Nutrition basics for children

Nancy A. Anchores, M.D.
,FPPS
Basic Goal
Satisfactory growth and avoidance of deficiency states
Advisable Intake
Indicates the amounts of various nutrients
recommended for the individual
Average values used as guides for estimating

requirements at any given age, but differences
in need should be recognized for each child
Minimum requirement
(specific nutrient)
The least amount of nutrient needed to produce
in an individual an optimum state of health
Varies with several factors such as age, sex,

rate of growth, body build and physical activity
Importance of Nutrition
Production of energy
Repair of tissues damaged or worn-out
by wear and tear
Production of new cells and tissues for growth
and development (physical and mental)
The amount of heat which food can supply and utilize

as fuel in the organism is expressed in CALORIES
Calories
Measurement of heat
One kilocalorie (1 kcal) is defined as the amount
of heat necessary to raise the temperature of one
kilogram of water from 14.5oC to 15.5oC
Average Distribution of Calories in a well-balanced diet
Protein 15% (9-15)
Fats 35% (35-45)
CHO 50% (45-55)
1 gram of protein/CHO = 4 kilocalories
1 gram of fat = 9 kilocalories
Basal Metabolism
Amount of heat given off or the calories spent
during sleep or rest
Highest during early life when the infant is small
and growing rapidly
12-18 months = 50-55 kcal/kg/day
Older children/adults = 25-30 kcal/kg/day
• For each oC of fever, BM increase by 10%
Calorie intake is adequate when it cause the infant

to thrive and grow satisfactorily
Basal Metabolism
Appetite is a reliable index of caloric needs in most healthy
children, but not for children with physical or psychological
problems
Poor = 18 months to 3 years
Improves = 4-6 years old
To avoid underfeeding, caloric requirement should be
calculated not on the basis of actual weight but on that
of expected weight.
Approximate Daily Requirement

1st year: 80-120 kcal.kg/day
Subsequent decrease of about 10 kcal/kg
for each succeeding 3-year period
Water
Requirements are related to:
 Caloric consumption
 Specific gravity of urine
 Loss thru respiration
Balance depends on:
 Fluid intake
 Protein and mineral content of diet
 Solute load for renal excretion
 Metabolism and respiratory rates
 Body temperature
Water
Functions:
 Solvent for cellular changes
 Transport of nutrients and waste
 Regulates body temperature
Daily consumption:
 Infants : 10 – 15% of BW
 Adults : 2- 4 % of BW
Approximate Daily Water Requirements
of Filipino Infants and Children (del Mundo)
Age Water (ml/kg)
0-3 days 120
10 days 150
1-5 mos 150
6-12 mos 150
1-3 years 140
4- 6 years 120
7-9 years 100
10-12 years 90
13-15 years 70
16-19 years 50
Essential Nutrients
Carbohydrates Vitamins
Proteins  Fat soluble
 Water soluble
Fats
Minerals
 Macronutrients
 Micronutrients
Carbohydrates
Functions
 Supply necessary bulk of diet
 Supply most of the body’s energy needs
 Source of stored calories (glycogen)
Oxidized as glucose but consumed

in various forms
 Monosaccharides (glucose, fructose)
 Disaccharides (lactose, sucrose)
 Polysaccharides (starches, glycogen)
Carbohydrates
Effects of Deficiency
 Ketones if intake is 15% of calories or in starvation
 Underweight
Effects of excess
 Overweight
 Various syndromes due to inborn errors
of metabolism (DM, glycogen storage disease)
Sources
 Milk, cereals, fruits, syrup, starches and vegetables
No specific requirement has been established,
by a dietary intake of 55-65% of total calories
is recommended
Proteins
Functions
 Supplies amino acids for building and repairing
body tissues
 Supplies heat and energy when there is shortage
of fats and carbohydrates
 Protective structure (nails and hair)
Constitutes 20% of adult BW
24 amino acids have been determined
The kind, number and arrangement of a.a. in a protein
molecule determines its characteristics
9 = essential for infants
3 = essential for LBW infants (tyrosine, cystine,
histidine)
Proteins
New tissues cannot be formed without all the essential
amino acids simultaneously present in the diet
The absence of a deficiency of only one essential a.a.
results in a negative N2 balance
Animal proteins are of higher quality than vegetable
proteins
Proteins are broken down in the digestive process
to oligopeptides and amino acids by different enzymes
(pepsin, chymosin, trypsin, etc.)
Proteins
Sources
 Plants (nuts, dried beans)
 Animals (milk, meat, liver, eggs and fish)
Requirement
 at birth: 2 - 5 g/kg/day
 1 year and older children: 2g/kg/day
Effects of excess Effects of deficiency

 Azotemia  Negative N2 balance
 Acidosis  Edema
 Hyperammonianemia  Retarded growth
 Kwashiorkor
 PCM/PEM
Fats
Functions
 Reserve energy sources
 Maintains body heat
 Carries fat-soluble vitamins
 Stimulates appetite; promotes satiety
 Spares protein
 Constitutes part of the structure of every cell
98% 0f natural fats are triglycerides
2% are free fatty acids, cholesterol, phospholipids,
monoglycerides, diglycerides
Fats
Naturally occurring fats contain straight-chain fatty acids
both saturated and unsaturated, varies in length
from 4 – 24 carbon atoms
Digestion varies with the melting point, degree of
saturation, and the position of the fatty acids in the
glycerol molecule
Ingested triglycerides are partially hydrolyzed by
lingual lipase and emulsified on stomach bile salts
from micelles which increase fat solubility
Short- and medium-chain triglycerides are hydrolyzed
by pancreatic lipase to free fatty acids
Fats
Two essential fatty acids
1. Linoleic acid – precursor of arachidonic acid,
prostaglandin, leukotrienes
2. Linolenic acid – modulates the rate of
production of arachidonic acid metabolites
and longer chain unsaturated fatty acids
(PUFA) necessary for brain development
Fats
Sources
 Plants (nuts, salad oils, vegetable oils, margarine)
 Animals (breastmilk, butter, cream, fats from real lard)
Requirement
 should supply 25-35% of TCR
 1-2% as linoleic acid
Effects of excess Effects of deficiency
 Overweight  Lack of satiety
 Atherosclerosis  Underweight
 Skin changes (intertrigo,
dryness, thickening,
desquamation) due to
linoleic acid deficiency
Vitamins
Organic compounds required in minute
amounts to catalyze cellular metabolism
essential for growth of maintenance of
the organism
Kinds of Vitamins
 Water soluble (Vitamin C, Vitamin B-complex)
 Fat soluble (Vitamin A,D,E and K)
Water-soluble Vitamins
Vitamin C (Ascorbic Acid)
Easily oxidized, accelerated by heat, light, alkali,
oxidative enzymes or traces of iron or copper)
Functions
 Integrity & maintenance of intercellular material
 Facilitates absorption of iron
Deficiency
 Dietary inadequacy
 Increase need on febrile illness
 Scurvy
 Poor wound healing
 Destroyed by prolonged cooking
Vitamin C (Ascorbic Acid)
Excess
 Oxaluria
RDA
 1st year: 30 mg/day
 1 – 12 years: 35 mg – 75 mg/day
Sources
 Citrus fruits
 Tomatoes
 Cabbage
 Green veggies
Vitamin B Complex – Vitamin B1
Anti-beri-beri vitamin
Alcohol soluble
Stable in slightly acid solution
in heat, alkali, sulfates
Functions
 Component of thiamin pyrophosphate
carboxylases which act in various oxidative
decarboxylations
 Promotes normal functioning of the nervous
system
Deficiency
 Beri-beri
 Fatigue, anorexia, constipation
 Edema
 Aphonia
Excess
 None from oral intake
 As medication - hyperthyroidism
RDA
 0.5 mg/day
Sources
 Liver, meat, milk
 Darak, unpolished rice
 Whole grain and enriched cereals
 Peanuts
Sparingly soluble in water
Sensitive to light and alkali
Stable to heat, oxidation, acid
Functions
 Co-enzyme in cellular oxidation reactions
 Retinal pigment for light adaptation
Deficiency
 Eye changes (photophobia, blurring of vision,
burning sensation, corneal vascularication)
 Mucocutaneous lesions (magenta tongue)
 Cheilosis
Sources
 Dark green leafy vegetables  Darak
 Liver, heart, kidney  Whole grain
 Milk and milk products  Soybeans
Excess
 None
RDA
 0.5 mg/day
(Pyridoxine, Pyridoxal, Pyrodexamine)
Destroyed by UV light
Functions
 Co-enzyme of amino acid metabolism
Deficiency
 Convulsions
 Hypochromic anemia
 Peripheral neuritis in patients receiving INH
 Oxaluria
(Pyridoxine, Pyridoxal, Pyrodexamine)
Excess
 Sensory neuropathy
RDA
 1-2 mg/day
Sources
 Whole grain cereals
 Legumes
 Vegetable oils
 Meat, liver, kidney, lard
Vitamin B Complex – Niacin (Nicotinamide,
Nicotinic Acid, Anti-pellagra vitamin)
Alcohol soluble
Stable to acid, heat, alkali and light
Functions
 Co-enzyme in glycolysis, protein, amino acid
lipid metabolism
Deficiency
 Pellagra (diarrhea, dementia, dermatitis)
 Found in exclusive corn diet (tryptophan poor)
Vitamin B Complex – Niacin (Nicotinamide,
Nicotinic Acid, Anti-pellagra vitamin)
Excess
 Flushing, nasodilation
 Vasomotor instability
RDA
 6 mg/day
Sources
 Meat, fish and poultry
 Green vegetables
 Cereals, peanuts
Vitamin B Complex – Vitamin B12 (Cyanocobalamin)
Labile in acid or alkali
Destroyed by heat
Castle intrinsic factor of the stomach required
for absorption
Functions
 Maturation of RBC in bone marrow
 Metabolism of nervous tissue
Deficiency
 Pernicious anemia (due to defect in absorption)
 Neurologic manifestations
Vitamin B Complex – Vitamin B12 (Cyanocobalamin)
Excess
 Unknown
RDA
 0.3 mcg/day
Sources
 Liver
 Heart
 Meat
 Fish
 Eggs
 Milk
Vitamin B Complex – Folacin
Group of related compounds containing
pteridine ring, PABA, glutamic acid
Functions
 Synthesis of purines, pyrimidines
and other nucleoprotiens
Deficiency
 In malabsorption disease
 Megalobalstic anemia
 Stomatitis, glossitis
Vitamin B Complex – Folacin
Excess
 Unknown
RDA
 50-100 mcg/day
Sources
 Legumes  Fish
 Soybeans  Sardines
 Leafy vegetables  Salmon
 Meat  Poultry
Fat-soluble Vitamins
Vitamin A
Vitamin A (retinol) is an alcohol of high MW
Provitamin A – 1/6 activity of retinol (plant pigments)
Functions
 Retinal pigment formation
 Formation and maturation of epithelium
 Bone and tooth development
Deficiency
 2o to deficient intake or absorption,
increased consumption (diarrhea, illness)
 Eye symptoms (nyctalopia, photophobia,
xeropthalmia, Bitot’s spots, keratomalacia,
blindness)
Vitamin A
Deficiency
 Keratinization of mucous membranes/skin
 Growth failure
 Impaired resistance to infection
Excess
 Carotenemia
 Anorexia, slow growth
 Drying and cracking of skin
 Hepatosplenomegaly
 Pain/swelling of long bones
 ICP
 Alopecia
Vitamin A
RDA
 1,800 IU/day
Sources
 Provitamin A – Leafy vegetables, yellow corn,
carrots, papaya
 Liver
 Fish oils
 Whole milk
 Eggs
 Cheese
Vitamin D
Group of sterols having physiologic activity
D2 – calciferol activated ergosterol
D3 – activated dehydrocholesterol
Bile is needed for absorption
Functions
 Regulates Ca and P absorption
(by affecting membrane permeability of intestine)
 Regulates conc. of alk. PO4 ase
(concern with Ca and P deposition
in bones and teeth)
Vitamin D
Deficiency
 Due to inadequate  Osteomalacia
exposure of sunlight  Cranial bossing
 Rickets  Bowed legs
 Infantile tetany  Persistently open
anterior fontanelle
Excess
 Hypercalcemia
 Calcification of soft tissues
(heart, blood vessels)
Vitamin D
RDA
 40 IU/day
Sources
 Fish liver oils
 Liver
 Heart
 Kidney
 Lungs
 Milk
 Margarine
 Exposure to sunlight
Vitamin E (Tocopherol)
Unstable to UV light, alkali
Readily oxidized by O2, iron and rancid fats
Bile necessary for absorption
Functions
 Minimizes oxidation of carotene, vitamin A
and linoleic acid
 Stabilizes membranes
 Free radical scavenger to prevent
peroxidation of PUFA
 Synthesis of blood pigments
Vitamin E (Tocopherol)
Deficiency
 Loss through steatorrhea
 RBC hemolysis in premature infants
 Loss of neural integrity
Excess
 Unknown
RDA
 4-5 IU/day
Sources
 Germ oils of various seeds  Nuts, legumes
 Green leafy vegetables  Fish liver oils
 Clams, oyster, salmon
Vitamin K
Group of napthoquinones
Vitamin K1 is phytoquinone
Bile necessary for absorption
Functions
 Necessary for prothrombin formation
Coagulation factors II, IX and X
Deficiency
 Hemorraghic manifestations
 Cirrhosis
Vitamin K
Excess
 Medicinally, may cause jaundice,
hemolytic anemic, nerve palsy
RDA
 1-2 mg/day
Sources
 Green leafy vegetables
 Pork
 Liver
 Egg yolk
Minerals - Macronutrients
Sodium
Extracellular cation, small amount in muscle
and cartilage
Serum conc: 135-145 mEq/L
Functions
 Maintenance of fluid volume in vessels
and tissues
 Muscle and nerve irritability
 Renal excretion, controlled by ACTH
Sodium
Deficiency
 Muscle cramps
 Dehydration hypertension
 Nausea
RDA
 1 g or 2.0 mcg/kg or 50 mEq/M2
Sources
 Table salt, all pickled, smoked and salted foods,
biscuits, breads
 Clams and oysters
 Raisins
 Seasoning and preservatives
Potassium
Primarily intracellular
80% excreted in urine, some in sweat,
in feces
Blood serum level: 4.0-5.0 mEq/L
Functions
 Muscle contraction
 Intracellular osmotic pressure
and fluid balance
 Cardiac activity
Potassium
Deficiency
 Muscle weakness
 Anorexia
 Abdominal distention
 Irritability or drowsiness
 Tachycardia
Excess
 Heat block (10 mEq/L)
Sources
 All foods
Calcium
Functions
 Structure of bones and teeth
 Nerve irritability
 Muscle contractility
 Blood coagulation
 Milk production
Deficiency
 Associated with Vitamin D deficiency
 Osteomalacia
 Osteoporosis
 Tetany (convulsions)
 Rickets
 Growth impairment
Calcium
Excess
 Hypercalcemia syndrome
 Thirst and polyuria
 Loss of weight, muscle weakness
 Heart block, renal stones
RDA
 Infants: 6-12 mos - 0.6 g/day
 Children: 1-9 year - 0.5 g/day
 Above 10 years - 0.7 g/day
Sources
 Soybeans, leafy vegetables
 Dried and evaporated milk
 Milk products (cheese, ice cream, egg yolk)
 Smoked, dried fish (dilis, dried shrimps)
Magnesium
Functions
 Activated cellular, enzymatic activity
esp. glycolysis
 Inhibitory to muscle contraction
 Principal cation of soft tissue
 Antagonist to calcium action
Deficiency
 Due to malabsorption states
 Tetany (associated with hypocalcemia,
hypokalcemia)
Magnesium
Excess
 None (dietary)
RDA
 150-300 mg/day
Sources
 Cereals
 Legumes
 Milk
 Nuts
 Meat
Chloride
Regulates osmotic pressure
Constituent of HCl in gastric juice
92% excreted in urine
Blood serum level: 99-106 mEq/L
Parallels sodium intake and output
Deficiency
 Hypochloremia alkalosis
(prolonged vomiting)
Chloride
Excess
 In itself none
 Edema (associated with sodium)
RDA
 0.5 g/day
Sources
 Table salt
 Meat
 Milk
 Eggs
Phosphorus
Functions
 Bone and teeth structure (with calcium)
 Structure of nucleus and cytoplasm
of all cells
 Buffer substance for acid-base balance
Deficiency
 Associated with Ca and vitamin D
deficiency rickets
 Muscle weakness
 Anorexia, malaise
 Growth arrest
Phosphorus
Excess
 Tetany during recovery from rickets
RDA
 Equal to calcium
Sources
 Milk and milk products
 Egg yolk
 Fresh foods
 Nuts
 Whole grain
Minerals - Micronutrients
Its content in the body constitutes less than
0.01%of total body weight (one part in 10,000)
Is essential to metabolic processes when
they are components of enzyme systems
or act either as integral components of
metalloenzymes or as cofactor for enzyme
activated by metal ions
Deficiencies have been shown to be
deleterious to health, growth & development
Currently, 12 are thought to be nutritionally
important to higher animals
Deficiency or excess of one trace element
may have an effect on the other
( Fe Zn absorption)
Copper (Cu)
Functions
 Constituent of ceruloplasmin
 Component of key metalloenzymes
 Role in corrective tissue biosynthesis
 Production of RBC, transferrin, Hb formation
 Absorption of iron
 Deficiency
 Refractory anemia
 Osteoporosis
 Depigmentation and delayed bone age
 Pseudoparalysis ataxia
 Metabolism deranged in Wilson’s Disease
(hepatolenticular degeneration) & Menke’s syndrome
Copper (Cu)
Excess
 Cirrhosis
 Gastritis
 Hemolysis
RDA
 0.5 – 1 mg/kg/day
Sources
 Whole grains, wheat bran
 Nuts, corn, oatmeal
 Liver, Oysters
 Meat and Fish
Iron (Fe)
Functions
 Structure of hemo- and myoglobulin
for gas transport
 Constituent of oxidative enzymes
 Increases resistance to infections
 Absorbed in ferrous form, aided by gastric
juice and ascorbic acid
Deficiency
 Anemia (hypochromic, microcytic)
 Anorexia, lethargy
Iron (Fe)
Excess
 Hemosiderosis
 Intoxication with medicinal iron
RDA
 Infants: 1 mg/kg/day
 Children: 10 –18 mg/day
Sources
 Liver
 Dark green leafy vegetables
Iodine
Functions
 Constituent of thyroid hormones (T4 and T3)
 Important in regulation of cellular oxidation
and growth
Deficiency
 Goiter
 Depressed thyroid function
 Cretinism
Excess
 Diet harmless
 Medicinal may cause goiter
Iodine
RDA
 34-45 mcg/day
Sources
 Iodized salt
 Seafoods
 Seaweeds
 Leafy vegetables
Fluorine
Functions
 Tooth and bone structure
 Makes enamel more resistant
Deficiency
 Dental carries
 Poor dentition
 Osteoporosis
Fluorine
Excess
 Fluorosis (mottled enamel) with intake
of more than 4-8 mg/24 hr
 Prolonged ingestion (10-20 years)
of 20-80 mg/24 hr
RDA
 0.5 – 1 mg/day or 1 ppm
Sources
 Drinking water
 Seafoods
 Plant and animal foods (depending on soil
and water content)
Zinc
Functions
 Constituent of several enzymes
(carbonic anhydrates, carboxypeptidase,
dehydrogenase)
Deficiency
 Dwarfism
 Iron-deficiency anemia
 Hepatosplenomegaly
 Acrodermatitis enterophatica (automosal
recessive genetic defect of zinc absorption)
 immunocompetence
 Poor wound healing
Zinc
Excess
 GIT upset
 Lethargy
 Anemia due to copper deficiency
RDA
 Unknown
 Estimated intake of 3-5 mg/kg/day
Sources
 All foods
Manganese
Functions
 Enzyme activation, esp. superoxide dismertase
 Formation of neuropolysaccharides
Deficiency
 Impaired growth
 Skeletal abnormalities
 Lowered reproductive function
 Neonatal ataxia
Manganese
Excess
 Dietary – none
 Toxicity of chronic inhalation severe
Psychiatric and neurologic disorders
(encaphalopathy)
RDA
 0.05 – 1.5 mg/day
Sources
 Nuts, whole grain
 Dried fruits
 Vegetables
Chromuim
Functions
 Maintenance of normal glucose metabolism
 Co-factor for insulin
Deficiency
 Disturbed glucose metabolism
Excess
 None
RDA
 .02 - .10 mg/day
Sources
 Brewer’s yeast, meat products, cheese
Selenium
Functions
 Co-factor of glutathione peroxidase in tissue
respiration
Deficiency
 Cardiomyopathy 2o to oxidative damage
Excess
 Alopecia
 Nail abnormalities
 Garlic odor to breath
RDA
 .02 - .10 mg/day
Sources
 Vegetables and meat
 The period during which other foods or liquids are
provided along with breastmilk is considered the
period of COMPLEMENTARY FEEDING, and any
nutrient-containing foods or liquids other than
breastmilk are called COMPLEMENTARY FOODS
Weaning
 Addition of supplemental foods when breastmilk becomes
inadequate in protein or energy for adequate growth
 Complete discontinuance/cessation of breast or bottle
suckling
Transitional Foods
 Complementary foods specifically designed to meet
the particular nutritional or physiological needs of the
young child
Factors for a Successful CF
 Early CF
 May result in less frequent breastfeeding
and less milk production
 May increase the risk to allergies
 May increase the risk to iron depletion and anemia
 Delayed CF
 Growth faltering (wasting/stunting)
 Nutrient deficiencies
 Critical period (optimal time for new behaviors
to be learned or mastered
Factors for a Successful CF
A. Nutritional needs of the infant
B. Physiological maturation (intestinal and renal maturity)
C. Developmental and behavioral readiness
D. Cultural practices
Age of Introduction of CF
 1990 – WHO/UNICEF meeting: The age range of 4-6
months was considered a transitional period to allow
breastfed infants to adjust to consuming solid foods
 1992 – 45th WHO Assembly reaffirmed that “…. from the
age of about 6 months, infants should begin to receive a
variety of locally available and safely prepared foods rich
in energy, other than breastmilk to meet their nutritional
requirements.”
 1995 – WHO Expert Committee reaffirmed that
introduction of CF, i.e. 4- 6 months
Given the worldwide variation in growth velocity,
an age range is an essential element of this feeding
recommendation
An infant is ready for CF when:
A. Baby’s weight doubles birth weight
B. Baby can hold head straight when sitting-up
C. Baby opens mouth when food approaches
D. Baby is interested in foods when others eat
E. Baby is able to transfer food from the front of the tongue

to the back
F. Baby is able to swallow

Introducing Complementary Foods
A. Introduce one new food at a time (3-4 days)
B. Start with small amounts of any food ( a tsp or less)
C. Use thin puree consistency when starting. Gradually
shifting to a more viscous food with higher nutrient
density
D. Never force an infant to eat
E. If baby objects to taking some food, mix it with
any other foods he likes
Introducing Complementary Foods
F. If after several trials, the baby refuses to eat a particular
food, omit it for a week or 2, then try again. If dislike
persists, omit entirely and substitute with another food
of similar nutritional value
G. Seasoned foods lightly. No added salts to diet before
age of 1 year
H. When baby is able to chew, gradually switch to finely
chopped vegetables, fruits, fish and meats. Do not
continue soft, smooth foods for too long.
I. A mother’s dislike for a particular food must not reflect
in the choice of food for the baby
The Neurological Development of Infants/children
and types of foods that can be consumed at different ages
(Adapted from Villa, 1991, Stevenson & Allari, 1991)
Age in mos Reflexes/skills present Type of food

0-6 • Suckle/suck and swallow Liquids
4-7 • Appearance of early “munching” Pureed foods
• Increased strength of suck Crackers
• Movement of gag reflex from mid
to posterior 1/3 of tongue
7-12 • Clearing spoon with lips Mashed,chopped
• Biting, chewing Finger foods
• Lateral movements of tongue
and movement of food to teeth
12-24 • Rotary chewing movements Family food
• Jaw stability
Food for Later Childhood and Adolescence
Older Children
 Diet similar to that of the family
 Cereals, fruits, vegetables, protein, dairy
 Varied diets to include
 Glass of milk daily
 Foods fortified with vitamins and minerals
 Good breakfast daily
(provides 1/3 to ¼ of the RDA of the day)
 Nutritional school lunch and snacks
Food for Later Childhood and Adolescence
Adolescence
 Period of rapid growth high requirement
 Girls are prone to dieting
 Regular weighing, well-balanced varied diet
spread over 3 main meals/small snacks
 Regular monitoring of iron status/
use of iron supplements
 Fast-food meal should be accompanied
by salad, milk and or fruit juice
Types of Milk
 Difference in the process employed to come-up with
the final product
 Read the label of milk cartons and packages to
identify the type of milk
Fresh Milk
 Directly sourced from cows, carabaos, goats
 Fat content not reduced
 Unless pasteurized, boil before consumption
 Good for those who want to gain weight/strength
Whole Milk/Full Cream Milk
 Similar to fresh milk except that it is pasteurized and
homogenized
 Available in evaporated or powdered form
Types of Milk
Recombined Milk
 Skim milk powder reconstituted to normal fat content
Reconstituted Milk
 Processed milk to which water is added to restore
its original water content
Evaporated Milk
 60% of the water has been removed
 Used for culinary purposes (desserts)
 Must be diluted properly before it is drunk
Filled Milk
 Butterfat has been removed and replaced with
vegetable oil
Types of Milk
Sweetened Condensed Milk

 Highly evaporated milk with sugar
 Made of 40% water, 40% sugar and 20% milk
 High sugar content gives it a long shelf life even
without refrigeration
 Not recommended for feeding infants
 Used in baking and for infants
Skim/Non-fat Milk
 Without milk fat but most of the other essential
nutrients intact
 Useful for those who limit their intake of energy, fat
and cholesterol
 History
 Diet (mother and child)
 Weight and height changes
 Anthropometric Indicators
 Deviations from average height and weight
 Depletion of fat deposits
 Decrease in muscle mass
 Change in psychic reaction
 Reactions to infection
 Evidence of specific deficiences
Anthropometric Indicators
 Weight
 Length
 Tricep skinfold thickness
 Head Circumference
 Mid-upper arm circumference

 Weight Measurements
 Simple, reproducible
 An index of acute nutritional status
 Reference Standard is necessary
for evaluation
 Height or Length Measurements
 Better criterion of growth since this
is unaffected by excess fat or fluid
 Assess growth failure and chronic
undernutrition
 Height for Weight Measurements
 More accurate in assessing body built
 Useful in identifying a child who is acutely
malnuorished
 Triceps Skinfold Thickness

 Provides an estimate of total body fat
(indicator of body energy stores)
 Determine chronic undernutrition when
used in conjunction with weight and height
 Head Circumference
 Influence by nutritional status until the
age of 36 months
 Mid-upper arm Circumference
 In conjunction with skinfold thickness,
used to determine muscle area and fat area
 Growth Velocity
 Evaluates change in rate of growth over
a specified time period and is expressed
in cm/per year
 A sensitive way of assessing growth
failure or slowed growth
 Helpful in the early identification of children
with undernutrition
BREAST
FEEDING
Human milk is the most appropriate
of all available milk for the human
infant because it is uniquely adapted
to his or her needs.
 ADVANTAGES
1. Always readily available at the proper
temperature and needs no time for
preparation
2. Always fresh and free of contaminating
bacteria
3. Allergy and intolerance are not seen
(colic, atopic eczema, diarrhea, melena)
4. Decrease incidence of DM (1st 4 months of life)
 ADVANTAGES (cont.)
5. Contains bacterial and viral antibodies,
including high concentration of secretory
IgA (confers protection against infection,
particularly NEC)
6. Macrophages present in colostrum & mature
milk may be able to synthesize complement,
lysozyme and lactoferrin
7. Contains all the necessary nutrients, except
fluoride & Vitamin D
8. Psychologic advantages for both mother
and infant
• Size does not determine how much milk it can make.
• Made up of fat, connective tissue & milk producing

glands.
• 15-20 lobes of glands >>>ducts>>>sinuses>>>tiny

openings/pores in the nipple
• Sinuses – are reservoirs for the collection of milk

Anatomy of the Breast
BREASTS
 Mammary glands
- accessory to reproduction in females;

rudimentary and functionless in males
- in the subcutaneous tissue overlying the pectoral
muscles
- amount of fat surrounding the glandular tissue
determines the size of breasts
Breast Quadrants
 Divisible into 4 quadrants
 Female breast extends transversely
from the lateral border of the
sternum to the MAL ; vertically
from the 2nd through 6th ribs
 A small part may extend along the
inferolateral edge of the pectoralis
major muscle toward the axilla
forming an axillary tail of
Spence
 Nipple usually at the level of the
4th ICS surrounded by areola
 Lactiferous duct
 Retromammary space
 Suspensory ligaments
of Cooper
Vasculature of the Breast
 Blood supply:
1. Internal thoracic from subclavian
2. Lateral thoracic and
Thoracoacromial from axillary
3. Post intercostal from thoracic aorta
Venous drainage:
1. Lateral thoracic and thoracoacromial
to axillary
2. Internal thoracic
 Lymphatic drainage:
1. Lateral Quadrants to Axillary
lymph nodes
2. Medial Quadrants to
Parasternal nodes
Nerve supply:
4th to 6th intercostal nerves
• Breast milk production is mainly dependent on how well
the breasts are emptied completely & regularly.
• Vigorous sucking of the breast by the infant is the best

stimulus to produce milk.
• Reflexes governing milk secretion:

1. Prolactin reflex
2. Letdown or milk ejection reflex
• Chewing action of the jaws on sinuses w/c expresses

milk into the baby’s mouth. The tongue acts as
a supporting pad for the nipple & areola.
Physiology of Lactation
Major Stages of Lactation
1. Lactogenesis(stage I)
- midpregnancy to 2 days postpartum
-initiation of milk synthesis
-differentiation of alveolar cells from secretory
cells
-prolactin stimulates mammary secretory cells to
produce milk
2. Lactogenesis(stage II)
- day 3 to day 8 or full milk secretion
-triggered by rapid drop in mother’s progesterone
Levels
-fullness and warmth of the breast
-onset of copious milk secretion
-switch from endocrine to autocrine control
3. Lactogenesis(stage III) or Galactopoiesis

- day 9 to beginning of involution
-maintenance of established lactation
-control by autocrine system (supply demand)
-breast size decreases between 6 and 9 months
postpartum
4. INVOLUTION
-average 40 days after last breastfeeding
-additions of regular supplementation
-decreased milk secretion from build up of
inhibiting peptides
-high sodium levels
Back to Sub Contents

Back to Main Con
MICROSCOPIC VIEW OF
FORMULA MILK
MICROSCOPIC VIEW OF
BREAST MILK
 Factors that may influence composition
of breastmilk
1. Time of day - fat content highest early in

the day; lowest at night
2. Mother’s Diet - more fat >> more yellow color
3. Mother’s emotional state
4. Whether fore or hind milk
5. Drugs: Chloramphenicol, INH, Metronidazole
6. Smoking, Alcohol
• Secretion of human breast
2-4 days postpartum
• Deep yellow containing more protein (globulins),

more vitamins (Vit. A), more salt, more immune
bodies, less fat and sugar than mature milk.
•Specific Gravity : 1.040 – 1.060

•pH : 7.7 (alkaline)
•10 – 40 ml secreted per day
• Higher number of macrophages (phagocytosis)

and lymphocytes (secretory IgA)
“Transitional” to “Mature” Milk
* changes over the 1st 4 weeks
* gradual increase in fats & lactose,
and decrease in proteins
Fore milk : 1st milk expressed during a
nursing period
clear, thin, bluish (low fat)
Hind milk : last milk obtained at the end

of a feed
thick, cream white (high fat)
• Once lactation is well established, mothers are
capable of producing more milk than their
infants’ needs.
• Care of the Nipples:

1. Avoid abrasions /cracking
2. Expose nipples to air to keep dry
3. Avoid soap, alcohol, benzoin
• Worry and anxiety should be avoided.

• Provide support plan for individual mothers.
• Mother may pump her breasts and feed the infant
via a bottle when the mother is not available.
• Additional pumping will usually increase milk
• Production and store extra milk in a freezer up

to 1 month or refrigeration up to 24 hours.
• Avoid fatigue.
Diet – should contain enough calories to
compensate for those secreted in the milk
as well as for those required to produce it.
• Avoid weight-reducing diets
Determining Adequacy of Breastmilk Supply
1. Infant is satisfied after each nursing period
2. Rest and sleeps well, 2-4 hours
3. Playful in between feeding
4. Gains weight
To assess adequacy during the 1st 6 weeks

of nursing, monitor:
1. Nursing frequency: q 2-3H; q demand at night
2. Wet diapers – 8-12x per day
3. Stool pattern -- 1-8x per day
4. Growth spurts -- 7-10 days; 36 wks; 12 mos
• At feeding time, infant should be hungry, dry, held
in a comfortable semi-sitting position
• The mother should be comfortable and completely

at ease
• The baby’s lips should engage considerable areola

as well as nipple.
1. Rooting reflex
2. Sucking
3. Swallowing
• If the infant seemed satisfied, a finger may be
inserted into the corner of the infant’s mouth
to decrease suction and facilitate removal.
• Burping procedure is necessary to assist in

expelling swallowed air.
• The infant should empty at least one breast at each

feeding to encourage maximal milk production.
1. The physician should discuss advantages of
breastfeeding during mid-trimester of pregnancy or
whenever the mother begins planning for her baby.
2. Mothers should maintain good health, balance of rest

and exercise, free from worry, early & sufficient
treatment of any intercurrent disease, and adequate
nutrition.
3. Retracted nipples usually benefit from daily manual

breast pump traction during the latter pregnancy.
• Mothers should be reassured that breast tone will be

preserved.
1. Lack of motivation and preparation of mother
2. Anxiety, fear and uncertainty of the mother.
3. Separate nursery and maternity wards.
4. Certain conditions
-- active TB -- cardiac disease
-- thyrotoxicosis -- epilepsy
-- mental disorders -- drugs
Breastmilk Jaundice
- due to increase in unconjugated bilirubin
related to some factors in breast milk
(enzyme)
- appears on 2nd – 5th day of life up to 4 weeks
- no ill effect
- Txt: Stop breasfeeding for 1-2 days
Objectives
 To recognize the four signs of good attachment

 To recognize the four signs of good
positioning
 To enumerate the two signs of effective
suckling
Signs of Good Attachment
 Infant’s chin should touch the breast.

 Infant’s mouth should be wide open.
 Infant’s lower lip should be turned outward.
 There should be more areola showing above.
Recognizing Good Attachment
Chin touching
breast
Mouth wide open
Lower lip turned

outward
More areola
showing above
Good attachment
Chin touching
breast
Mouth wide open
Lower lip turned
outward
More areola
showing above
Attachment Not Well

Chin touching
breast
Mouth wide open
Lower lip turned
outward
More areola
showing above
Attachment Not Well

Chin touching
breast
Mouth wide open
Lower lip turned
outward
More areola
showing above
Attachment Not Well

Chin touching
breast
Mouth wide open
Lower lip turned

outward
More areola
showing above
Good attachment
Chin touching
breast
Mouth wide open
Lower lip turned

outward
More areola
showing above
Attachment Not Well

Chin touching
breast
Mouth wide open
Lower lip turned

outward
More areola
showing above
Good attachment
Chin touching
breast
Mouth wide open
Lower lip turned

outward
More areola
showing above
Good attachment
Chin touching
breast
Mouth wide open
Lower lip turned

outward
More areola
showing above
Attachment Not Well

Signs of Good Positioning
 Infant’s head and body should be straight.

 Infant’s head and body should be facing the
breast.
 Infant’s body should be close to the mother.
 Mother should be supporting the infant’s entire
body.
Recognizing Good Positioning
Infant’s head and

body straight
Infant’s head and
body facing breast
Infant’s body close to
the mother
Mother supporting
infant’s entire body
Good Positioning
Infant’s head and

body straight
Infant’s head and
body facing breast
the mother
Mother supporting
Good Positioning
Infant’s head and

body straight
Infant’s head and
body facing breast
the mother
Mother supporting
Positioning and Attachment Not Well

Infant’s head and

body straight
Infant’s head and
body facing breast
the mother
Mother supporting

Infant’s head and

body straight
Infant’s head and
body facing breast
the mother
Mother supporting
Good Positioning and Attachment

Infant’s head and

body straight
Infant’s head and
body facing breast
the mother
Mother supporting

Signs of Effective Suckling
 Infant suckles with slow deep sucks.

 Swallowing may be seen or heard.
 An infant who is suckling effectively may

pause occasionally.
 The mother should allow her baby to finish the
feed and release the breast himself.
 An infant who suckles effectively will be
satisfied after breastfeeding.
 Askquestions about the child’s usual
feeding during this illness.
– Ask:
 Do you breastfeed your child?
– How many times during the day?

– Do you also breastfeed during the night?
 Does the child take any other food or
fluids?
– What food or fluids?
– How many times per day?
– What do you use to feed the child?
– If very low weight for age: How large are
servings? Does the child receive his own
serving? Who feeds the child and how?
 During this illness, has the child’s feeding
changed? If yes, how?
Up to 4 months of age
 Breastfeed as often as
the child wants, day and
night at least 8 times in
24 hours
 Do not give other foods
or fluids
4 months up to
6 months
the child wants, day or
night, at least 8 times in
24 hours
 Only if the child:
– shows interest in semisolid foods, or
– appears hungry after breastfeeding, or
– is not gaining weight adequately
Give small amount of lugaw with added oil,
mashed vegetables or beans, steamed
tokwa, flaked fish, pulverized roasted dilis,
finely ground meat, eggyolk, mashed ripe
fruits like banana, mango, avocado.
Give these foods 1 or 2 times per day after

breastfeeding
6 Months up to
12 Months
the child wants
 Give adequate amount of
lugaw with added oil,
mashed vegetables or
beans, steamed tokwa,
flaked fish or chicken,
pulverized roasted dilis,
chopped meat, eggyolk
bite sized fruits.
– 3 times per day if breastfed
– 5 times per day if not breastfed
Feed the baby nutritious snacks like taho and

fruits
12 Months up to 2 Years
 Breastfeed as often as the child
wants
 Give adequate amount of family
foods or:
rice, camote, potato, fish, chicken,
meat, mongo, steamed tokwa,
pulverized roasted dilis, milk and
eggs, dark green leafy and yellow
vegetables (malunggay, squash),
fruits (papaya, banana).
Add oil or margarine
5 times per day
Feed the baby nutritious snacks like fruits
2 years and older
 Give adequate
amount of family
foods at 3 meals each
day. Also, twice daily,
give nutritious foods
between meals, such
as:
boiled yellow camote, boiled yellow corn,
peanuts, boiled saba banana, taho, fruits
and fruit juice
If the child is not being fed as described in the
above recommendations, counsel the mother
accordingly. In addition:
 If the mother reports difficulty
with breastfeeding, assess
breastfeeding. As needed,
show the mother correct
positioning and attachment for
breastfeeding.
 If the child is less than 4 months old and is
taking other milk or foods:
– Build mother’s confidence that she can
produce all the breastmilk that the child needs
– Suggest giving more frequent, longer
breastfeeds, day and night, and gradually
reducing other milk or foods.
If other milk needs to be continued,
counsel the mother to:
– Breastfeed as much as possible, including at
night
– Make sure that other milk is a locally
appropriate breastmilk substitute
– Make sure other milk is correctly and
hygienically prepared and given in adequate
amounts.
– Finish prepared milk within an hour
 If the mother is using
a bottle to feed the
child:
– Recommend
substituting a cup for
bottle
– Show the mother how
to feed the child with a
cup
 If the child is not being
fed actively, counsel
the mother to:
– Sit with the child and
encourage eating
– Give the child an
adequate serving in a
separate plate or bowl
 If the child is not
feeding well during
illness, counsel the
mother to:
– Breastfeed more
frequently and for
longer if possible
– Use soft, varied,
appetizing, favorite
foods to encourage
the child to eat as
much as possible, and
offer frequent small
feedings
– Clear a blocked nose if it interferes with
feeding
– Expect that appetite will improve as child gets
better.
 Follow-up any feeding problem in 5 days.
BREASTFEEDING
HISTORY
BREASTFEEDING HISTORY
1. Baby’s feeding now

2. Baby’s health and behavior
3. Pregnancy, birth and early feeds
4. Mother’s condition and family planning
5. Previous infant feeding experience
6. Family and social situations
Breastfeeding
Problems
ENGORGEMENT
COMMON BREASTFEEDING PROBLEMS
DURING THE FIRST FEW DAYS OF THE
INFANT’S LIFE
ENGORGEMENT-Under the influence of
hormones, the breast increase milk production
from 36 to 96 hours
Riordan, 2005
Engorgement
Engorgement
CAUSES AND PREVENTION OF
BREAST ENGORGEMENT
CAUSES PREVENTION
 Plenty of milk
 Delay starting to  Start breastfeeding soon
breastfeed after delivery
 Poor attachment to breast  Ensure good attachment
 Infrequent removal of  Encourage unrestricted
milk breastfeeding
 Restriction of length of
feeds
DIFFERENCES BET. FULL AND
ENGORGED BREASTS
FULL BREASTS ENGORGED BREASTS

 Painful
 Hot  Edematous
 Heavy  Tight, especially nipples
 Shiny
 Hard  May look red
 Milk flowing  Milk not flowing

 May have fever for 24 hours
 No fever
TREATMENT OF BREAST
ENGORGEMENT
 If the baby is able to suckle he should feed frequently
 If the baby is not able to suckle, help his mother to express
milk
 Before feeding or expressing stimulate the mother’s oxytocin
reflex
-warm compress on her breasts or warm
shower,massage neck and back, massage breasts lightly,
stimulate her breast and nipple skin, help her to relax
TREATMENT OF BREAST
ENGORGMENT
 After a feed, put a cold compress on her
breasts
 Build the mother’s confidence
INVERTED NIPPLES
NIPPLE INVERSION
INVERTED NIPPLES
MANAGEMENT OF FLAT AND
INVERTED NIPPLES
 Antenatal treatment is probably not helpful
 Build the mothers’ confidence
 Explain that the mother suckles from the breast- not
from the nipple
 Encourage her to give plenty of skin to skin contact,
and to let her baby explore her breasts
MANAGEMENT OF FLAT AND
INVERTED NIPPLES
 Help her to position her baby
 Help her to try different positions to hold her
baby
 Help her to make her nipple stand out more
before a feed
To shape her breasts…
 The mother supports it from underneath with

her fingers and presses the top of her breasts
gently with the thumb.
 She should be careful not to hold her breast too
near the nipple
 Use the syringe technique or an evert it
nipplette
AFTER TREATMENT
LARGE OR ELONGATED NIPPLES
LARGE NIPPLES
SORE NIPPLES-seen during the first 10 days
post partum, usually peaks between 3rd to
6th day
NIPPLE TRAUMA
POSITIONAL SORE NIPPLES
MANAGEMENT OF SORE
NIPPLES
 LOOK FOR A CAUSE
-check attachment
-examine breasts
-check baby for tongue tie
 GIVE APPROPRIATE TREATMENT
-build mother’s confidence
-improve attachment and continue breastfeeding
-reduce engorgement-feed frequently
MANAGEMENT OF SORE
NIPPLES
 Advise the mother to
-wash breast only once a day and avoid using
soap
-avoid medicated lotions and ointments
-rub hindmilk on areola after feeds
Edema
 women who receive excessive intravenous
fluids throughout labor may develop edema
Areolar compression:edematous
areola
Nipple pulls inward with pressure
Fingers leave impression
Tissue pressed and held
Edema pressed out
Nipple pliable and easily grasped
IMPACT ON INFANTS
WEIGHT LOSS
 Weight loss of more than 7% from birth weight may

be an indicator of breastfeeding difficulties and
requires evaluation of the feeding process for the first
10 days
 Weight loss of less than 500 grams in a month is also

an indicator that baby is not getting enough milk
Back to Main Contents

Back to Main Con
SMALL AMOUNT OF URINE
-PASSING SMALL AMOUNT OF URINE

INFANT CONDITIONS
 Do a complete pediatric history and physical

examination
The Ten Steps to Successful
Breastfeeding
Every facility providing maternity

services and care for
newborn infants should:
 1. Have a written breastfeeding policy that is routinely
 communicated to all health care staff.
 2. Train all health care staff in skills necessary to
 implement this policy.
 3. Inform all pregnant women about the benefits and
 management of breastfeeding.
 4. Help mothers initiate breastfeeding within a half-hour
 of birth.
 5. Show mothers how to breastfeed, and how to maintain
 lactation even if they should be separated from

their
 infants.
 6. Give newborn infants no food or drink other than
 breastmilk, unless medically indicated.
 7. Practice rooming-in -- allow mothers and infants to
 remain together -- 24 hours a day.
 8. Encourage breastfeeding on demand.
 9. Give no artificial teats or pacifiers (also called
dummies
 or soothers) to breastfeeding infants.
 10. Foster the establishment of breastfeeding support
 groups and refer mothers to them on discharge from
 the hospital or clinic.

Nutrition basics for children

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Nutrition basics for children

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Nancy A. Anchores, M.D.

Average values used as guides for estimating

Varies with several factors such as age, sex,

The amount of heat which food can supply and utilize

Calorie intake is adequate when it cause the infant

Approximate Daily Requirement

Oxidized as glucose but consumed

Effects of excess Effects of deficiency

B. Physiological maturation (intestinal and renal maturity)

C. Developmental and behavioral readiness

B. Baby can hold head straight when sitting-up

C. Baby opens mouth when food approaches

D. Baby is interested in foods when others eat

E. Baby is able to transfer food from the front of the tongue

F. Baby is able to swallow

Age in mos Reflexes/skills present Type of food

Sweetened Condensed Milk

 Mid-upper arm circumference

 Triceps Skinfold Thickness

• Made up of fat, connective tissue & milk producing

• 15-20 lobes of glands >>>ducts>>>sinuses>>>tiny

• Sinuses – are reservoirs for the collection of milk

- accessory to reproduction in females;

• Vigorous sucking of the breast by the infant is the best

• Reflexes governing milk secretion:

• Chewing action of the jaws on sinuses w/c expresses

3. Lactogenesis(stage III) or Galactopoiesis

Back to Sub Contents

1. Time of day - fat content highest early in

• Deep yellow containing more protein (globulins),

•Specific Gravity : 1.040 – 1.060

• Higher number of macrophages (phagocytosis)

Hind milk : last milk obtained at the end

• Care of the Nipples:

• Worry and anxiety should be avoided.

• Additional pumping will usually increase milk

• Production and store extra milk in a freezer up

To assess adequacy during the 1st 6 weeks

• The mother should be comfortable and completely

• The baby’s lips should engage considerable areola

• Burping procedure is necessary to assist in

• The infant should empty at least one breast at each

2. Mothers should maintain good health, balance of rest

3. Retracted nipples usually benefit from daily manual

• Mothers should be reassured that breast tone will be

 To recognize the four signs of good attachment

 Infant’s chin should touch the breast.

Lower lip turned

Attachment Not Well

Attachment Not Well

Attachment Not Well

Lower lip turned

Lower lip turned

Attachment Not Well

Lower lip turned

Lower lip turned

Lower lip turned

Attachment Not Well

 Infant’s head and body should be straight.

Infant’s head and

Infant’s head and

Infant’s head and

Positioning and Attachment Not Well