MBBS V Paediatrics – Child with Basic Nutrition Need

Child with Basic Nutrition Need

Learning objectives
1. Diagnose failure to thrive and identify underlying causes
2. Interpret data on child growth and plan management of failure to thrive
3. Understand nutritional needs of children and importance of breast feeding

Case example
 5 month old boy referred by maternal and child health centre for suspected growth
problem
3 bones fusion site: fontanelle
 Growth parameters: 2 bones fusion site: suture
o Body weight (most sensitive: nutrition)  Allow brain to develop and grow
o Body length (for 5 months old)  300g at birth till 900g at 1 year
o Head circumference (reflect brain growth and intracranial
 1. Microcephaly:
 Premature fusion of suture: can intervene!
o Abnormal head shape (sharp: acrocephaly, flatten:
brachycephaly, asymmetrical: plagiocephaly)
(depending on which fontanelle closes abnormally first)
o Smaller head
o Craniosynostosis (EMERGENCY): due to congenital
reasons  affect growth potential  increase
intracranial pressure
 Irritating (do not say headache for 5 month old)
 Vomiting
 Feeding intolerance
 Seizures
 Drowsiness
 Signs
 Sunset eyes
 Dilated scalp veins
 Papilloedema (fundi)
 Specific for craniosynostosis
 Overlying suture lines
 Associated with syndromes
o Alport syndrome
o Carpenter syndrome
 Retinitis pigmentosa
 2. Brain injury  poorly early brain development 
TORCH
handicapped, cerebral palsy, neurological complication
-Toxoplasmosis o a. Congenital brain malformation
-Rubella  Congenital infection: TORCH
-Cytomegalovirus  Drugs:
-Herpes simplex
 Cocaine (affect vasculature – broken
nasal mucosa, atrophic gums, atrophic
changes in placenta – anacephaly)
o b. Prematurity 24-25 weeks cx
 Intra ventricular haemorrahge
 Hypoxic brain injury
o c. Brain asphyxia (perinatal hypoxia)
MBBS V Paediatrics – Child with Basic Nutrition Need

o Metabolic causes
 Prolonged hypoglycemia (hyperinsulinemia:
mother or fetus  heavier + brain growth)
(glucose is most important energy source – the
only nutritional component going into BBB)
 Risk of hypoglycemia is higher in infants
o Muscles and liver less developed –
insufficient storage
 Especially small size and premature
babies (must deliver glucose infusion)
 Hypothyroidism (poor fontanelle growth, poor
growth, myxedema, hypotonia, hyporeflexia)
 Macrocephaly:
 Hydrocephalus: increase, brain haemorrhage, brain tumour
(fontanelles have yet to close initially at 18 months – 2 years)
 Widely open fontanelle (still at 2 years)
 Hypothyroidism (bone growth affected)
o Fat composition: skin fold
o Body height: most important in primary and secondary schools (hormonal
problems: growth hormone, sex hormone, thyroid hormone)
 Standing height (stadiometer)
 Sitting height
 Upper segment and lower segment ratio
 Approach
o History
 1st baby of Chinese couple
 Parents separated during early pregnancy
 Both parents are working in China
o Perinatal history
 Term: 37 weeks (late antenatal visit in Hong Kong)
 Normal vaginal delivery: birth weight 3.1kg
 Brought back to HK for vaccination in MCHC (but taken care by
mother alone in Guangdong)
 Mother is still quite fresh in childcare
o Risk factors
 Lack parental skills
 Single parent
 Mother lives in mainland, difficult to receive health education in MCHC
 Infant nutrition vs adult nutrition (mother lacks knowledge)
o Relative energy required is higher
o Pattern differs
 Newborn: Drinks milk every 3 hours (3oz)
 Smaller stomach cannot tolerate that much milk
 Higher risk of hypoglycemia
 Night-feeds
 <4 months: will continue night feeds
o Consistency differs: no solid foods (GI system is premature: unable to absorb
solid foods; liquid diet <6 months; semi-solid foods: 6-12 months = “wean”;
after 12 months: solid foods)
 >12 months: actually still drink milk (but no longer primary)
o Breast feeding
MBBS V Paediatrics – Child with Basic Nutrition Need

 <6 months: exclusive breastfeeding

 6-12 months: semi-solid food introduction (if continue to exclusively
breastfeed, may risk iron deficiency, vitamin d deficiency)
 Importance of food
o Energy
 Growth
 Metabolic rate = maintain basal metabolic rate (esp. hypothermic pt.)
o Growth
 Height
 Weight
 Skeletal growth
o Development
 Brain development (nutrition is foundation of development: needs
environment, child protection)
o Reserve for extra demand
 Sickness: borderline/no reserve in sick patients
o Psychology of food
o Social implication
 Importance of energy
1. Basal metabolic rate
2. Thermoregulation
 For hypothermic patients, cannot raise their temperatures too quickly
 heart overload (must be an incremental type of raise)
3. Costs of digestion and metabolism
 Cachexic patient should NOT suddenly increase enteral nutrition
(instead parental nutrition should be opted for – easily absorbed)
4. Energy loss
 Fecal: diarrhea
 Urine
 Vomiting
 Heat loss by evaporation and radiation
5. Activity (variable = must be tailor made)
 Higher activity levels in children
 Concept of calorie
o Small calorie: approx. energy needed to increase temp of 1g of water by 1 oC
(around 4.2J)
o Large calorie (in medicine) = Food calorie: energy needed to increase temp of
1kg of water by 1oC (around 4.2kilojoules)
 Applying the concept of calorie to obesity: imbalance between intake and expenditure
o Everyday if excess 200cal, in 35 days = heavier by 7000cal
o 1lb around 3500 calories of over-intake
o *Catastrophic event/wasting: calculate if body weight is appropriate
 Essential nutrient in food and milk
o Protein (macronutrient): essential for brain development
o Fat (macronutrient)
o Carbohydrate (macronutrient)
o Minerals (micronutrient)
o Vitamins (micronutrient)
o Water

Protein = critical for child growth

MBBS V Paediatrics – Child with Basic Nutrition Need

 Protein in human breast milk adequate for normal term infants (2-2.5g/kg/day)
 Essential amino acids are ENOUGH (no advantage in powder milk)
 *Powder milk: easier fortify iron and vitamin D
 Composition of protein in breast milk
o Whey proteins
 60-80% of proteins in human breast milk: its ratio changes with stage of
lactation) – easier to digest
 Soluble in acidified state
 Alpha-lactalbumin
 Lactoferrin
 Binding proteins
 Immunoproteins
 Enzymes (e.g. lipase, lysozyme)
 *Mature breast milk: 6:4 (changes with mother and baby)
 Whey dominance is higher: sickness, prematurity
 Caesin dominant if very sick: metabolic acidosis
 *Colostrum: 9:1 (changes with mother and baby)
 First milk: if no GA  will clamp cord and initiate first feed (clamp
cord to prevent anemia and polycythaemia)
 Higher chance to successful breastfeeding
o Caesin – longer retention by forming complexes of protein and salt
 Insoluble in acidified state (becomes a complex in stomach)
 20-40% of proteins in human milks
 80% of bovine milk: not ideal for baby’s (vitamin D and iron deficiency)
(difficult to digest as more casein)
o Cow’s milk based infant formula (not actually made from cow’s milk)
 Contain partially hydrolyzed proteins
 Extensively hydrolyzed proteins
 Whey hydrolysates
 Caesin hydrolysates
 Amino acid hydrolysates
 Whey or casein dominant (standard cow’s milk: casein dominant)
 No difference unless in special circumstances
o 1. Premature or ICU babies
 Avoid casein formula
o 2. Normal babies (clinical observation that casein results in
more “full” satisfaction/less crying/less hungry due to
insolubility  remain in stomach for longer
 Whey dominant infant formula: more expensive
 E.g. synthetic milk adaptation (SMA is 60:40)
 No nutritionally superior to casein-predominant formulas for
healthy term infants
 Premature infant formula: whey dominant formula may reduce
metabolic stress for premature babies
 Changes as infant grows: fulfil growth and brain development
o Breast milk: protein concentration (g/100cal) changes with age and tailored
o Formula milk (breast milk substitute: not cow’s milk – made in factory):
 Designed to meet highest possible needs (e.g. youngest infants)
 Excess nutrients and increase metabolic stress (>50% over-nutrition)
 For premature baby: breastmilk is the best nutrition  necrotizing
enterocolitis risk is a lot smaller
 Significant proportion of overweight and obesity (commercial interest)
Fat in diet (difference types of fat aids brain growth and cellular formation)
MBBS V Paediatrics – Child with Basic Nutrition Need

 Dietary fat consists of provision of 40-50% of total caloric intake with at least 3% of
total calories as linoleic acid
 Types
o Medium chained triglyceride (MCT):
1. Boost calories
2. Reduce metabolic compensation – reduce risk of hypoglycemia
o Long chain polyunsaturated fatty acid (LC-PUFA):
1. Growth and development of retina and brain
 Examples: n-3, n-6 essential fatty acid (LA, DHA, ARA)
 DHA: essential fatty acid polyunsaturated
 All sufficient and present in breast milk (no need for excess
which is marketed in formula milk) = no additional health
benefit

Carbohydrates
 Normal glucose utilization rate in term infant: 4-6 mg/kg/min (6-10g/kg/day)
o Fasting patient: glucose must be maintained at this level (hence, fasting a baby
cannot be >12 hours)  risk of hypoglycemia  development stunt
 Prolonged hypoglycemia:
o Must give sufficient replacement
 Constituents during fasting
o Glucose: 4-6mg/kg/min
o Fluid: 100-120 ml/kg/day (for babies) (depends on age and status of baby)
 If 3kg = everyday require 300ml/day
o Other supplements: e.g. Ca (only electrolyte in short fasting period - hours)
 Na and K only in prolonged fasting (1-2 days) or loss due to GI upset
 Example for calculating components to replace during fasting covering glucose
utilization rate
o Body weight: 3kg
o Glucose requirement: 26g glucose per day (using above formula)
o Fluid requirement: 300ml/day
o Selection of fluid: D10 (around 10g/100ml)
 Continuous infusion 300ml over 24 hours at D10, with Ca supplement
 *Different solutions via IV
1. Colloid fluids
2. Crystalloid fluids
o Dextrose concentrations: D5, D10, D20, D50 (if high
concentration dextrose into peripheral vein 
extravasation and thrombophlebitis/abscess)
 Max: D12.5 in peripheral vein
 Higher concentrations given via central line

Case follow-up relating to initial case presentation

 Ho Man received breast feeding until 1 month old, when his mother brought him back
to Mainland for further care
 Mother is planning to work as part time
 She has been advised by a friend that she is too thin for breastfeeding and a new
formula milk could make his baby more clever

How do you compare nutritional value of breast and formula milk

MBBS V Paediatrics – Child with Basic Nutrition Need

 Mature human milk

o Ratio differs - 1 protein: 4 fat: 7 carbohydrate
o Lowest renal solute load esp. patients and children is important
 If risk of renal failure: should not eat heavy renal solute load foods
 Newborn children renal function is 1/3 of adults (esp. premature baby –
must monitor carefully)
 Until 3 years: renal function is similar to adults
o Less iron
o Less vitamin D – (supplementation: 400IU = one drop per day)
 Vitamin D deficiency (in general population in HK due to lack of
sunlight exposure) – emerging field
 Rickets: skeletal growth (short, abnormal head shape)
 Risk of infection: immunity
 Risk of allergy: eczema, allergic rhinitis, asthma
 Mental health: depression, psychosis risk
 Cancer risk increase
 Cow milk formula
o Attempt to be similar to breast milk composition
o 1 protein: 4 fat: 7 carbohydrate (number 1 infant formula)
o Different ratio – more protein is needed (number 2 infant formula)
o Number 3 infant formula: similar to adult milk (only exist for commercial
purpose)
 By 1 years old: no need to intake infant formula
 Should drink breast milk till 2 years (1-2 meals of milk per day)
o Fortified iron and vitamin D
 Cow milk (not formula)
o Different proportion of protein: fat and carbohydrate (3:4:5)
 Soy milk: lactase deficiency (should not be recommended long term)
o Use: lactase deficiency
 Primary lactase deficiency (unlikely present at birth)
 Secondary ex:
 Protracted diarrhea: loss of lactase in mucosa (may benefit
from transient intake of soy milk) – e.g. infection, celiac dx
o Very high renal solute load
 UTI: MUST sample, no misdiagnosis in children
 Kidenys are premature in children: e.g. recurrent UTI, reflux, high renal
solute load will damage kidney
o But high heavy metal (aluminum, mercury)
Advantages of breast feeding
MBBS V Paediatrics – Child with Basic Nutrition Need

 Components  benefits to growth and brain development

o Contains >400 bioactive substance
 Growth factors
 Hormones
 Antibodies
 Essential fatty acids
 Benefits to baby
1. Nutritional value: best composition with high bioavailability
2. Reduced obesity and overfeeding
3. Protect against infection and allergy (many antibodies, esp <6 months)
4. Less contamination, readily available (must have clean water and hygiene for
formula milk  actually increases mortality rate)
5. Contains enzymes, hormones and immune factors
6. Immunologic protection
 Match sequence of post-natal development of immune system
i. Anti-inflammatory agents
ii. Immuno-modulatory agents
iii. Direct acting anti-microbial agents
 Help adaptation of GI tract in switch from fetal to postnatal life
7. Reducing future health risks, reduce:
 Diabetes 40%
 Obesity 25%
 Otitis media (recurrent ear infection) 60%
 Hospitalisation for asthma or pneumonia 250% (global data)
 Death in 1st year 27% (global data)
 Benefits to mother
1. Involution of uterus
2. Better physical shape
3. Reduce neoplasm
 Breast cancer reduce 39%
 Maternal type 2 diabetes reduce 14%/year
4. Improves psychological wellbeing
5. Less postnatal depression (13% in Hong Kong)
 Universal screening in 2010: Edinburgh postnatal depression scale
 If early PND features, adjustment disorder  better support and
buffering  helps prevent
 Benefits to family
1. Maternal infant bonding (attachment) – biosocial  oxytoxin level higher in
both mother and fetus
 Function of oxytocin
 Contraction of uterus
 Ejection of breast milk
 Better parenting skills and tolerant to babies – “good parent”
 Less school withdrawal
 Behavioural problems
 Child abuse
2. Contraceptive effect (birth control)
3. Economic and effective way of feeding
 Benefits to society
o Less medical consultations, hospitalization, medical expense for infections
MBBS V Paediatrics – Child with Basic Nutrition Need

Disadvantages of breastfeeding
1. Physical exhaustion of mother (exception: e.g. breastfeeding jaundice in hospitals)
o Frequency
o On demand feed
2. Emotional stress on mother (may feel guilty)
3. Sleeping quality (mother) impaired
4. Infections: virus (e.g. HIV, CMV, HTLV)
o Absolute contraindication: certain infections
5. Transmission of undesirable drugs (e.g. chemo, radiotherapy, psychiatric drugs)
o Absolute contraindication: chemo and radiotherapy, recreational drugs
o Most psychiatric drugs are suitable for breastfeeding (may need to adjust dose)
– e.g. most TCA, anxiolytics, methadone (can be a motivation to quit drugs)
6. Inborn error of metabolism requires special diet
o Certain metabolic diseases

Breastfeeding epidemiology
 Extremely low relative to other countries
 Breastfeeding initiative in hospitals
o No free formula milk in hospitals
o Encourage breastfeeding in hospitals
MBBS V Paediatrics – Child with Basic Nutrition Need

Contraindications of breastfeeding
1. Chemotherapy
2. Drugs of abuse
o Marijuana, heroin, PCP/amphetamines, nicotine
3. Radioactive compounds
4. Certain psychiatric medications: anxiolytics, anti-depressants, anti-psychotics
5. Certain drugs
o Lithium, tetracycline, cyclosporine, ergotamines, bromocriptine (suppress
lactation)
6. Maternal illness
1. Toxemia (drugs for tx of toxemia are usually contraindicated)
2. Active tuberculosis
3. HIV positive mothers (virus transmitted via breastmilk – but in 3rd world
countries, this may still be necessary)
o *Not contraindicated in
 Mastitis and breast abscess (Staphylococcus infection)
 Candida infection of breast
 Urinary tract infections (just avoid sulfa drugs, tetracyclines)
 Hepatitis A
 Hepatitis B (due to predominantly vertical transmission)
 Hepatits C
 Varicella (can pump milk and feed if only mother infected)
 Herpes (avoid herpes lesions contact, but can breastfeed)
 Cytomegalovirus (avoid if preterm but breastmilk has antibodies)
 Syphilis (avoid if lesions are on breast)

Public health issue

 Provides ideal nutrition for infants during first 4-6 months of life
 Protects against certain childhood and possibly adult diseases
 Improve cognitive development
 Beneficial to mother’s health
 Cost saving for community
 WHO recommendation
o Exclusive breastfeeding is recommended up to 6 months of age
o Continued until 2 years with complementary foods
o May be more difficult for after 2 years

Lactating mother’s status

 Ho Man’s mother even if malnourished does NOT affect breastmilk composition

Growth of 5-month old boy

 Body weight: 5.5kg
o Birth weight: 3 – 3.5kg (3.2kg for girl; 3.4kg for boy)
 If born with smaller birth weight – then may be ok if <6kg
o Newborn: increase by around 1kg/month (hence everyday 30g-40g)
o Double in 3-4 months (around 6kg)
o Triple by 9-10 months (around 9kg)
 Body length: 63cm
 Head circumference: 41.5cm
MBBS V Paediatrics – Child with Basic Nutrition Need

Growth chart
 Weight: below 3rd percentile
o Drop percentile line crossing 2 percentile lines within 6 months

 Head circumference: 30-10th centile

 Would be ideal for additional time points: every 2 months to MCHC (vaccination at 2
months, 4 months, 6 months)  for trend progression = gradual dropping

Feeding history (nutrition is most important at early stage of life) – know calc for exam
 Man Ho is receiving normal formula milk 4.5-5 oz per feed (4 times per day)
o Current calorie intake for Man Ho
 1 oz of milk = 30 ml = 20 calories
 5 oz x 4 times = 20 oz or 600ml of milk per day
 20 oz x 20 calories = 400 calories
o Current body weight is 5.5kg: calorie intake/body weight/day
 400 Cal / 5.5kg = 73 cal/kg/day
 73 cal/kg/day is not enough
 Ideal intake:
o Expect 100-110 cal/kg/day
o Must use EXPECTED weight at 10th percentile = 6.5kg to calculate ideal intake
o =100 Cal x 6.5 = 650 Cal/day
 Calories in amount of formula milk (20 Cal per oz or each 30ml = 20 calorie)
o 650 Cal /20Cal x 30 ml (expect 5 feeds per day) = 975 ml (=32 oz) per day
 Man Ho needs to increase milk intake from 20 to 32 oz milk per day
o If assuming a 5 month old feeds 5 times per day, then will need 6oz per feed
 Diagnosis: failure to thrive

Failure to thrive
 Definition (dynamic definition) (know)
o Failure of expected growth and wellbeing in children <3 years/5 years with
a downward crossing of two percentile lines in weight over 6 months
 Overview of common causes (intake and utilization): organic vs inorganic causes
1. Intake problem (amount, technique – chewing: cleft palate, process)
2. Digestion and absorption problem
3. Excessive loss (upper GI and lower GI)
4. Extra energy demand
5. Energy utilization problem (ICU): heart failure, cancer, TB
 Classification of causes
1. Organic causes (most common in HK)
2. Inorganic causes (globally: more common)
MBBS V Paediatrics – Child with Basic Nutrition Need

Organic causes of failure to thrive

 1. Inadequate food intake
a) Insufficient or inappropriate food (not available, poor technique, neglect)
b) Feeding problem (poor technique, inappropriate schedule, neurological)
c) Mechanical (cleft palate, GI abnormalities)
i. May use special teats to help with cleft palate that are flat headed
d) Anorexia (reduced appetite due to chronic illness, anemia, psychosocial dx)
 2. Reduced absorption or digestion of nutrients
a) Pancreatic insufficiency (e.g. cystic fibrosis)
b) Small intestine: loss or damage to villous surface due to coeliac disease,
inflammation, or food allergy
 3. Excessive loss of nutrients
a) Vomiting
 GI: gastroesophageal reflux, obstructions, pyloric stenosis
 Pyloric stenosis: pylorus thickening and lengthening
o Features: fam hx, 4 weeks
o S/S: projectile vomiting, succession splash, visible
peristaslsis
o Cx: metabolic alkalosis, hypoK, succession splash
o Invg: ultrasound during feeding
 CNS: increased ICP, drugs
 Systemic: UTI, other infections, metabolic disorder
b) Diarrhea (GI loss)
 Post-enteritis enteropathy
 Disaccharidase deficiency
 Cow’s milk protein intolerance
 Inflammatory bowel disease
 Coeliac disease
 Colitis
c) Renal losses (uncommon, can be missed)
 Renal failure
 Renal tubular acidosis: loss nutrients
 DM, DI
 4. Extra energy demand
a) Chronic illness: heart failure, respiratory disease, immunodeficiency
b) Chronic infection: TB
c) Chronic inflammation: SLE, IBS
d) Endocrine: thyrotoxicosis
e) Immunodeficiency
 5. Inability to utilize ingested nutrients
a) Chromosomal or genetic abnormality (e.g. trisomy)
b) Metabolic disorder (e.g. amino acid disorder)
c) Endocrine disorder
MBBS V Paediatrics – Child with Basic Nutrition Need

Inorganic causes of failure to thrive

 1. Family dysfunction
a) Maternal depression
b) Marital discordance
c) Parental alcoholism, substance abuse
d) Single parent, lack of social support
e) Inexperience in parenting
f) Poor parent-child bonding
 2. Feeding disorder
a) Inappropriate food
b) Distraction
c) Meal time chaos
d) Poor technique
 3. Child maltreatment and neglect

Man Ho’s progress

 Dietary advice: adequate intake of nutritious diet
 Body weight catches up gradually in subsequent few months
 By 12-18 month old follow up, growth along 3-10th centile

Nutritional requirements in preterm infants

 Principles: higher amino acid requirement for preterm baby
o At term: 1.5-2g/kg/day
o 30-36 weeks: 2-3g/kg/day
o 24-30 weeks: 3.6-4.8g/kg/day
 Intravenous nutrition can be started soon after birth in preterm infants, many risks
1. Transient tachypnea of newborn
2. Wet lung
3. Pneumothorax
4. Poor nutritional growth
5. Brain development
 Principles of nutritional supplementation for premature babies
o Minimal enteral feeding: little is enough (pump breast milk)  nasogastric
tube  stimulate GI adaptation  start enzyme secretion  increase
establishment of successful feeding
 Reduce necrotizing enterocolitis
 Faster weight gain
 Shorter time to full enteral feeding
o Slowly increase feeding over 30-120 minutes preferably to continuous feeding
o Encourage breastfeeding
 But NOT enough at 24-28 weeks since very high energy requirements
 Alternative to breast milk: premature infant formula
o Fortified milk supplements (on top of breastfeeding): 2 packets (24 cal/oz)
 Premature babies require fluid restriction (get most from limited feeds)
 Congenital heart disease  pulmonary edema
o Patent ductus arteriosus: attempt to encourage closure
of PDA in premature babies
o Tx: prostaglandin inhibitor (indomethacin) and
fluid restriction, surgical ligation (last line)
 *NOT prostaglandin (prevents PDA closure)
o S/E of indomethacin: NEC risk increase, renal fx
MBBS V Paediatrics – Child with Basic Nutrition Need

 Indication for human milk fortifiers

 Body weight <1800g
 Osmolality below 450 mOsmol/kg (AAP)
 Vitamin D 400 IU/day
 Iron 2mg/kg/day
 Types of fortified milk supplements
 Enfamil
 Similac
o Overall: 24 cal per oz of milk (supplemented breast milk/premature formula)

Updates in Hong Kong

 WHO standard growth chart (growth chart used in HK was 30 years ago)
o New International Standard WHO standard growth chart (growth reference)
o Now developing a new growth chart for Hong Kong
 User friendly environment for breastfeeding (e.g. partnering with shopping malls)
o Reduce stigmatization

Extra information about growth rate

 Pre-pubertal normal growth rate: 4-6cm/year
o If primary school: below optimal level  growth hormone deficiency
o Growth hormone deficiency diagnosis is complicated process
 A stress hormone (hence spot diagnosis is not enough, requiring
stimulation tests)
 Highest level: deep sleep (sleep deprivation: growth impaired)