the styroflfe These standards (hitp//wwwwho int cildgrowth) ate the result of a study in which >8,000 children were selected from 6 coun: ies, "The infants were selected based on healthy feeding practices (breastfeeding). good health cae, high socioeconomic status, and non- smoking mothers, so that they reflect the growth of breastfed infants fn the optimal conditions and can be used a8 prescriptive rather than rormative curves, Charts are available for growth monitoring from bith to age 6 yr. The Centers for Disease Control and Prevention (CDC) recommends use of the WHO growth charts for infants 0-23 ‘months of age and CDC growth chart for ages 24 mo to 20 yr. Formula Feeding (Fig. 45-1) Despite effort to promote exclusive breastfeeding through 6 months, less than 50% of women continue to breastfeed at 6 months, Most ‘women make thei infant feeding choices eanly in pregnaney. Parental preference is the mort commen reason for using infant formula However, infant formula it also indicated in infants whose intake of breast milk is contraindicated for infant factors (eg, inborn errors of metabolism), and maternal factors (see Table 45-3) I addition infant formula is wed as a supplement to support inadequate weight gain in breasted infants, Infant formulae marketed in the United States are safe and nutrition- ally adequate a the sole source of nutrition for healthy infants for the first 6 months of lie. Infant formulas are available in ready-to-feed, concentrated liquid or powder forms, Ready-to-feed products gener= ally provide 20 keal30 ml. (2 o2) and approximately 67 keal/AL. Con- centzated liquid products, when diluted according to instructions, de a preparation with the same concentration. Poveder formelas ‘ome in single or muhiple servings and when mixed according to ‘nstretions wil result in similar calorie density, ‘Although infant formulas are manufactured in adherence to good smanulacturing practices and are regulated by the US, Food and Drug ‘Administration (HDA), there are still potential safety issues. Powéer preparations are not sterile, and although the number of bacteria colony-forming units per gram of formula is generally lower then allowable limits, outbreaks of infections with Enterobacter sakazak have been documented, expecially in premature infant, The powder preparations can contain other coliform bacteria but have not been inked to disease in healthy term infants. Care must be taken in following the mixing instructions to avoid over- or underdiltion, to ute boiled of sterilized water, and to use the specific scoops pro: vided by the manufacturer as scoop sizes vary: Water that hae been boiled should be allowed to cool fully to prevent degradation of heat Inbile nutrients, specifically vitamin C. Well water should be tested regularly for bacteria and toxin contamination. Municipal water can Contain variable concentrations of fiioride, andl if the concentrations ste high, bottled water that is defluoridated should be used to avoid tonicity ‘Parents chould be inctructed to use proper handwashing techniques when preparing formula and feedings for the infant. Guidance to fallow writen instructions for storage should also be given. Once opened, ready-to-feed and concentrated liquid containers can be covered with aluminum fol or plastic wrap and stored inthe refrigera- tor for no longer than 48 hr. Powder formula should be stored in @ «ool, dry place: once opened, cans should be covered with the original plastic cap or aluminum foil, and the powdered product can be used ‘within 4 weeks. Once prepared, all bots regardless of type of formula should be ured within 24 hours, Formula showld be used within 2 hours of removal from the refrigerator and once a feeding bas started, ‘hat formula zhould be used within an hour or be discarded. Prepazed formula stored in the refigeratr should be warmed by placing the container in warm water for ~5 min. Formula should not be heated in microwave, because it can heat unevenly and result in burns despite sppearing to be al the right temperature when tested Formula feedings should be ad libitum, with the gos! of achieving arovth and development to the childs genetic potential The ural intake to allow a weight gsin of 25-30 giday wil be 140-200 ml/kg! day inthe ist 3 months of Ie. The rate af weight gain declines from 3-12 monthe of age ‘COW MILK PROTEIN-BASED FORMULAS Intact cow mill-based formulas inthe United States contain a protein concentration varying from 18 to 3 g/100 keal or (1.45-1.6 g/d.) con- siderably higher then in matere Breast milk (5 g/100 kel). Ihis Increased concentration is designed to meet the needs of the youngest infants but leads to excess protein intake for older infants. In contrast, breasted snfants receive protein intakes that match theie needs at various ages. The whey: casein ratio varies from 18:82 to 60:40; one ‘manufacturer markets formula that 100% whey. The predominant ‘whey protein i globulin in cow milk and cc-acalbumin in human milk This and other diferences between human milk and cow milk based formulas result in diferent plasma amino acid profiles in infants on different feeding patterns, but clinical significance of these di fences has not been demonstrated Plant or a mixture of plant and animal oil ae the source of {infant formals fat provides 40-50% ofthe energy in cow mill-Dased formulas, Fat blends are better absorbed than dary fat and provide saturated, monounsaturated, and polyunsaturated fatty acids (PUFAS) ‘All infant formulae are supplemented with long-chain PUPA, docors- hexaenoic acid (DHA), and arachidonic acid (ARA) at varyingChapter 45_¢ Feeding Healthy Infants, Children, and Adolescents _289 48 ‘Same fay Tactose-tee months Contrainicated — Yes “ons eiical basi, difrantason of gE medias or non gE Imada ow mk proainalorgy = aut and hero i cross ‘esctly wi sy pte allay. Theatre, a patein Frost Formas sugnte, Figure 45-1 Feeding algorithm for term infants. (From Gamble Y, Bunyapen C, Bhatia J: Feeding the term infant. In Berdanier CD, Duyer J, Feldman EB, editors: Hanabook of nutiten and fead, Boca Raton, FL, 2008, CRC Pres, pp 271-284, Fig. 15-3) ‘concentrations. ARA and DHA ar found at varying concentrations ia Ihuman milk and vaty by geographic region and maternal dit. No studies in erm infants have found s negative eet of DIA and ARA supplementation, ad some studies have demonstrated positive eects fo visual acity and neurocognitive development. A cxsical review ‘concluded that there ate no consistent effects of long chain PUEAS on ‘sual acaty in term infants. A Cochrane review concluded that routine supplementation of milk formula with long chain PUEAS to improve the physica seurodevclopmenal or visual outcomes of tema Infants cannot be recemmended based on the corns evidence. DHA and ARA ate derived from single-cell microfungi and microalgae and ‘re clasifed ae generally recognized a sal for sei infant formolat at approved concentrations and ratios LEsctowe isthe major carbohydrate in breast mak and in standard cow malle-ased formulas for term infants Frese for term infants ‘may also contain modifed starch or other complex carhobydrates Carbohydrates comprise 69-75/1 of cow milk-based formula ‘SOY FORMULAS Soy protein-based formulas on the market ate all free of cow milk ‘based protein and lactose and ure sucrose, corn syrup colds, and/or maltodextzin to provide 67 kealidl, They meet the wiamin, mineral and lecirolyte guidelines from the AAP snd the EDA for feeding erm infants. The protein isa soy isolate supplemented with L-methionine, ‘Leazniine, and taurine to provide a protein content of 245-28 g per 100 keal or 17-148 g/dl. ‘The quantity of specific fats varies by manufacturer and is usualy similar to the manfacturers corresponding cow milk-based formula “he fat content is 5.055 g per 100 keal or 3.4.3.6 gid. The oils wed in both cow milk and soy forma include soy, palm, cunllower, olin, salower, and coconut. DHA and ARA are also added In term infants, although soy protein-based formulas have been ‘used to provide nutrition resulting in normal growth patterns, there are few indications for use in place of cow milk-bated formula, Indica- lions for soy formula include galactosemia and hereditary lactase def ciency, Beaute soy-based formulas ae lactore-free, and situations in which a vegetarian dit is preferred. Most healthy infants with acute {gastroenteritis can be managed after rehydration with continued se ‘ofbreast milk or cow-based formulas and do not require lactose-free formula, such as soy based formula, However, soy protein-based formulas may be indicated when documented secondary lactose intl- cerance occurs. Soy protein-based formulas have no advantage over ‘covr protein-based formulas ax « cupplement for the breasted infant, unless the infant has one ofthe indications noted previously and are ‘not recommended for preterm infants The rine Use of soy protein based formula has no proven value in the prevention or management of infantile coli, fussines,oratopi disease_Infants with documented ‘ovr protein-induced enteropathy or enterocolitis often ae also sens- luve to soy protein and should not be given isolated soy protein-based formula They should be provided formula derived from extensively hydrolyzed protein or synthetic amino acids. Soy formulas contain, phytoestrogens, which have been shown to have physiologic activity in rodent models bata meta-analysis of the topie done by the Center for ‘the Evaluation of Riske to Human Reproduction conchaded that there is minimal concern for adverse developmental effects i infants fed soy formula PROTEIN HYDROLYSATE FORMULA Protein hydrolysate formulas may be partially hydrolyzed, containing ‘oligopeptides with a molecular weight of <5000 Da, of extensively Iiydrolyed, containing peptides with a molecular weight <3000 Da Partially hydrolyzed proteins have fa bends similar fo cow milk-based formulas, and carbohydrates are supplied by corn maltodextrin or cor, syrup solids Because the protein is not extensively hydrolyzed, these formulas should not be fed to infants who are allergic to cow protein In studies of formula fed infants who ate at high risk of developing,290_Part VI_¢ Nutrition topic disease there is modest evidence that Liss may be delayed of prevented by the use of extensively or partially bbydzolyzed formilas, compared with cow milk-based formula, Com. prative studies ofthe various hydrolyzed formulas have also indicated that not all formulas have the same protective benefit. Extensively bye farms may he move eee an pata ye to cone mille or soy formulas are lactore fee and can include medium chain wiglyeerdes, making them arefl in infante with gastrointestinal malabsorption 22 consequence of cystic fibrosis, short gut syndrome, prolonged dae thea, and hepatobiliary disease AMINO ACID FORMULAS ‘Amino acid formulas are peptide-fee formulas that contain mixtures of essential and nonessentl amino acids, They are designed for infants twith dairy protein allergy who failed to thrive on extensively hydro: lyzed protein formulas. the effectiveness of amino acid formulas to prevent atopic diseare has not been sted, and Other Fluids Neither breastfed nor formula-fed infants require addtional water unless dictated by high environmental temperature. Vomiting and pit 3g up are common in infants. When weight gain and general well- being are noted. no change in formula is necessary ‘Whole cow milk shoud not be introduced until 12 mo of age. Ia children between 12 and 24 mo of age for whom being overweight or obesity i 4 concern or who have a family history of oberity, dyslipid- emia, o cardiovascular disease, the ute of reduced-fat milk is appro. priate Otherwise whole milli recommended until age 24 months ‘hanging to 2% at 24 months, and 196 at 3 yr of age for healthy chi Gren, Regardless ofthe (ype, all milk consumed should be pasteurized Infants and young children are particularly susceptible to infections sich at E coh, Campylobacter, and Salmonella found in ra or unpas ‘ecurized milk: For cultural and other reasons, such as parental prefer «ence, goat milk is sometimes given in place of formula although this fe not recommended. Gost milk hae been shown to cause significant clecteolye disturbances and anemia because it has low folie acid COMPLEMENTARY FEEDING “The timely introduction of complementary foods (solid and liquid foods other than breast milk or formla, also called weaning foods or beikos:) during infancy is necessary to enable transition fom milk feedings to other table foods and is important for nutritional and developmental reasons (able 45-6). Uhe ability of exclusive breastéced- {ng to meet macronutrient and miexonuteient requirements becomes limiting with increasing age of the infant, The recommendation for Begin at 6 mo of age Ac the proper age, encourage a cup rather than a bole Introduce" food at 3 me Energy densty should excoed that of breast mik lron-eontaining fonds (meat, for-supplemented cereals) are reasired Zine intake should be encouraged wth foods such ar meat, dary products, nest, and nee Phyate intake should be low to enhance mineral sosorption Breast rik should continue to.12 mo, formula or cow milf then Substituted Give no more than 24 o2/day of cow milk Fluids other than breast milk, formula, and water should bo discouraged Give no more than 4-6 oz/day of frit juices; no sugar sweetened ‘beverages ies for Weaning timing of complementary feed initiation is based on the beneite on neurodevelopment nd prevention af future comorbidities (see Tule 45-2) from exclusive breastfeeding for 6 months. The AAP, WHO, and European Society for Pedistrc Gastroenterology, Hepatology, and [Natrition Committee on Netstion all recommend exclusive breast- feeding for the frst 6 months, Similar data on the benefits of the exclusive ute of formsla for 6 months have not been published ‘Some complementary food: are more nutritionally appropriate than, others to complement breast milk or infant formula. The food con: ‘sumption patterns of US. snfante and toddlere demonstete that nearly all snfants <12 mo consumed some form of milk every days snfants >a mo consumed more formula than human milk and by 9-11 mo of ge 20% consumed whole cow milk and 254% consumed nonfat of reduced-fat milk. "The most commonly fed complementary foods hetween 4 and 11 mo of age are infant cereals, Nearly 45% of infants between 8 and 11 mo of age consumed noninfant cereale, Infant eating paterne also vary, with up to 61% of infants 4-11 mo of age consuming no Vegets bles. Among thore who consumed vegetable, French frie were the ‘most common vegetables in toddlers, Positive changes in the last decade include increased duration of breastfeeding, delayed introdc- tion of complementary foods, and decreased juice consumption. Con. ‘ining concerns included lack of fruits and vegetable, diets low in iron, essential faty acide, fiber and whole grains, and high in saturated fatand sodium, Tube 45.6 summarizes the AAP recommendations for initiating complementary foods “The complementary foods should be varied to ensure adequate smacro- and micronstrient intake. In adeition to complementary foods Antroduced at § mo of age, continued breastfeeding a the use of infant formula for the entze Ist year of life should be encouraged. Overcon- sumption of energy-dense complementary foods can lead to excessive ‘weight gain in infancy, reeling in an increased risk of obecity in childhood FEEDING TODDLERS AND PRESCHOOL-AGE CHILDREN Toddlerhood is a period when cating behavior and healthful habits can be established and ss often a confusing and anxiety generating period Growth after the 1st yr slows, motor activity increases, and appetite decreases. Birth weight triples during the Ist year of Ife and quadru: ples by 2 yr of age, reflecting this slowing in growth velocity. Eating behaviors eratic, and the child appears distracted as the child explores the environment, Children consume a limited variety of foods and ‘often only "like" «particular food for a period of time and then reject the favored food. The use of growth charts to demonstrate adequate groveth and to provide guidance about typical behavior and eating Fabite will help allay concerns of pazents. Important goals of eaely childhood niatsition ae to foster helthfal eating habits and to offer foods that are developmentally appropriate, Feeding Practices ‘The period starting after 6 mo until 15 mo is characterized by the sequisition of zelf-feeding sls because the infant can grasp finger foods, leara to use spodn, and eat soft foads (Table 45-7), Around 12 mo of age, the child leamne to drink from a cup and may still breasticed oF desire formla battle feeding. Bote weaning should begin around 12-15 mo and bedtime bottles should be discouraged because of the association with dental caries, Unless being used at mealtime, the sippy cup should only contain water to prevent caries Sugar-swectened beverages and 100% fruit juice thould also be dis couraged from being used in bottles in ll infants at all mes. Cops ‘without a lid can be used for no moze than 4-6 o2/day of 100% fruit juice for toddlers. In the 2nd year of if, selffeeding becomes a norma Sand provides the opportunity forthe family to eat together with lest sees, Self feeding allows the child to mst the childs intake, Chad feeding it an interactive process. Children receive cuce regarding appropriate feeding behaviors ftom patents, Parents should ignore negative cating behaviors unless the behavior jeopardizes the health and safety of the child In addition, parents should eat with theirChapter 45 ¢ Feeding Healthy Infants, Children, and Adolescents _291 FEEDING/ORAL SENSORIMOTOR Nipple feeding, breast, or bottle Hand on bottle during feeding (2-4 me) Maintains somifloxed posture ding ‘ooding Prametion of ifant-parent interaction Binh to 46 6.9 (vansition feodina) Feeding more in upright pesition Spoon feeaing thn, pureed ‘ods Both hands 0 hold Botte Finger feeding mvoduced, Vertical munching of easly dssolvble solids Profeance for parents te feed 92 Cup drinking Eats lamoy mashed food Finges feeding for easly dssolvable solids Chewing includes rotary jaw action 218 Selfeeding, grasos spcon with whole hand Holds cup with 2 hands Drinkin with 4-5 consecutive swallons Holding and tpping bottle 124 Swallowing with lp closure Sell-feeding aredominstes Chewing broad range food Up-down tongue movements precise 24.36 ireulstory jaw rotations Chewing with lies closed ‘One-handed cup holding and open cup drinking ‘sith no sping Using fingers tefl spoon Esting wide range of roid food Total teltfoeding, using fore ‘Adagio tom Arvedhon JC Suaionng ad eosin nara ara young ‘idran GI Mtot iy anne (206) 3010 1038/9007 todalers and not simply fed them in order to model positive eating behaviors “The 2 yr old child should progres fom small pieces of soft food to prepared table foods with precautions At this stage, the child se not ‘apuble of completely chewing and swallowing foods, and particular alention should be paid lo foods with a choking risk. Hard candles, fnuts, and raw carrots should be avoided. Hot dogs, sausages, and. {rapes shouldbe sliced length wise, Caregivers shosld always be Vig Tant and present during feeding, and the child should be placed in a high chait or booster seat. The AAP discourages eating in the presence fof distractions such as television, tablets, mobile devices, and other screens, oF eating in car where an adult cannot adequately observe the child. ‘Young children have a natural preference for sweetened foods and ‘beverages that begins in infancy. Reluctance to accept new foods i a ‘common developmental phase. Anew food should be offered multiple lumes (8-15) belore being considered rejected by the ebild Toddlers need to cat 3 healthy meals and 2 enacke daily. Milk con- lunges to be an important source of nutrition, Guidelines for vitamin 1D supplementation recommend a dally vitamin D intake of 600 IU) day forall infants beginning inthe first few days oflife, and for chldven ndadolescente who are ingesting <1000 mda of vitamin D-fortified ‘mill or formula. Toddlers and preschool children often fail to meet the recommended servings of frit, vegetables, and fiber, whereas intakee ‘of food with fat and added suger ate high. Giving vegetables at the ‘beginning of the meal and increasing the portion size of vegetables served during meals can bean effective strategy for increasing vegeta: ‘le consumption in preschool children, Eating in the Daycare Setting ‘Many US. toddlers and preschool children atend daycare and receive reals and snacks in this setting, Thee isa wide variation inthe quality ay, Choose elon Figure 45-2 MyPlate food guide. (From US. Department of Agricul ture: mypyramid gov. hip choosemyplate 300!) ‘of the food offered and the level of supervision during meals. Parents ae encouraged to assess the quality ofthe food served at daycare by 4sking questions, visiting the center, and taking part in parent com- miltees. Free or reduced-price snacks and meals are provided in daycare centers for low. and medium-income communities through the US. Department of Agriculture (USDA) Child and Adult Care Food Program, Pariipating programs ate required to provide meals and snacks thet meet the meal regulations eet bythe USDA, guarantee ings certain level of food quality Hoseeve, often for monetary reatons, sy dayne centers il sougletprovide high-quality mel and FEEDING SCHOOL-AGE CHILDREN AND ADOLESCENTS MyPl ‘The USDA MyPlate (wrivw choosemyplate gov) isa bass for building an optimal dit for children and adults (Fg. 15-2). MyPlate is based ‘on the Dietary Guidelines for Americans, 2010 and replaces MyPyra ‘mi. MyPlate is aimed atthe general public to provice a visual repre- sentation of the diferent food groups and theit portion sizes. In addition to food group information, the website provides discretionary. ‘alori information. t provides weight management strategies, and ablities to track calories and physical activity goals. A personalized ‘ating plan based on these guidelines provide, on average over a few days, all the essential nutrients necessary for health and growth, while limiting nutrients associated with chronic disease development [MyPlate can also be used as an Internet interactive tool that allows ‘customization of recommendations, based on age, sex, physical activ- iy, and, for some populations, weight and height Print material is also avaiable for famulies without Internet access, Recommendations based on MyPlate emphasize making half the plate vegetables and fruit, one half of the plate protein and grains, ‘with protein having the smallest eection. Protein replaces the mest ‘ategory as many protein sources are not from animals. A separate dairy section is included. Physical activity recommendations to achieve a healthfal energy balance are not visually displayed, but are provided on the website. MyPlate has removed foods that have low nutritional value, such as sweetened sugar beverages, and sweetened bakery product. In the United States and in an increasing number of other coun leis, che vast majority of children and adolescents do not consime & diet that follows the recommendations of MyPlate. The intake of292_Part VI_¢ Nutrition discretionary calories is much higher than recommended, with fre- ‘quent consumption of sweetened sugar beverages (sods, juice drinks, feed tea, sport drinks), snack foods, high-fat meat (bacon, sausage) and high-fat daity products (cheese, icecream). Intake of dark green and orange vegetables (as opposed to fied white potatoes), whole fruits, reduced-fat dairy products, and whole grain is typialy lower than recommended, Furthermore, wnbealthful eating habits ech as larger-than-recommended portion sizes: food preparation that adds fat, sugar, or salt; chipping breakfast and/or lunch grazing: or follow ing fad diet ie prevalent and ascacisted with a poorer diet quality. MyPlate offers « helpful and custome-feiendly tool to assist pediatt familie on optimal eating plane for short. and long- term health Eating at Home At home, much of what children and adolescents eat ie under the control oftheir parents. Typically, patente shop for groceries and they control, to some extent, what food is available in the house. Ithas been ‘demonstrated that modeling of healthful eating behavior by parents is 4 exiteal determinant ofthe food choices of children and adolescents Counseling to improve diet should include guiding parents in using ther influence to make healthier food choices available and attractive athome, ‘Regular family meals siting at a table, as opposed to eating alone, fn the ving room, of watching television/sereen, ate associated with improved diet quality, peshaps because of increased opportunities for postive parenting diring meals Such an ideal situation is recom ‘mended but a challenge for many families who, with busy schedules and other stressors, are unable to provide such a seting, Another renting challenge isto contzl the excess appetite of some children nd adolescents, Encourage children to eat at a slower pace and to chew their food properly. Encourage conversation atthe dinner table to prolong eating to 15 minutes Ovfering vegetables while chiléren sre hungry atthe beginning of the meal has becn shown to increase vegetable consumption. Useful strategies, when the child ie stl bhungry afer a meal ineide a 15: to 20-min pause (allow child to engage in another activity) before a second serving or offering foods that are insliciently consumed, such at vegetables, whole grains, of fit Eating at School ‘The National School Lunch Program and the School Breakfast Program provide low-cost meds to moze than 5 billion children nationwide. Guidelines for meals are taken from the Dietary Guidelines Jor Americans and the Dietary Reference, 2005. Recommendations regarding the use of age-grade portion sizes, and amounts of vegetable and fruits, grains, and fats were included (Table 458), The traning and equipment for schoo! food service stall school community engage ‘ent, parent education, and food industry involvement are among the necessary components, The year 2020 is the target year for achieving recommendations for sodium. Tn the meantime, while schools are ‘working on implementing changes, parents should be encourage to txamine the weekly men with their child and assist with ther chotces ahead of time, If chldzen bring theit lunch fom home recommends tions for what constitutes a healthy lunch should be provided by the Pediatrician, Parents can be directed to wwwchoosemyplat or for healthy lunch ideas. tn addition parties within clasrooms should be imited to once a month Eating Out ‘Tae number of meals eaten outside the home or brought home from cout restaurants as increased in all age groupe of the US. popula tion, The increated convenience of this meal pattern se undermined by the generally lover nstrtional vale ofthe meals, compared to home- cooked meals, Typically, meals consumed of purchased in fst food of ‘casual restaurants ate of large portion size, are dense in calorie, an contain large amounts of saturated fat, salt, and sugar and low amounts fof whole grains, uit, and vegstables, Although stl problem cur rently, trans fat ie slowing being phased out of most commercial prea) 1d National School Lunch Program ees ters caer + Fonton sizes of food are to be based on age-grade groups + Shoe! linchos ae bresKants il have annum sno maximum calore level matimum saturated fat content, and 3 traximum sodium content + Foods must eontan sero grams of tans ft per soning ‘The inlsion of unsaturated vegetable oil fe encouraged within alors lints Magetabies and fut are not interchangoable Vegetable oferinge a lunch murtincle 7 cup equivalent of the folving: dar geen vegntaols, bight orange vegetables, ser legumes No more tan ha of fut servings may bein he form of jie At lest of reasigrain offrea must be whole gran Mik must be fates favored and eer ft res or 1% i pain ‘Students ust select rut option at breaiast wth thar meal fre ether a rut ora vegetable at unch forthe mea fo be reimbursable ‘ape rom 10M Onse of Neceine School reals ulling block or heslny ehiaron Washington, DC 2010 National Aesdomes Pros. restaurants, Although an increasing number of restaurants offer healthier alternatives, the vast majority of what is consumed at restau rants doce not ft MyPlate ‘With increasing age, an increasing number of meals and snacks are slo consumed during peer social gatherings at friends houses and parties, When a large part of a childs ot adolescents diet is consumed fn these occasions, the det quality can sufler. because food alferings ste typically of low nutritional value, Parents and pediatricians need to {guide (ens in navigating these occasions while maintaining a heath! ‘et and enjoying meaningful social interactions. Inese occasions often sre also opportsnitis for teens to conrume alcobol: consequently, adult cupervsion ie important NUTRITION ISSUES OF IMPORTANCE ACROSS PEDIATRIC AGES Food Environment ‘Most families have some knowledge of nutrition and intend to provide ‘heir cildzen with a heakthfal det, The diserepancy between this fact snd the actual quality of the diet consumed by US. children is often explained by challenges in the environment for families to make healthful food choices. Because the final food choice ie made by indi- vidal children or their parents, interventions to improve dit have Focused on individual knowledge and behavior changes, bu have bad imited success, A main determinant of food choice is taste, but other factors also influence these choices. One ofthe most useful conceptsal frameworks for understanding the childs food environment in the context of obesity illustrates the variety of individal food and physical sctivily choices. Many of there determinants are not under the direct control of individual children or parents (Fig. 45-3), Understanding the context of food and lifestyle choice: help in understanding lack of changes oF ‘poor compliance” and can deereae the frustration often experienced by the pediatricians who might "blame the victim” for behavior thats not entirely under their control ‘Marketing and advertising of food to children i «particularly dias. trative aspect of the food environment, Marketing includes strategies as diverse as shelf placements, association of cartoon characters with food products, coupons, and special ofers or pricing. all of whch inilucnce food purchate choices Television advertising an important part of how children and adolescents hear about food, with an est- ‘nated 40,000 TV commercials pet yr seen by the average US. child, ‘many of which are for food, as compared tothe few hours of nutrition education they receive in school Additional food. advertisement Increasingly occurs as brand placement in movies and TV shows, on websites, and even video games.Chapter 45_¢ Feeding Healthy Infants, Children, and Adolescents _293 iy Acoessiity Figure 45-3 conceptual framework ofthe conten of foo andere choices, Ci ik faces (shown in uppercase leven) re bal haractenisce ofthe child (shown in talc leterng) interact wth child rk factors and ht fe, moderator variables). (Fram Davison KK, Bich Ll: Childhood overweight.» aviore associated with the develooment of overweight ‘contextual factors to influence the development ef averwe ‘Community, demographic, nocltal charactors Parent aight | Acasa of convnisnce ‘Gods and restaurani Sosaaconomio ‘tone acy Family ise tne, ‘ey 10 child contextual madel and recommendation for ftute research, Obes Rev 2.189-171, 2001. © 2001 The iternaticnal Association for the Study of Gbesiy) Using Food as Reward {isa prevalent habit to use food as a reward or sometimes withdraw food as punishment. Most parent ure this practice oceasionally, and some use it almost systematically, sarting a young age, The practice is ao commonly uted in other settings where children spend time, such as dayeat, school, or even athletic settings. Although it might be 1 good idea to limit some unhealthy but desirable food categories to special occasions, using food as a rewatd is problematic. Limiting aceess to some foods and making its access contingent on partcula ‘Accomplishment increases the desirability of that type of food, Con- versely, encouraging the consumption of some foods renders them less desirable. Therefore, phrases such as “nish your vegetables, and. ‘you wil get ee cream for dessert” can result in establishing unhealthy {ating habits once the child has more autonomy in food choices. ‘Parents should he counseled on such issues and encouraged to choose items other than food as reward. such as inexpensive toys or sporting, ‘equipment, family time, special family events, or collectable items Similar types of behavior ae also seen in schools and extra-curricular events. AS opposed to rewarding or punishments of food (pizzal ‘andy) daycare providers, teachers, and counselors should be encour- aged to ure alternative rewarde such as minutes office time, siting in the teachers chair, being the teacher helper, and homework-free nights Cultural Considerations in Nutri and Feeding Food choices, food preparation, eating patterns, and infant feeding practices all have very deep cultural roots. In fact, beliefs, attudes, and practices surrounding food and eating are some ofthe most important ‘components of cultural iZentity. Therefore, te not eurprising that in rulliultual societies, great variability exists in the cultural character istice of the diet. Even ina world where global marketing forces tend tw reduce geographic diferences inthe types of food, ot even brands, that are available, most famalis, especially during family meals at home, ae still much infuenced by ther cultural background, There- {ore pediatricians should become familiar withthe dietary characte {stcy of various cultures im their community, so that they can identify and address, in a nonjudgmental way and avoiding stereotypes, the potential nutritional issues elated tothe dit of theie patients Vegetarianism Vegetarianism i the practice offllowing a diet chat excludes animal flesh foods, including beet, pork, poultry, fish, and shellfish. There ate several varianl of the diel, some of which also exchade eggs and/or some products produced from animal labor, such as dairy products and honey. There are many diferent variations in vegetarianism: { Veganism: exciudes all animal products It may be part ofa larger practice of abstaining from the use of animals products for any purpose. ‘+ Ovavegetarianism: includes eggs but not dairy products, * Lactovegetarianism: includes dairy products but exclades eggs. ‘¢ Tactoovovegstaranisn: includes eggs and dairy products, « Flexitaran: recent term referring to-a vegetarian who wall, oceasionaly eat meat, Another expression used for vegetarianism and veganism is “plant- based dete Other dietary practices commonly associated with vegetarianism include frutarian diet (fruits, nuts, seeds, and other plant matter gath- ‘ered without harm tthe plat) Su vegetarian diet (adit that excludes allanimal products as well as onion, garlic scallions, leks, or shallots); a macrobiotic diet (whole grains and beans and, in some cases, fish) nd raw vegan diet (fresh and uncooked frit, nuts, seeds, and vege tables). "The safety of these restrictive diets has not been studied in children. These diets ean be very Iimited in macto- and micronutrients land ae not recommended for children. Implementing vegetarian dite in teenage girls may be a sign of an eating disorder Vegetarianism is considered s healthful and viable dict; both the ‘Academy of Nutrition and Dietetics (formerly the American Dietetic ‘Association) and the Dietitians of Canada have found that a properly planned and well-balanced vegetarian diet can satisty the nutritional294 Part VI_¢ Nutrition goals forall tages of if. Compared with nonvegetarian diets, vegetar fan diets have low levels of saturated ft, cholesterol, and animal protein, and relatively higher levels of complex carbohydrates, fiber, ‘magnesium, potassium, folate, vitamins C and E, and phytochemicals. Vegetarians havea lower body mass index, cholesterol and blood pres: sure, and ate at decreased risk for cancer and ischemic heat disease ‘Specific nulrents of concern in vegetarian diets include: ‘+ Tron: Vegetarian diets have similar levels of iron compared to nnonvegetarian diets, but the tron has lower bioavailability than fon from mest cources, and iron absorption may be inhibited by other dietary constituents, such a phytate (see Chapter 54), ron sores are lower in vegetarians and vegans than in nonvegetarians and iron deficiency is more common in vegetarian and vegan ‘women and children, Foods rich in icon include iron-fortied cereals, black beans, eashews, kidney beans, lentils, oatmeal raisin, black-eyed peas, soybeans, sunflower seeds, chickpeas, smolases, chocolate, and tempeh + Vitamin By, Plants are not a good source of By (see Chapter 49.7), Additional vitamin By can be obtained through dairy products and eggs: vegans need fortified foods or supplements Breastfeeding by vegan mothers can place an infant a rick for vitamin B, deficiency, 1 Fatty acids: Vegetarians and vegans may be at risk for low levels of ‘leosapentaenoic acid (EPA) and DHA. The inclusion of sources of Innolenic acid (precursor of EPA and DHA) such as walnuts, coy products, Naxseed, and canola cis, are recommended. + Calcium and vitamin D: Without supplementation, vegan diets are low in calcium and vitamin D putting vegane at re for ‘impaired bone mineralization (see Chapter 51). Vitamin DOH levee should be monitored in vegans and supplemented for levee <0 df, Calcium sousces include leafy greens (with low oxalate; broccoli, kale, or Chinese cabbage). Caleiom and vitamin D are found in almond and soy milk, and fortified orange juice { Zine: The bioavailabity of ine in plant sources tends to be low because of the presence of phytate: and fiber that inhibit zine absorption (see Chapter 54). Zine is found in soy products, Tegumes, grains, cheese, and nuts. Organic Foods Parents may prefer organic foods to feed children secondary to on cern regarding chemical and hormonal treatment of animals and produce, The nutiional difeences between organic and conventional foods may not be diically relevant Children consuming org foods have lower or no detectable levels of pesticides in their urine compared to those consuming nonorganic fonds. I remains unclear whether sucha reduction in esporre to chemicals ie cinialy sgn fant Organic foods tend to have higher antioxidant level and lower levels of cadmium, Similaiy despite concerns of parents, the amount «of bovine growth hormone in conventional mile is thought tobe neither sgnicant nor bilogieally acive im humans. Additionally, zk constmption from extogen-tested cows doesnot esultin endo tine disruptions in infants. However other chemicals in the enon ment. such at Buphenol-A (]und tn plastics), nitates, endocrine -3 SD Moderate woightforhoight << Severe WHO (tunting) — <2t9>3$D Moderato heighsforage 42 SD). To diagnose obesity, additional mea sures of adiposity are desirable ac a high BMI can result from high ‘musculanty, and not only from excess subcutancous ft. ‘Micronutrient deficiencies are another dimension of undernutt. tion. Those of particular public health significance are vitamin A, fodine, ion, and zine Vitamin A deficiency is eaused by a low intake of retinol (in animal foods) oF its carotenoid precursors, mainly beta-carotene (in orange: Figure 46-3 Weasuring mid-upper arm circumference, (image cour 1057 of Nyani Cuarmyne/Panes Pictures) colored fruits and vegetables and dark green leaves) (see Chapter 48). “The prevalence of clinical deficiency i asessed from eymptome and sight of rerophthalmia (principally night blindness and Bitot spot). Subelinical deficiency i# defined 3 serum retinol concentration <0:70 mol/l, Vitamin A deficiency isthe leading cause of preventable blindness in children, Ise also assoctated witha higher morbidity and mortality among young children Tdine deficiency i the main cause of preventable mental impair ment (see Chapter 54). An enlarged thyroid (goiter) is a sign of deficiency, Severe deficiency in pregnancy causes fetal loss and perma- nent damage to the brain and central nervous system in surviving ‘offspring (cetiniem). It can be prevented by iodine supplementation before conception or durin the frst trimester of pregnancy. Postnatal iodine deficiency ig asocieted with impaired mental function and growth retardation. The median urinary iodine concentration in chil dren ages 6-12 yr is ueed to assess the prevalence of deficiency in the general population, and a median of <100 g/l sndicatesinvuticient fodine intake. ‘ron deficiency anemia common in childhood either from low ion snakes or poor sbvorption, or asa rerult of illnes or parasite infesta- tion (see Chapter 54). Women also have relatively high rates of anemia a6 result of menstrual blood loss, pregnancy low ion intakes, poor sbrorption, and illness. Hemoglobin cutoffs to define anemia are 110 giL for children 6-59 mo, 135 g/L for children 5-11 yrand 120 g/L {or children 12-11 yr. Cato to define anemia for nonpregnant wemen ate 120 g/L, 110 g/L for pregnant women, and 130 g/L for men, ine deficiency increstes the rick of morbidity and mortality from, diarrhea, pneumonia, and possibly other infectious diseases (see Chapter $4). Zine deficiency also has an adverse effect on linear {growth Deficiency atthe population levels assessed from dietary zine snakes, Prevalence of Undernutrition [is estimated that approximately 15% of birth in low- and middle {income countries in 2010 were LBW. Rate of [BW are highest (26%) dn southern Asia, and are twice those of sub-Saharan Aftica India sccounts for approximately 40% ofthe work's low-weight births Glob- Sly im 2011 16% of children <5 yr of age wore underweight (weight- for-age <-2 SD). The lobal prevalence of stunting (height-for-age <2 SDy has declined from an estimated 40% to 26% over the last 20 ‘with the greatest reductions having taken place in Asia. Stunting preva. Tence is now highest in the Aftiean region (36% prevalence). Wasting (weight-for-height <2 SD) affects 8% of children 10 10 10 10 10300_Part Vi ¢ Nutrition 6-13 DQ (developmental quotient) points. Iodine and iron deficiencies also lead to loss of cognitive potential. Indications are that bildzen living in areas of chronte iodine deficiency have an average reduction in 1Q of 12-185 points compared with children in iodine-sufiient areas, Ion deficiency has a detrimental effect on the motor develop. ‘ment of children Z_ Provenveat hypotonia = 3. Trealprevent doyeraton — @__Conectimbatance of ation —————_—_ 5 Treat invectons —— Cored deficiencies of micenation =o no — 7.__ Start cautious feodng > &.__ Rebull wasted sou (eatchup grow) ——— 8. _ Provigo loving car ana play > 10. Prepare for folow-up ———— Figure 46-6 The 10 steps of treatment for severe acute malnutitin and their approximaChapter 46 ¢ Nutrition, Food Security, and Health 303 ‘CONDITION IMMEDIATE ACTION Shock 7 Gus oxygen Sethargie or 2. Give stenle 10% glucose (5 mL/kg) by IV Unconscious and 3. Ge IV Fuid at 15 mulkg over 1 hr, ung + cole hands + Ringers lactate wth Si daxtrose ot Pls ether { halbnormal saline with 9% dextrose or + ow capillary refill + halestangth Darrow solution vith Si dextrose Gonger than 2 se] or» ifallof the above ae unavailable, Rnger lactate + woak fast pulse 4, Mosrate and record pulse and respirations at ne start and If thee ae signs of improvement (pulse and respiration rate fall repeat V 15 mL/kg for 1 more he Then switch to coral or nasogastric renyaration wth ReSoMal, 5-10 m/kg i altamata hr (ea Tabl= 46 stp 2 I there are no signs of improvernent assume septic shock and Give maintenance uid 1 (4 ml/kg) while wating for blood 2. Order 10 mig fresh whole blood and transuzo slowly over 3 hr If signs of heart alate, give 5-7 ml/kg packed celle athar than whole oloed 3. Give furosemide 1 mL/kg W atthe start of the ansfsion Hypealycemia Sen Table 6-8 step 1 for oatment Blood glucose less than Sommol. Severe dehydration Do not ave lV fui except in shock Soe Tabiné-8 stop 3 for vearment Very severe anemia If very severe anemia (or Hb 4-6 g/dL AND respiratory dates Hb tess than @ 1. Ge whole oloed 10 mL/kg slowly over 3 hr Il signs of heart flrs, give 5-7 mL/kg packed celle rather than whole bloos 2. Give furosemide 1 mL/kg W atthe start ofthe ransfusion Hf comes uleraton Give vitamin A immectately fage 12 me 200,000 L) 2. Inell top atropine (1%) Into afacted eye 20 alex the eye and provent the lens from pushing out ion PREVENTION ‘TREATMENT ‘Aveid long gaps without ‘oad and conscious blood glucose <3 mmol/L minimize need for ghicose 1.10% glucose (50 ml), oF feed (see step 7), or I teaspoon suger Feed immediately Lunder the tongue.whiehever ss quickest 2 Feed every 3 hr day and night 2. Feed every 2 hr for at laast the fst day. Initially avo % of food Bar fib every 20 m 3. Feed an time 3. Keep wars 1 Keep warm 4. Star broad-spectrum antibities 5. Treat infections Whey compete for uneonscous alucoze) 1. Immediately give strile 10% alucose (5 ml by IV Note: Hypoglycemia and 2. Foed every 2hr for at leas frst day. Intilly ave of feed every hypothermia ofen coexist and are 30 min. Use nasogastric (NG) tube f unable to arnt sgn of severe infection 3. Keep arr 4. Star broad-spectrum antibioties 2. Prevent/veat hypothermia Keep warm and dey and feed ‘Acivaly rewarm auilary <25°C @S'F) rectal frequently 1 Feed S55 59°F) 1 Avid exposure 2. Skirstoskin contact with carer ("kangaroo technique") or dress in 2, Dress warmly including head and warmed clothes, cover head, wrap in warmed blanket ane provide cover wth blanket indict heat (og. heater, wansnarmer matvess; ncandescert 2. Keep room net; svoid draughts lam) 44 Change wat clothes snd bedding 3. Monitor temperature hourly (r every 20min if using haste) 5. Donat batre very 4, Stop rewarming when rectal temperature is 365°C 97 1°F) 6. Feed frequently day ard night 7. Treat infections R 2 Pre envhrest dehydration Replace stool losses Do not give IV ids unless the child isin shock 1''Give ReSoMal ater each watory 1 Give RoSeMal 5 ml/kg every 30 min for frst 2 hr orally or NG tube seo] ReSoMal (375 mmol Na/l) 2. Then give 510 mL/kg in akemate hours fr up to 10 hr Amount ‘3 Tow-sodium rehydravon depends on stool loss and eagemess fo drink Feed in he other solution fer malnut Shemate hour 3, Monitor houtly and stop if signs of overload develop (oulse rate increases by 25 beats/min and respratoy rate by breaths/min Ineteasing edoma; engorged jugulr veins) 4, Step whan rahyeatad (3 or mere signs af hydration: lass thirsty, passing urine, skin pinch less slo, eyes less suneen, mast mouth, fears, lees lthargis improved pulse and respiratory rate. Continued304 Part VI ¢ Nutrition PREVENTION. 4 Corea elecrolte imbalance—defct of potassium and magnesium, 5. Proven Minimize rik of croseinfaction 1 Avo evereroweling 2. Wash hand 2. Give menses vaccine to Unmmunized children age >6 mo 9 infactions 6. Comect micronutrient defcencies Note: Folie acid, multivitamins, zine, copper, and other trace minerals are already added in Nutiset F75, fina F100 packe Stor eautour feeding ‘TREATMENT 7 Gwe oxira potsssum & mmolka/day) and magnesium (06 mmol ka/day) fort least 2 wh Gee Taolo 46-12) Note: Petassium and magnesia are already added in NutisetF7S ‘nd F100 packats Infections are often silent. Starting on the fst day, give broad: ‘pectur antinotics teal ch loren 1 For antibiotic choas/schedule sea Tabla 46-9 2. Ensure all doses are given, and given on time 3. Cover sen lesions £0 they do nol become mniocted Noto: Avoid stroias as they depress immune function Do nat give iron inthe stabilization phase 1. Give sitamin Aon day 1 (under &rmo 50,000 units; 612 mo 100,000 unis; >12 mo 200,000 units) child has any eye signs of vitamin A sefcency or hat had recent measles Repeat ths dose on oaye 2 Fale aid 1 mg (5 mg on day 1) Zine @ malglday) and copper (0.3 mo/ka/dayh.These are inthe slecvolte/mneralsoluson and Comined Mineral Varin mic (CM) and can bs acded vo fecs and ReSoMal 4. Makistamin syrup oF CMV 1. Give &12 small foode of F75 to provide 130 mi/eg/day.100 kek! day and 1-18 9 protein/kg/day 2. gross edema, reuce velume ta 100 r/kg/day 2. Keep a 24-hrintake chart Messure feeds carfull, Record leftovers 4 feild has poor appetite, coax and encourage to fish the feed. If Uunfiniznes, refer bter Use NG tube eating 80% or less ofthe Smount offered 5. Hlreastfec, encourage continued breasteading but also give F75 6 Tansfer to F100 when appetite retums (usualy within 1 wid and edema has been lost or reduced Weigh daily and plot weight if ne complications If complications (chock, hypoalycmia, hypothermia, skin lesions, resoitatory or winary tact infections, of lethargysickh) GIVE ‘Arnoxiclin oral 25 mg/kg twice daly for days and Arspicilln (50 mg/g IV or IM) every 6 hr for 2 days, then oral amoxielln (25-40 marks) every 8 hy for 5 days {7.5 mafkg V or IM) once daly fer? days Forsersten darhesismsll bowel vergonsr, ad mavomacle 5 malig arb very 8 hr for? dy, 100 mL to which potassium, magnesium, and micronutrients are added), will zestablish metabolic contol, reat edema, and restore appetite The parenteral route should be avoided: children who lack appetite should be fed by nasogastric tube, ae nutrients delivered within the gut lumen help in its repai, Table 46-10 gives recipes for preparing the special feeds, and their nutrient ‘Composition. Two recipes for 75 are shown: one requires no ‘ooking, the athe i cereal based and has a lower osmolality, ‘which may benefit children with persistent dissrhes. #75 is ako avaliable commercially in which maltodextsins replace some of the ‘sugar and to which potassium, magnesium, minerals, and vitamine are already added. Dehydration states ie easly misdiagnosed in severely wasted children, asthe usual signs (tuch as slow skin pinch, sunken eyes) may be present even without dehydration, Rebydration mst therefore be closely monitored for signe of fluid overload. Serum clectzoyte levels can be misleading because of sodium leaking from the blood into cells and potassium leaking out of cll. Keeping the intake of electrolytes and nutrients constant (see Table 469) allows systems to stabilize more quickly than adjusting intake in response to laboratory results “Table 6-11 gives a tecipe forthe special rehydration soltion ‘used in severe malnutrition (ReSoMal). Therapeutic Combined ‘Mineral Vitamin mix (CMV) contains electrolytes, minerals, and vitamins and is added to ReSoMal and feeds. If unavalable, potassium, magnesium, ving, and copper ean be added as an clectroyte/mineral stock solution (able 46-12 provides a recipe) and a multivitamin supplement given separately +» Rehabilitation: Tae signals for entry o this phase are reduced) ‘minimal edema and return of appetite ‘A controlled transition over 3 day i recommended to prevent the “refeeding syndrome” After the transition,Chapter 46 ¢ Nutrition, Food Security, and Health 305 Ee F7s: FS (STARTER) F100" (STARTER) (CEREALBASED) (cATCHUP) Dried skimmed rik (a) 2 2B 80 Sugar (g 100 7 50 Corea four = 5 - Vegetable alg) » » © Elacrolyte/mineral solution ml" ~ 2 2 Water: make up to) 1000) 1009 1000 ‘Content/100 ml. Eneroy heal) 8 8 100 Protein (g) 09. u 29 Lactose (a) 13 13 42 Potassium (mmod 40 42 63 Sodlam immo 08 08 19 Magnesiuem (mel) oa 0.48 on Zine ima} 20 20 23 Copeer ima) 025, 025, 028 % Energy from p 5 ‘ 2 1% Energy from fat 2 2 sa Osmolality (mOsmvt) 43 334 a9 sk at high pees to prevent ol fom separating ox See Tales or ecp, owe compara valabletherapesic Combined Mineral Vain mic CMM Reomparabie| Scan be made orn 359 ore male 100.9 tage 209 ol 20 mL elecaarerl slur, nd watt 100 rl; fom 00 ri fll Pers ian erate een a Je 46-12 | Recipe for Concentrated Ele Mineral Solution’ Vite a Pea cle KE 2d Brel aa oe MagresionclereMGCk HO 760 ol ovata Sey gga an ?7 3TH om 8 Wir ak walimited amounts should be given of igh-energy, high protein milk formla such as 100 (100 keal and 3 g protein per 100 ml), or ready-to-use therapeutic food (RUTE), or family food: modified to have comparable energy and protein To make the transition, for 2 days replace B75 with an equal volume of F100 and then increaze each successive feed by 10 mL until some feed remaine uneaten (eevally at sround 200 milkg/day, ‘After the transition, give 150-220 kealkg/day and 4-6 protein! kegiday and continue to give potassium, magnesium, and ‘da 20 mL nen preparing 1 Lo ea or Ri “Wace Heth ach mon Use cote voll wer micronutrients, Add iron (3 mg/kg/day) I breastfed, encourage continued breastfeeding. Children with severe malnutrition have developmental delays, so loving care, structured play, and sencory stimolation during and iter treatment ate essential to ad recovery of brain fet Community-based treatment Many children with severe acute mal- nutetion ean be identified in their communities before medieal com plications arc, Irthese children have a good appetite and ae clinically ‘well, they can be rehabilitated at home through community-based therapeutic care, which has the added benefit of reducing thes expo: sate fo nosocomial infections and providing continuity of eate ater306 Part VI ¢ Nutrition recovery. It alto reduces the time caregivers epend sway from home snd their opportunity costs, and ean be costelfective for health Tigute 46-7 shows the criteria for inpatient versus outpatient cate ‘To maximize coverage and compliance, community-based therapeutic ‘Severe acute malntition —————_ With complications Without complications: ‘Severe edema (#¥#) Edema (+/+#) oR oR MUAC <115 mm AND any ofthe flowing MUAC >115 mm AND Anorexia Cinically unwe Al ofthe folowing Notalet ‘Good appetite CCineally wall ‘Aor Inpatient care Outpatient therapeutic care Figure 46-7 Flow diagram for inpatient and outpatient care in the child with severe acute malnutrition. MUAC, Mid upper arm ‘reumference, an oe care has 4 main elements: community mobilization and sensitization; sctve cae-findings therapeutic cae; and followup after discharge ‘Community-bared therapeutic care comprises steps 8-10, plus & broad-spectrum antbiotic (sep 5). RUTF i usally provided, espe cially in times of food shortage, RUTE is specially designed for reba bilitating children with severe acute malnutrition at home Kis high in energy and protein and has electrolytes and micronutrients added. The ‘most widely used RUTF is a thick paste that contains milk powéer, peanuts, vegetable oi, and sugar. Pathogens cannot grow in it because ofits low moisture content. Hospitalized children who have completed ‘eps 17 and the (ansition ean be transferred to community dased ‘are for completion oftheir rehabilitation, thereby reducing thei hos pial stay to about 7-10 days. Bibliography is available at Expert Consult, 46.1 Refeeding Syndrome Robert M. Klagman Refeeding syndrome can complicate the acute nutritional rehabilita tion of children who are undernourished fom any cause (Isle 46-13). Refeeding eyndrome is rare when the WHO recommendstions for the treatment of malnutrition are followed (see Chapter 46); howeves, may follow overly aggzestive enteral or parenteral slimentaion. Mal- ntrition usually har normal serum electrolytes but associated with intracellular electrolyte depletion. When excessive carbohydrates are administered, the resultant increase in serum insulin fevels may reduce hypokalemia, bypophosphatemia, and hypomagnesemia. Tae hallmark of refeeding syndrome ts the development of severe hypo phosphatemia after the cellular uptake of phosphate during the Ist wk Of starting to teefed. Serum phosphate level of $05 mmol/l. can roduce weakness rhabdomyolysis, neutrophil dysfunction cardore Epirtory flute, athythmias, seizures, altered level of consciousness, ‘or sudden death, Phosphate levels should he monitored during refeed ing, and if they are low, phosphate should be administered during VITAMIN/THIAMINE, opium HYPOPHOSPHATEMIA _HYPOKALEMIA _HYPOMAGNESEMIA DEFICIENCY RETENTION HYPERGLYCEMIA Cardiac Cardiac Cardiac Encephalopathy Fluid overload Cardiac iypotension Artsy Arenythmias Laetc aiaesis Pulmonary edema Hypotension Decreased stroke Respiratory Neurologic Death Cardiac compromise Respiratory volume Fralure Weakness Hypereapnie Respiratory Neurologic Tromer Fala Impated diaphragm Weakness Tetany Other conraciy Paras Seaures Ketoacidos' Dysonea Gastrointestinal Altered mental status Coma Respirtory fellre Nausea Come Dehyalration Neurologic Vornting Gastrointestinal Inmpases immune Parecineia Cons Naurea Tfnevon Weakness Muvcular Vomiting Confusion Rhabdamyalsis Dares Disorientation Muscle necrosis Other sthoray Other Refractory refine paras: Death hypokalemia and Seuwes hypecsleemia Coma Death Hematologic fukooyie dysfunevon lomolsis Thrombecytopenia Other DeathChay Bibliography ‘Awortn A Rha 5, Jackson A, el Gude fr he inpatient reset of very malnouvhed chen 200, Wotd Hea Ongoiaton, ‘edington I Avaarsaman M.Catk Meta Ashe ear ef of late change Bia Report fom he Commision on Staal Arcata ad imate Chang, Copebagen, 2012, CCABS. hip ces cgaors ‘Blick RE ilove C6, Wier St sb Natena and cid wndermsrion and ‘overweight ia Tow and mile ncome counties, Lance 38242745 201, Rtpiwwnlobdnutitoneres ore, ‘caryalbo NE Renney RD, Caringlon Pa Severe sonal dete is todderseking fom bea food ml skernaves, Pers 7}, ng F. Granthan-MGregor lack Mc a. How t wid he os of potent In otr 20 lion young chien nthe evlping wal. Child Heth Bac ayster, 209 {AOL IEAD and WIP Te State of Food Bec th World 2019 The mile imenson of fod ei, Rome 2013 BAO piney eee 8) ibsbtepet ‘Gray HC, Beddington I, Cet Ra Food ecu The challenge of Ted # bln people, Sen 327-612-418, 200. ‘Gordo aren Jone rth Chalengs in aeeerasng hanger whe preening obey, Lancet 340 747-78, 2012 ‘adda L: Why Ind eed «ttl mio tee. BMT 38.4667, Jay Rul MT Raw (upaseured mil: at elon onsets aking anhalt? Cl let Di S:AV8-L9, 2010, Nutrition, Food Security, and Health 30 ‘dig DS Blumenthal}. Wile WC: Opportunies to educe ldbood Tbonger and obesity JAMA 30824)2567-256, 202. StatagneW Seat Rhett food secur MT 4548273, 2012 ‘Derney FF Sae Shyer Horsherkr som a evere dietary ection 9 ‘sb #onth infant in sabuban Deri. Mihigas case report and reve of berate fr J Devt 4500-06, 2010, richanL Goldbach HS, LaGzone EN, ea: Antboie pst ofthe manageeat of veer sete malnron Bgl) Med 3625-435, 203 United Nations Department of Beene nd Socal Aft The Milena Development Goals Repor 2013, New Yat, 2013, United Niions rndgsanore ‘Valid eeratonl Commi based hepatic cae (CTC) A fel mana ‘Onlor, 2006, Vl Internationa ‘Yon GrbmerK Ringler C,Rosrant MQ, ea 2012 Gab Hunger Inde The ‘Challenge of hanger Enurng atin fod racy unde lan, wae, and ‘ery sees, Bona, 2012, WetbungerieIFPRL and Cancer Woslewide ‘Mtplde dado 102188574065029949. ‘yen SB, Roberto D, Cater a Tretnent of severe ate maluteon fa Taft aged £6 monty i Niger J Pan 16285-39208 ‘World Bink Nuiton nthe pore-2015 development apna Report of an Eapert ‘Constation, Wshngon, 201% hp: ws wack oriesteral ed WDSContet Serve WDSP/E/201309/370022037 2013s S008 ‘World Hea Ongnsatin: Pocket bok of api are for len: ue for ‘he management of omon line, Genera 2013, WHO, ‘World Heath Orgnieon: Managemen af severe marion a anal fr ypc ander ser heh workers, ed 2, Gener sprees, WHO,Peet and Obesity Sheila Gahagan ‘Obesity isan important pediatric public health problem associated ‘with rik of complications in childhood and increased morbidity and ‘mortality throughout adal if. EPIDEMIOLOGY ‘Obesity is a global public health problem, sparing only dramati- cally poor regions with chronic food scarcity such as sub-Saharan ‘Africa and Haiti. In 2008, according to the World Health Organiza- lion, more than 1.4 billion persons 220 yr old were overweight or obese. Tn the United States, 36% of adults are obese, and an additional 35% of adults are overweight. In children, the prevalence of abesity increased 300% aver approximately 40 yr ‘The National Health and [Nutrition Examination Survey, 2009-2010, found 329% of childeen, 2-19 yr ld to be overweight or obese, and 17% in the obese range ‘Childrens isk varies signiicanly by raceethnicity In 2008-2010, 24% of non-Hispanic Black, 21% of Hispanic, and >20% of American Indian/Alaskan Native children and adolescents were abese compared to 14% of white children. Across all racial groups, higher maternal ‘education contess protection against childhood obesi Parental cbesity correlates with a higher risk for obesity in their children, Prenatal factors including high preconceptual weight, geta- tional weight gin, high birth weight, and maternal smoking are assoc ated with increased risk for later obesity, Paradoxically. intrauterine ‘growth restriction wit ealy infant catch-up growth is associated with the development of central adipority and adult-onset cardiovaccular risk, Breastfeeding is only modestly protective fr obesity: Infants with high levels of negative reactivity (temperament) are at rsk for obesity, ‘eter self regulation is protective BODY MASS INDEX ‘Obesity or increased adiposity is defined using the body mass index (BMD, waich isan excellent proxy for more direct measurement of Dody fat. BME = weight in kg/(height in meters). Adults with a BMI 2230 mect the criterion for obesity, and those with a BMI 25-30 fll in the overveight range, During childhood, levels of body fat change Jbepinning with high adiposity during infancy. Body ft levels decrease for approximately 55 yr unt the period called adiposty rebound. ‘when body ft i typically atthe lowest level. Adiposity then increasse ‘until early adulthood (Sg. 47-1). Consequenty, obesity and over ‘weight are defined using BME percentiles; chidzen >2 yr old with a BMI 295th percentile meet the criterion for ebesity, and thoze with 3 BMI between the 85th and 95th percentiles fall in the overweight range. ETIOLOGY Humans have the capacity to store energy in adipose tissue, allowing ‘improved survival in times of famine, Furthermore, bumans innately prefer sweet apd salty foods and reject bitter flavors. Many vegetables are bitter, There preferences probably reflect evolstionary adaptations to svoid consuming toxic plants. Nonetheless, repeated exporure t0 Ihelthy foods promotes their acceptance and liking, especialy in early life. Simplistiall, obesity results from an imbalance of caloric intake and energy expenditure. Even incremental but sustained caloric excess results im excest adiposity. Individual adiposity 12 the result of 3 ‘complex interplay among genetically determined body habits, appe lute, nutritional intake, physical acuity, and energy expenditere, Envi- ronmental factors determine levels of availble food, preferences for Chapter 47 + Overweight and Obesity 307 types of foods, levels of physical activity, and preferences for types of activities. Environmental Changes Over the last 4 decades, the food environment has changed dramati- cally. Changes inthe food industry relate in part to social changes, as ‘extended families have become more dispersed. Fewer families ros tunely prepare meals. Foods ate increasingly prepared bya food indus- tay, with high levels of ealores, simple carbobiydrats, and fat The price ‘ofmany foods has declined relative tothe family budget. These changes, in combination with marketing pressure, have resulted in larger portion sizes and increased macking between meals, The increased ‘consumption of high carbohydrate beverages, including sodas, sport drinks, frit punch, and juice, adds to there factors (One-third of US. childyen consume fastfood dally. A typical fast food meal can contain 2000 keal and 44 g of fat Many children, ‘consume 4 servings of high-carbohydrate beverages per day. resulting {nan additional 550 keal of low nutritional value Sweetened beverages Ihave been linked to increased risk for obesity because children who drink high amounts of sugar do not consume less food, The dramatic increase in the ure of high-Sructose corn syrup to sweeten beveragee and prepared foods is another important environmental change, Tending to availabilty of inexpensive calor Since World War If, levels of physical activity in children and adults Ihave declined, Changes i the built environment have revulted in more reliance on ears and decreased walking, Work s increasingly sedent and many secors of society do not engage in physial activity during. leisuretime. For children, budgetary constraints and pressure for aca- demic performance have led to less time devoted to physieal education in echools, Perception of poor neighborhood safety is another factor that can lead to lower levels of physica activity when children are requited to stay indoors. The advent of television, computers, and video games has resulted in opportunities for sedentary activities that {do not burn calories, Changes in another health behavior, sleep, might also contribute. Over the last decades, children and adults have decreased the amount ‘of time spent sleeping. Reasons for these changes may relate to increased time at work, increased time watching television, and a gen ‘rally faster pace of fe. Chronic partial slep loss can increae risk for ‘weight gain and obesity, with the impact possibly greater in children than in adults In studies of young, healthy lean men, ehort sleep dura tion was associated with decreased leptin levels and increased ghrelin levels, along with increased hunger and appetite Sleep deb aleo ersle in decreased glacore tolerance and invulin sensitivity related to alters. tions in glucocorticoids and sympathetic activity. Some effects of sleep debt might relate to orexins, peptides eynthesized in the lateral hypo- thalamus that can increase feeding, arousal, sympathetic activity, andi ‘or neuropeptide ¥ activity. Genetics Genetic determinants also have a role in individual susceptibility to ‘obesity (Tile 47-1), Findings from genome-wide association studiee ‘explain a very small portion of interindividual variability in obesity, One important example, the FTO gene at 16q12, is associated with adiposity in childhood, probably explained by increased energy intake {Table 17-1), Monogense forms of obesity have also heen ‘centifie, including MCAR deficiency, astocited with early-onset obesity and food-secking behavior. In addition, there ae genetic conditions assoei- ated with obesity, such as Prader-Wilh syndrome, which results from, absence of paternally expressed imprinted genes in the L3qll.2-q13 region. Prader Will syndrome is characterized by insatiable appetite and food seeking Hpigenetic environmental modification of genes may Ihave aeole in the development of obesity, especially during fetal and any lf Endocrine and Neural Physiology Monitoring of “stored fuels” and short-term contol of food intake (appetite and satiety) occurs through neuroendocrine fedback loops linking adipose tissue, the gastrointestinal tact, and the central308 Part VI_¢ Nutrition 2 to 20 years: Boys NAME Body mass index-for-age percentiles RECORD # Dae [ Age | Woant | Sie [our %5 mi ss x 3 » Teeter waam ts) Sau (ny "Sue (e709 29 2 2 z 2 2% 2s 2 a a 2 2 2 2 a a 2 2» 19: e 19: ‘6 ‘8 tr ‘n 's ‘5 0 ‘2 ts te ‘e kgim* "AGE (YEARS) kgim’ PPE Te ee Te Nee Pe eg oe et wee EE count Fur 471 Sey oap poets ann Aan gis and ee Dod byte Natal Caner as, States in collabaration with the National Center for Chronic Dsease Proventon and Heabh Promation (2000). Se ‘wen ede govlgrowehenarsChapter 47 ¢ Overweight and Obesity 309 2 to 20 years: Girls NAME Body mass index-for-age percentiles RECORD # Date [Age | Want | Stato [Sr Cont 27: 26 25. 24 2 2. 2 20 19 18 7 16 16 14 13 2 kgim* ‘AGE (YEARS) 23 4 5 6 7 8 8 0 1 12 13 14 15 18 17 18 19 20 Puntns ay 38, 2000 oid 1800. ‘hese goiarowhchae " B Figure 47-1, cont'd310_Part VI» Nutrition SYMPTOMS LABORATORY ENDOCRINE Cushing syndrome GH deficiency Central obesity hirsutim, mocn face, hypertension Shor stature, slow Inoar groth Dexamethasone suppression test Evoked Gil responee, IGF=! Iyperineulmism [Nes cloblistori, pancreas adenoma, hypoglycemia, Insulin lel Maurae syndrome Hypothyroicsm Short stature, weight gain fatigue, constipation, cold TSH, FTs nee, myxedema Sore metacaroals,sucutanecus calceatons, dysmorphie ‘aces, mental retardation shor: stature, nypocaleemia, Psoudohypoparathyroidism Urine cAMP after synthetic PTH infusion Generic Alster syndko Cognitive impairment, retinitis pigmentosa, diab AIMS! gene melts, Hearing lass, ypogonadiam retinal degeneration Bardot Bieal syndrome Retin pigmentass, ronal aonormalties,pelydacyh, 8851 gone hypoaanadsm Cognitive impairment, is calabama, hypogonadism, pobdach ly Polyaactyhy syndactyy, cranial synostosis, mental retardation Biemond syndrome Carponter syndrome Mutations in the RAB23 gone, located fon chromosome 6 in humans Mutations the VPSI2B gana (ften alled the COHT gene) st locus 8422 Cohen syndrome Mid-chlsheod-onset obesity, shert stature, erominent rmaxilery incisors, hypotons, mental retardation, microcephaly, decreared viual acti Earhconset obesity, mental retardation, brachycaphah, Symophys,progasthism, behavior snd sleep dsturbances short stature, dyamonphie facies, mental retardation Insulin estance, childhood ooesty Hypothalamic surnor Dytregulation of orexigenic hormone acylghrlin, poor postprandial appetite suppression Exrl-onset severe obesity, inferily hypegcnadotropic Deletion 9034 Deletion 9034 Down syndrome: ENPP? gone mutations Frohlich syndrome FTO gene pelymorphism Tisomy 21 Gone mutation on chromarome 65 Homorygous for FTO AA allele Leptin or latin receptor gone Leptin defcency hypogonadsm) Melanocortin 4 receptor gene Earh-anset severe obesity, increased linear growth, MCAR mutation mutation ryperanag's, typerinsulinemia Most common known gonatc cause of ebesity Homozygous worse than heterozyaous [Neonatal hypotonia, si infant growth, small hands and {fect ments retardation, kypogenedsmy, hyperphagia leasing to revere ober'y, paradox cally elevated grrelin (Obesity red hair adrenal msutfcioncy, hyperproinsuineia Panial deletion of chromosome 1S oF loss of paternally expressed genes Prader-will Syndrome Proopiomelsnecortn deficiency Loss-ofunetion mutations ofthe POMC gene Unknown genes May be 2 paranooplastc disorder Rapid.onset obesity with hypothalamic dysfunction hypoventilation, ana autonome Gysregulation ROHKAD) Often confused with congenital central hypoventilation syndrome (CCHS), presentation 15 yr with weight gain, nyperanag's, rycoventistion, cardiac arest, central Glabetesirsio dus, hyeothyreiism, grouth hormone Jeviciency, pain sens tity hypotherm a, precocious puberty, neural crest tumors karan eysgeness, mmpredems, web neck, short stature, cognitva impairment Turner syncrome XO chromasome (NR, eee aderonne monophosohae ce tyrone, GH, eons hormone, IR insu erwin lato PTH pethyond homone; TSH, thyoistmulaing Fomore nervous sytem (ig, 47-2). Gastrointestinal hormones, including cho- leystokinin, glucagon-like peptide-1, peptide YY, and vagal neuronal feedback promote satiety. Ghrelin stimulates appetite. Adipose tise provides feedback regarding energy storage levels to the brain through bormonal release of adiponectin and leptin, There hormones act on the arcuate nucleus in the hypothalamus and on the solitary tract nucle im the brainstem and, sn turn, activate distinet neuronal net. works. Adipocytes secrete adiponectin into the blood, with reduced levels in response to obesity and increased levels in response ofa Reduced adiponectin evel are associated with lower inralin sensitivity and adverse cardiovascular outcomes, Leptin i ditetly involved in ‘ily slow leptin level stimulate food intake and high leptin levels {inhibit hunger in animal models and in healthy human volunteers. Aaipositycorzelates to serum leptin levels among children and adults, ‘with the direction of effect remaining unclear ‘Numerous neuropeptides in the bran, including peptide YY, agouti related peptide, and orexin, appear to allect appetite stimulation, ‘whereas melanocortins and ci-melanocottin-stimulating hormone are involved in satiety, The neuroendocrine control of sppetite and weight involves a negative-feedback system, balanced between short-term contol of appetite and long-term control of adiposity (including leptin), Peptide YY reduces food intake via the vagal-brainstem= hypothalamic pathway. Developmental changes in peptide YY are evident as infants have higher levels of peptide YY than school-age children and adults, Obese childzen have lower fasting level of peptide YY compared to adults, Weight los may restore levels of peptide YY in children even Uhough this does not happen in adults. In addition, patients homozygous for the FTO obesity risk allele demansteate pot regulation ofthe orexigenic hormone acyl-ghrclin and have poor post- pranial appetite suppression,Chapter 47 ¢ Overweight and Obesity 311 ‘Endocrine Outputs Fat Outputs Re Aiponectin fe Taiponectin <=> Autonomic Outputs Muscle OP ‘Autonomic Nutrients Ins onomle Lapin Ghrelin Outputs ow curs Figure 47-2 Regulation of energy homeostasis by the brain-adipose tssue-intestinal axis. Leptin stimulates hypothalamic anorexigenie and inhibrs orexigenie neurons. Adiporactn simulates hepatic, nd muscle glucore wilaation and increases ineuln sen ‘contrnuter to adipose tissue, muscle and hepatic naslin resstance, Peptide YY (YY) inhibits orexigense and glucag while interleukin (6) ike peptide 1 (GLP-1) Stimulates anorexgenie hypotholamie nevrons G.P-1 alo augments glicore stimulated pancreatic sulin secretion and suppresses glucsgen fecrotion Inulin stimulates adipose tise and muscle glicore uptace, enhances Ipagenes , suppressor hepatic glucose production, and has 2% inhibtery effect an the hypthalamie anarexigon system. Ghr Polonsiy KS, Larsen PR, Kronenberg HI: Wilms Textbook o ‘COMORBIDITIES ‘Complicetions of pediatric obesity occur during childhood and ado- lescence and persis into adulthood. An important reason to prevent land treat pediatric obesity is the increased risk for morbidity and mortality later in life. The Harvard Growth Study found that hoys who ‘were overweight during adolescence were twice as likely to die from cardiovascular disease’ as those who had normal weight. Mote lates the eroxgenic hypothalamic patnways. (Madiied from Melmed 8, joctnology, ed 12, Philadelphia, 2011, Saunders. Fig. 35-1) immediate comorbidities include type 2 diabetes, hypertension, hyper lipidemia, and nonalcoholic faty liver disease (Iable 47-2). insulin resistance inereases with increasing adiposity and independently aMlects lipid metabolism and cardiovascular health. The metabolic -yn- «drome (centeal obesity hypertension, glucose intolerance, and hyper lipidemia) increases risk for cardiovascular morbidity and mortality, Nonalecholic fatty liver disease (NAFLD) occurs in 10-25% of obese312_Part VI» Nutrition DISEASE POSSIBLE SYMPTOMS LABORATORY CRITERIA ‘CARDIOVASCULAR Dyslipidemia HDL 120, total cholesteral 9200, Fasting total cholesterel, HDL, LDL, vighcovides Hyperens.on ENDOCRINE Type 2 diabetes melitus Metabolic syndrome Polyeystc ovary synckome GASTROINTESTINAL, Gallbladier case Nenaleonoic fatty lve asease (NAFLD) NEUROLOGIC Preudotumor cere Migraines ‘ORTHOPEDIC Blount disease (cba vara) Musculoskeletal problems Slipped capital femora epiphysis PSYCHOLOGICAL Behavioral complications PULMONARY Athena Coercive deep apnea SBP 295% for sex. age, height a chosisrigran, polyuria, poljclpsls Cental adiposity insulin resistance, dyslipidemia, Typertension, glucose intolerance Inegulr menses, hirsutism, sene, insulin resstance, hyperandogenomia ‘Abdominal pain, veriting, jaundice Hepstomegaly,sodominal pain, dependent ‘edema, Pansarinases Can progress to foros, cithosis Headaches, vision changes, pepilledems Homeransa, noadachor Severe bowing of bia, knoe pain, ime Back pain, jont pain, Frequent strains or spain, limp, nip pain, groin pal, ag boning Hip pain, knee parr, limp, decreased mobilty of ty, depression low self-esteem, disordered signs of depression, worsening school performance, social salon, problems wih bulking or being bullied Shorinass of breath, wheezing, coughing, ‘xercse intolerance Snoring, spnes,resles seep, bohsworal probleme Seral testing, urinalysis, oe nitrogen, creating sroltes, Blood ures Fasting blood glucose >'10, hemoglobin As. insulin level, C-pentide, oral elucose tolerance tost Fasting glucose, (DL ard HOL cholestorl Irasound, re testorerene, Li, FSh sound AST, ALT, ukrasound, CT, or MRI Cerebrospinal fuld opening pressure, CT, MRI None Koo seraye Xeays Hip wraps Child Behavior Checklist, Children’s Depression Inventory Peds GL, Eating Disorder ventory 2 subjctive ratings of stress ana depression, Behavior ‘Assessment System for Chidren, Pedavic Symptom Cheese, Pulmonary function tess, peak Few Polyromnography, hypoxia, electolytes (respiratory Sedaris with metabolic sisters) ALT sorte aminotastease, AST, appurate aminotensiease, CT, corpated ‘omegrhy: FSH, folide-stmuletng mone: HDL, hgh-ders ty Tsaprotain {DL Tonideestyipopreen LH luciizng Homone al ragnelc resonance magna, Peds GL, Pesatie Quel o Lie hvenoty, SB, sale ble pressure adolescents. NAFLD ie now the most common chronic liver discate in US. children and adolescents. It can present with advanced fibrosis cor nonalcoholic steatohepatitis and may resul in cirrhosis and hepa: tocellular carcinoma, Insulin resistance Is commonly associated, Fur thermore, NAFLD is independently associated with increased risk of cardiovascular disease, ‘Obesity may aio be associated with chronic inflammation. Adipo: nectin, a peptide with antiinflammatory properties, occurs in reduced levels in obese patients as compared to insulin-sensitve, lean persons. Low adiponectin levels correlate with elevated levels of fee fatty acide sind plasma triglycerides as well as high BMI, and high adiponectin levels correlate with peripheral inslin sensitivity. Adipocytes secrete peptides and cytokines into the circulation, and proinflammatory pep- fides euch interleukin (IL)-6 and tumor necrosis factor-& (INF-2) ‘occur in higher levele in obese patients. Specifically, 1-6 stimulates production of C-reactive protein in the liver. C-reactive protein is a {marker of inflammation and might link obesity coronaty disease, and subeliniea inflammation. ‘Some complications of obesity are mechanical, including obstructive sleep apnea and orthopedie complications. Orthopedic complications {include Blount disease and slipped femoral capital epiphysis (see Chap. ters 677, 678.) ‘Mental health problems can cocxst with obesity, with the possiblity of bidivectional effects. These associations are modified by gender, ethnicity and socioeconomic statu, Self-eteem may be lower in obese adolescent girls compared to nonobese peers, ome studies have found fn asociation between oberisy and adolescent depression. There is Considerable interest in the cooccurrence of esting disorders and obesity IDENTIFICATION Overweight and obese children are often identified as past of routine ‘medical care, and the child and family may be unaware that the child bas increased adiposity. hey may be unhappy with the medical pro- vider fo rising this isue and respond with denial or apparent lack of Concern. Iti ofen necessary to bepin by helping the family understand the importance of heathy weight for cursent and future health espe- cially because intervention requires considerable effort by the child and the family. Forging a good therapeutic relationship is important, because obesity intervention requires a chronic disease management spptosch, Successfl recolution ofthis problem necessitates consider able family and child effort over an extended period in order to change tating and activity behaviors. EVALUATION “The evaluation ofthe overweight or obese child begins with examina tion of the growth chart for weight, height, and BMI trajectories; consideration of possible medical causes of obesity, and detailedChapter 47 ¢ Overweight and Obesity 313 exploration of family cating, nutritional, and activity patterns. A com- plete pediatric history is used to uncover comorbid disorders. The famuly history focuses on the adiposity of other family members and the family history of obesit-associated disorders, The physical exami nation adge data that can Iead to important diagnoses. Laboratory testing is guided by the need to identify comorbid conditions Examination ofthe growth chart reveals the severity, duration, and timing of obesity onset. Children who are overveight (BMI in the ‘85th-95th percentile) ae es likely tohave developed comorbid cond tions than those who are obese (BMI 295th percentile) Those with 2 [BMI-=99th percentile are even more hikely to have coexisting medical problems. Once obesity severity is determined, the BMI tralectory is ‘examined to elucidate when the child became obese, Several periods ‘during childhood are considered eensitive period o times of increased riskfor developing obesity. including infancy. adiposity rebound (when Dody fat is lowest at approximately age 55 yx), and adoleseence. An abrupt change in BMI might signal the onset of a medical problem or «period of family or personal stress forthe child. Examination of the ‘weight tajectory can further expand understanding of hovr the problem developed. A young child might exbsbit high weight and high. Ineight because linear growth can increase early in childhood if child ‘consumes excess energy. At some point, the weight percentile exceeds the height percentile and the childs BMI climbs into the obese range. [Another example isa child whose weight rapidly increases when she ‘reduces her activity level and consumes more meals avay from home. amination of the height trajectory can reveal endocrine problems, ‘which often occur with slowing of knear grovth, Consideration of possible medical causes of obesity i extential, even though endocrine and genetic eauses are raze (See Table 71), Growth hhormone deficiency, hypothyroidism, and Cushing syndrome are ‘examples of endocrine disorders that can lead to obesity. In genera, these disorders manifest with slow Linear growl, Because children ‘who consume excessive amounts of calories tend to experience acceler ied linear growth, short stare warrants forthe evaluation. Genetic Gisorders associated with obesity can have coexisting dysmorphic features, cognitive impairment, ion and hearing abnormalities, oF short stature. In some children with congenital cizorders such ae ryelodyaplasia or muscular dystrophy owe level of physieal activity ‘an lead to secondary obesity. Some medications can cauce excesive appetite and hyperphagia, resulting in obesity. Atypical antipsychotic ‘medications often have this dramatic side effect, Raps weight g 4 child or adolescent taking one ofthese medications might require 8 ‘scontinvation of that medication, Poor linear growth and rapid changes in weight gain ate indications for evaluation of possible ‘medical eases Exploration of family eating and nutritional and actinty patterns ‘begins with a description of regular meal and snack times and family Inabts for walking bicyele riding, active recreation, television, com- ptr, and video game time. It is useful to request a 24-hr dietary recall ‘with special attention to intake of fruits, vegetables, and water, 36 well 4X high-calorie foods and high-carbohydrate beverages. When possi- De, evaluation by a nutritionists extremely helpful mation will form the basis for incremental changes in esting behavior, caloric intake, and physical activity during the intervention Initial assesment of the overweight or obre child ince a com- plete review of bodily systems focusing on the possibility of comorbid conditions (sce able 47-2). Developmental delay and visual and ‘hearing impairment canbe associated with genetic disorders. Dificulty sleeping, snoring, or daytime sleepines suggests the possibilty of slp apnea. Abdominal pain might suggest NAFLD. Symptoms of polyuria, nocturia, or polylipsia may be the result of type 2 diabetes. Hip ot knee pain can be caused by secondary orthopedic probleme, including ‘Blount disease and slipped capital femoral epiphysis. regular menses may be associated with polycystic ovary syndrome. Acanthosisnigr- ‘ans can suggest insulin resistance and type 2 diabetes (Fig. 473) The famiy history bepine with identifying other obese family members. Parental obesity isan important rsk for child obesity. If ll family members are obese, focusing the intervention on the entire family is reasonable. ‘he child may be at increased risk for developing Figure 47-3 Acanthosis nigricans (rom Gahagan S: Child and ado- leseent cbesity, Cur Probl Pediat’ Adolesc Health Care 24:6-43, 2008 type 2 diabetes if family history exists, Patents of Aican- American, Ilispanic, or Nalive American heritage are alzo at increased risk for developing type 2 diabetes. Identification ofa family history of hyper tension, cardiovascular disease, or metabolic syndrome indicates increased rik for developing there obesity associated conditions ‘one helps the family to understand that childhood obesity increases risk for developing these chronic diseases thie educational interven- tion might serve as motivation to improve their nutrition and physical Physical examination should be thorough, focusing on posible ‘comorbid conditions (see Table 47-2), Careful serening for byperten- sion using an appropriately sized blood pressure cult is important. ‘Syrematie examination of the skin can reveal scanthosts nigricans, suggesting insulin resistance, or hirsutism, suggesting pelycytic ovary syndrome. Tanner staging can reveal premature adrenarche secondary to advanced sexual maturstion in overweight and obese gil Laboratory testing lor fasting plasma glucose, triglycerides, low density lipoprotein and high-density lipoprotein cholesterel, and liver function tests are recommended as part of the initial evaluation for newly identified pediatric obesity (Jable 47-3). Overweight children (EMI s5th-95th percentile) who have a family history of diabetes mel- Iitus or signs of insulin resistance should also be evaluated with a fasting plasma glucose test, Other laboratory sertng should be guided by history or physical examination findings INTERVENTION "There is evidence that some interventions result in modest but signifi- ‘eant and sustained improvement in body mass. Based on behavior ‘change theories, treatment includes specifying target behaviors, monitoring, goal setting, stimulus control, and promotion of self efficacy and self management ski. Behavior changes associated with improving BMI include drinking lower quantities of sugar-aweetened beverages, consuming higher-quality diets, increasing exercise, watch- ingless TV, and self-weighing. Most successful interventions have been famaly based and take into account the childs developmental age “parently” treatment can be as effective az “parent-child” treat ment, Because obesity is multifactorial, nat all children and adoles ‘cents will espond!to the same approach. For example, "lors-of-contal ‘ating, sssoctated with weight gain and obesity, predicts poor outcome in response to family-based treatment. Furthermore, clinical treatment programs are expensive and not widely avaiable, Therefore there ie interest in novel approaches including Internet based treatments and ‘guided self help. Tis important to begin with cleae recommendations about appropri: ate caloric intake for the obese child (Isble 47-4). Working with a ‘ettian is very helpful, Meals should be based on frit, vegetables, ‘whole grins, lean meat fish, and poultry. Prepared foods should be chosen for their sutitiona value, with atention to calories and fa. sds that provide excessive calories and low nutritional value should bbe reserved fr infrequent teats,314_Part Vi ¢ Nutrition ‘Weight-redction diets in adult generally do not lead to sustained weight los. ‘Therefore, the focus should be on changes that ean be ‘maintained for lif. Attention to esting patterns is helpful. Families should be encouraged to plan family meals, including breakfast Tis almost impossible for a child to make changes in nutritional intake tnd eating pattern if other family members do not make the same changes. Dietary needs also change developmentally, as adolescents requite grestly increzed calories during their growth eports, and adults who lead inactive liver need fewer calories than active and roving children LABORATORY TEST. NORMAL VALUE (Clucore ‘Omalal Insulin <5 mut Homoalobin A, om AST (age 2 y) seul AST (age 9-15?) 2 yr old and that children <2 yr ‘ld not watch television, Televison watching i often astocated with cating, and many highly calorie food products are marketed directly to children during child-oriented television programs. Pediatric providers should ati families to develop goals to change ntritional intake and physical activity. They can also provide the child snd family with needed information, The family should not expect immediate lowering of BMA percentile related to behavioral changes bbutcan instead count on a gradual decrease in the rate of BMI percen- tile increase until i stabilizes, followed by a gradusl decrease in BMI percentile. Referral to multdisciplinary, comprehensive pediatric ‘weight-management programs it ideal for obese children whenever possible “There is no effective pharmacotherapy esuling in reversal of excess adiposity in children and adolescents, Available medications result in LIFESTAGE RELATIVELY SEDENTARY LEVEL MODERATE LEVEL OF GROUP AGE (yt) (OF ACTIVITY (keal) [ACTIVITY (keal) ACTIVE (ea) Chile 23 00 1,000.1 400 (£001,400 Female 43 11200 1.40021,600 1,400.1 800 oa 1600 11400.2/000, s{400.2.200 ae sia00 2,000 2,400 Male 48 11400 1.40021,600 +,600.2,000 oa 11800 1/8002,200 2000.2,600 ate 2.200 2,400-2,800 2,800-3,200 ‘Adapted or US. Deparment of Agree Dietary guidelines lor Aercans, 205, hip ow heath go¥/DIETARYGUI! Tabl INES/apa2005/docurenth eee FEATURE GREEN LIGHT FOODS: ‘YELLOW LIGHT FOODS RED LIGHT FOODS Gusliy Tow-caloria,high-fber, low-fat, __Nutvient-dense, but higher in eslories High in calories, sugar, and fat rutventadense ara fat Types of food Fruits, vegetables Lean meats, dain starches, gains Fatty meats, sugar, sugar sweetened beverages, fad foods Quantity United Limited Infroquont or avoided!Chapter 47 ¢ Overweight and Obesity 31. ‘modest weight loss or EMI improvement even when combined with Iyehavioral interventions, Various classes of drugs are of interest, including those that decrease energy intake or act centrally a¢ anorexi. Ants those that affect the availablity of nutrients through intestinal or ‘renal tubular reabsorption, and those that aflet metabolism. The only US. Food and Drug Administration (FDA)-approved medication for ‘obesity in children <16 yr old is which decreases absorption of fat, resulting in modest weightloss. Complications include fatu- lence, ly stool, and spotting. This agen offers litle benefit to severly ‘obese adolescents. Because there are multiple redundant neural mech- anisms that act to protect body weight, promoting weight loss s# ‘extremely dificult, For this reason, there ie considerable interest in ‘combining therapies that simultancously target multiple weight regulating pathways. One example, approved for adults, combines phentermine. a noradrenergic agent, with topiramate, a’y- aminobutyric acid (GABA) ergic medication. This combination resulted in a mean 10.2-kg weight loss compared to 1.4 kg in the placebo group. Side «effects ae common and include dry mouth, constipation, paresthesias, insomnia, and cognitive dysfunction. Another promising example ie the combination of amylin (decreases food intake and slows gastric ‘empiying) with leptin (which has no anorexigenc effects when given. alone). This combination requees injection and isin clinical teal in Adults. Another FDA approved (for adults) drug is lorcaserin 2 selec- tive serotonin 2C receptor agonist. Establishing long-term safety and tolerability in children isa challenge as medications of interest have central nervous system effects or interfere with absorption of nutrients leratologic effects must be considered for ute in adolescent gels In some cases it is reasonable to refer adolescents for evaluation for ‘bariatric surgery. The American Pediatric Surgeal Assocation Guide lines recommends that surgery be considered only in children with ‘complete or neat-complete skeletal maturity, 4 BMI 240, and a medical ‘complication resulting from obesity, afer they have failed 6 mo of a ‘multidisciplinry weight management programs. Surgical approaches include the Roux en-¥ and the adjustable gastric and In obese adult, bariatric surgery reduces the risk of developing type 2 dishetes mel tus, In obese adult patents with existing type 2 diabetes, baritsie surgery improves the contol of diabetes PREVENTION Prevention of child and adolescent obesity is essential for public Incalth in the United States and most other countries (Table 47-6 and 47-7). Efforts by pediatric providers can supplement national- and ‘community-level public health programs. The National Insitetes of Health and Centers for Disease Control and Prevention recommend & varity of initiatives to combat the current obesigenic environment, including promotion of breastfeeding, access to fruits and vegetables, walkable communities, and 60 miniday of activity for children. The US. Department of Agriculture sponcore programs promoting 55 ‘cups of fruits and vegetables per day. Incentives fr the food industry to promote consumption of healthier foods should be considered. Marketing of unhealthy foods to children has begun to be regulated. ‘We expect to see changes in federal food programs including com- ‘modity foods, the Women, Infant, and Children Supplemental Food Program, and sehool-lunch programe to meet the needs of today’ chile. Pediatric prevention efforts begin with careful manitoring of weight and BMI percentiles at healthcare maintenance visit, Atention to changes in BMI percentiles can alert the peditric provider to increasing adiposity before the child becomes overweight or obec ll families shoul be counseled about healthy nutrition for ther children Ibecause the current prevalence of overweight and abesty in adult ie (65%, Therefore, approximately two-thirds ofall children can be con- sidered at risk for becoming overvieight or obese at some time in their lives. Those who have an obese parent are a increased risk Prevention clforts begin with promotion of exclusive breastceding for 6 mo and total breastfeeding for 12 mo. Introduction of infant foods should focus on cereals fruits and vegetables, ean meats, poultry, and fish may be introduced later inthe let year of life. Parents should be specially counseled to avoid introducing highly sugared beverages id foods in the Ist year of lf, Instead, they should expoce their infants and young children toa rich variety of feuts, vegetables, grains, lean meats, poultry, and fish to facilitate acceptance of a diverse and healthy diet’ Parenting matters, and authoritative parents are mote Likely to have children with a bealthy weight than those who ate authoritarian or permissive, Families who est regularly scheduled reals together ate less likely to have overweight or obete children, Chi health professionals are able to address a child nutritional statue and to provide expertise in child growth and development (Child health professionals can also promote physical aciity during regular healthare maintenance vst, Parents who spend some of theit leisuretime in physical activity promote healthy weight in their chi- dren. Beginning in infancy, parents should be cognizant oftheir childs developmental capability and need for physical activity Because telev- sion, computer, and video game time can replace health-promoting physial activity: physicians should counsel parents to mit sereen time for their children. Snacking during television watching chould be ci ‘couraged, Parents can help their children to understand tht television ‘commercials intend to sell a product. Children can learn that their ‘patents will help them by responsibly choosing heathy foods, ‘As obesity is determined by complex multifactorial conditions, pre- vention will take efforts at multiple levels of social organization, One ‘example, EPODE renons TObEItE Des Enfants), is a raltilerel prevention strategy, which began in France and has besn Aulopted by more than 500 commutes sn 6 countries. The goal i for local environments, daycare centers, schools, recreational settings and. families to adopt practices that promote healthy lifestyles for children from birth to 12 yr old. This initiative relies on 4 necessary compo- nents: political commitment to change, resources to support social ‘marketing and changes, support services, evidence-based practices. All EEPODE sites include monftoring and evaluation. Similar efforts ate laking place in the United States. An example of a US. community ‘fortis Shape Up Somerville, a citywide campaign to increase daly pphysial activity and healthy eating in Somerville, MA, which hasbeen ‘ongoing since 2002, The syrteme intervention focuses on cool health curricula, healthier food in schools and restaurants, safe routes to school, walkable and bikeable strets and worksite wellness. Comms nitywide programs ate important because neighborhood environmen tal factors (poverty have been associated with obesity in its residents Although these effort have resulted in lower weight guin in older Children and adolescents, there ie considerable interest in footing ‘are in the life cycle Beginning obesity prevention curing pregnancy and engaging health systems, early childhood programs, and commu: nity systems to eupport healthier le cycles is an approach with teemendous promise, Bibliography is available at Expert Consul316 Part Vi Nutrtion PREGNANCY Normalize body mass in De not smoke Maintain moderate exercise as tolerated In-aostationalslabetcs, provide motculous glucose contol Gestavonal weight gan with the Institte of Med'cne OM) recommendations POSTPARTUM AND INFANCY Breactoding: exclasive fr 46 mo, continue with other foods for 12 mo. Postpone the introduction of baby foods to 4-6 mo and juices to 12 mo FAMILIES Eat meals asa family in a fixed place and time 9 not skip meal, eepacial breakfast No television during meals Use small plates, and keep soning dishes away from the table, Avoid unnecessary eet or faty foods ana sugsr-swoetened drinks Remove salavisions rom children’s bedrooms; resvics tines for television viewing and video games. D9 not use food ss 3 reward. schoois Eliminate candy and cookie sales as fundsaisars Review tne contants of vending machines and replace with healthier choices; eliminate sods, ‘Avoid financial support for sports teams from beverage and food industies, Install wator fountains and hydration tations Edueste teachers, expecially physical education and ecionce faculty, about basic nuvtion and the be Edueste cildfen ftom praschoel through high school on appropriate dit and Waste Mandate min mum standard for physeal education, incluaing 60 min ef stranucus exercise 5 times weakly snooutage “the walking school bus": groups of children wing to school with adult supervision, ‘comMUNTES Irerease farly-rienaly exercise andl sae ply facilities for childven of all ages. Develop more mixed residenia-commerel developments for wakable and biyclable communis Discourage the ure of elovators and moving walkway Prove information on how to shap and prepare healthier versions of cukure-specic foods HEALTHCARE PROVIDERS Explain th biologic and gonstic contriutions to obesity Give age-appraprate expectations for Body weight in children, Ware toward classifying ebesiy as 8 disease to promote recognition, reimbursement for car, and willngness and ably to provide treatment. inpusTRY Mandate age-appropriate nutition labeling for products aimed at children (eg, red lgh/grean light foodt, with portion sie Encourage marketing ef iteractve video games in which ehlaran must exavcte In ore to play Use celebrity advertising drected at chichen for healt foods to promote breakfast and regutr meas Rechice portion size fines snd mes) GOVERNMENT AND REGULATORY AGENCIES Classify chichood obesity asa legitimate disease ind navel ways to fund nealhy Ifessyle programs (@., wi Subsidize government-sponsored programs to promote the consumption of fresh fits and vege Provide inancial incentives to industry to develop mare healthful products and to educate the consumer on product content Provide financial incentives to schools that infiste Innovative physical activity and nutriton programs, Allow tax deductions for ho cost of woight loss and exercise programs Prove uroan planners with funding vo astaelsh beyee, ogging, and walk Ban adverasing f fart foods, nonmutitious foods, and sugarsvee school-age children Ban faye a gis to chilean for purchasing fast foods ts of physical activity. paths ed beverages rected at preschool children, andl restrict advertising to ‘Adapted rom Speiser PU, Rudo! MCI, AnhaleH, ot a Consens aterrnt childhood abeaty, J ln Erdcrnel Mata 9018711887, 2 Euan Do not punish a child during mealtimes with regard to eating. The emotional atmosphere of a meal is vory important Interactions during meals shouldbe pleasant and happy 9 not use foods as renards Patents, siblings, and peers should madel healthy eating, tasting new foods, and Children should be exposed to a wide range of foods, tastes, and textures, Now foods should be offered muliale times. Ropeated exporure leads to acceptance and biking ‘orcing a child to eat a crtin ‘ood will decrease tha childs preferanco for that food. Childrens warness of row foods is nermal and should be expected. Offering 2 varaty of feods wth low-energy dansty helps eniaren balance eneray intace, Parents should contol what foods are inthe hore, Restricting access to foods inthe homme wil increase rather for that food CChilaren tend tobe more sare of satiety than ads, so allow children to respond to sates, and stop eating Do not free chldron to “clan ther plate wn decrease a chills dire ‘duped ror Berton D. Role a pureis in the determination of ood preferences of chien and the development a bes, J Obes Flat Metab Disord pease, td by permion orm MacranPubtahers UdChapter 47 ¢ Overweight and Obesity 311 Bibliography ‘Aion RS Aor BA: Brin egsliton of spt and ay. 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Yenowsk JA Long erm drug estes fer obeys sytematic and mel review JAMA 31Chapter 48 ¢ Vitamin A Deficiencies and Excess 3 eee) eT w sw aiteCira ry and Excess A. Catharine Ross and Libo Tan OVERVIEW OF VITAMIN A ‘Vitamin A sa fat-soluble micronutrient that cannot be synthesized de novo by the mammalian body, ths iis an obligatory dietary factor “The term itamin Ai generally used to reer toa group of compounds that posses the biologie activity of al rans retinol (Pg 8-1). As fatecluble micronutrient vitamin A i recognized as being extetial {oral vertebrates for normal vision, production, cel and Ussue di {erentiation, and functions ofthe immune system, Vitamin A playe clita oes in neonatal development Its equied for normal embry ‘onic development. hematopoiesis, immune response, metabolism, and {iow and difrctition of many types of call ‘Vitamin A canbe obtained from the diet where s main form se a¢ retinyl esters, auch as renylpalmiat, which ae called preformed vitamin A They ate found primarily in certain foods of aniral orig ‘Organ meat (especialy iver, key) ae very ic in wamin A, wle other mets, milk nd cheese contain moderate levels. Other sources ‘of vitamin A inclade several provitamin A carotenoids, which ate found naturally in many fats and vegetables, spec yellow-orange vegetables (pumphin squash, sweet potato), andleafy green vegetables (chard, spinach, brocoli). One of the most abundant carotenoids is Bearotene. ce Gartene and Prryptoxanthin also possess vitamin A activity a a lower bioactivity In the body, these precursors are sed forthe synthesis of2eseaial metabolites of vitamin A. One sal ans retinoic aid the form of vitamin A required for cell diferentition and the regulation of gene sransripion. Tis the most bioactive form fofviamin A. The oteris1-is renal required for vision tfanctions asthe light absorbing chromophore ofthe visual pigments rhadapsin snd indepsa, METABOLISM OF VITAMIN A Tngested rein esters must fist be hydrolyzed in the intestinal ume, 4 proces that ibertes unevteried retinal, forthe absorption of ‘itamin A, Most ofthe retinol is then reesterfied inthe enterocytes. “The aborpion of preformed vitamin Ai very elliot. Approximately 70-90% of dietary preformed Vitamin A i absorbed a ong a there {10 g of more ft in the meal, Chronic inlerinal dvondert oF lipid malabsorption can result im vitamin A deficiency. Uncleaved provitamin-A catotenods in the iletin ae also Sncorporated into ‘hylomicrone and delivered to various tissues The erimated abeorp- ton efficiency of eazotenods is approximately 20-50%, and pears ‘bemore variable among individals than for preformed vitamin A. The «tency of conversion af B-catotee to ztinl is much lower than fapected. The carotene cleavage enzyme Prarotene monooxygenase present i the enterocyte exhibits cetaln single nucleotide polymor. pPhisms hatreduce the elicency of eonversion of carotene oren0. Once retinol eteried in the enteroyte ein estr is then pace aged into nascent chylomicrons, which ae then secreted ito them hati eee and transported via the circulation to the liver oro other tissues. When vitamin A status is adequate, most mammals. ncuding Thumans, store most ofthe toa! body vitamin Aan the liver, within stellt cells When theit vitamin A status is deficient, vitamin stores ‘an be mobilized; the released retinol can be used by extrahepatic tisues, Stored vitamin A ie elessed from the liver into the etcultion 4s retinol bound to ie specific transport protein, retinol binding protein (RBP), which binds tothe thyrau! hormone transport poten tesnathyretin (TTR); thie complex delivere retinol (ax well as the thyroid hormone) to alge numberof vitamin A target tsues. ‘The major physolngte mediator of retinol uptake by cli > many tases {2 Stab, widely expresred mullitrnemembrane domain protein that funetons asa eal surface receptor for retinal ound to RBP Tn target tissues, sein i either estered ino eelinyl esters for storage of ondized ito retinoic acid for function. Ta the eye, II-cle- retinal i formed Vitamin A Status in Neonates ‘Neonates begin life with low levels of vitamin A. in plasma, liver, and ‘extrahepatic tissues, compared with those in adults, Normal plasma levels of retinol are 20-50 gid. in infants, and increase gradually as cildten become older. Median serum retinol values are 119 jsnoll fn both boys and girl ages 4-8 yr: 14 and 1.33 mol/L in boys and s-Carotene: ory 40H tot XK RE GHOfaty gop grup oy eter A Roc00H relooe an Distary | Preformed orn forms: vitamin A ‘carotenoids a xureton sole etn ne eA int tna Eg > OR ‘Hycrolysis, ‘Reduction metabolites vorere menteston Conjugation stage oe on Mo Descvaon products 4 Exeretion Figure 48-1 Vitamin A structures (A) and averview of vitamin A metabolism (8)318 Part VI ¢ Nutrition itl, respectively, ages 9-13 yr; and 1.71 and 1.57 mol/L in boys and Bil, respectively, ages 14-18 yr (or conversion, | kmol/. = 28 6 ugh GL). Values of 196 and 185 mol/l. are found in 19-30 yr old adult men and women, respectively. ‘Retinol levels are even lower in neonates in developing counties where vitamin A intakes may be low and vitamin A deficiency is a ‘common and significant noteitional problem. Lower vitamin A stores snd plasma retinol concentrations aze seen in low birthweight infants snd in preterm newborns, Malnstriton, particulaly protein nutition, ‘an cause vitemin A deficiency becauce of the impaired «ynthesis of REP. Inflammation as a Cause of Low Plasma Retinol Inlammation i cause of reduced levels of plasm retinol as a result of reduced synthesis of REP and TTR. This condition may mimic @ Jack of vitamin A, but will not be corrected by supplementation. In US. adults, these with moderately clevated levels of C-reactive protein, indicative of mild inflammation, had lower average plasma retinol levels, The extent to which inflammation is a factor in low plasma retinol in children is uncertain but tis ikely to be significant in acute {infectious diseases such as measles, and possibly in chronic inflamma. tory conditions such as eystic fibrosis. FUNCTIONS OF VITAMIN A AND. MECHANISMS OF ACTION Except for its role in vision, the pleiotropic actions of this micronutri fat include many systemic functions that are mediated atthe gene level by all-trans-retinoic acid (RA), which isa ligand for specific nuclear ‘wanscription factors, the fetinoid receptors: RARS and RXRs, When an RAR is activated bythe presence of RA, it combines with an RXR, and the resulting heterodimer binds to specific DNA sequences present fm retinoid responsive genes (RAREs and RXREs, rexpectively) and therefore induce or repress the expresion ofa large nuraber of genes In this manner, vitamin A, via its active form, RA, regulates many genes that ace involved in the fundamental biologic activities of cell, such as eel division, cell death, and cell diferentiation, The term ret hide includes both nateral end synthetic compounds with vitamin A Activity and is most often used in the context of vitamin A action at ‘he gene level. large number of synthetic retinoide have been pro-

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