Pediatrics L2

Dodo Agladze
Pediatric Nutrition and Nutritional Disorders

Diet of Normal Infant

Normal growth
Resistance to infections
Long-term adult health
Optimal neurologic and cognitive development
Breastfeeding
Importance of breastfeeding
Promotion of breastfeeding

Breastfeeding decreases:

Incidence and severity of diarrhea

Respiratory illnesses
Otitis media
Bacteremia
Bacterial Meningitis
Necrotizing enterocolitis
Mothers who breastfeed
Experience:
Short-term health benefits

Decreased risk of postpartum hemorrhages

Rapid uterine involution
Longer period of amenorrhea
Decreased postpartum depression

Long-term health benefits

Reduction of hypertension
Reduction of hyperlipidemia
Reduction of cardiovascular disease
Reduction risk of diabetes
Adequacy of milk intake

Stooling patterns
Well-hydrated child
Colorless urine
Rate of weight gain
Common Breastfeeding Problems
Problem of mother:

Breast tenderness
Engorgement
Cracked nipples
Mastitis
Breast abscess

Problem of child:

Galactosemia
Phenilketonuria
Diet of Normal Child and Adolescent
Milk
Jucies
,,Choose my plate” recommendations
Obesity
Epidemiology

Clinical manifestations

Assessment
BMI-Body Mass Index
Prevention of Obesity
Treatment
Physical activity
Decrease size of serving
Decrease to 20mg fat
Decrease sugars
Less junk food
Avoid soda/juices

Surgical treatment
Pediatric Undernutrition
Inadequate food supply
Food access,
Food utilization
 Poor access to health and sanitation;
 Inappropriate feeding or child care practices.
Causes
Failure to Thrive – Organic and nonorganic

Marasmus

Kwashiorkor

Mixed Marasmus-Kwashiorkor
Treatment of Malnutrition
Nutritional rehabilitation should be initiated and advanced slowly to
minimize complications
Correction of dehydration and anti-infective (bacteria, parasites) therapy
Calories can be safely started at 20% above the child’s recent intake

Complication: refeeding syndrome

fluid retention,
 hypophosphatemia,
 hypomagnesemia,
hypokalemia
Complications of Malnutrition

Infections:

Sepsis, pneumonia, gastroenteritis

Hypoglycemia, Hypothermia, Bradycardia
Micronutrient deficiencies
Mortality
Routine evaluation of well-child

1. Anthropometric data
2. Dietary and physical activity history
3. Physical examination
4. Laboratory studies
Vitamin and Mineral Deficiencies

Ascorbic Acid
Vitamin C are ascorbic acid and the oxidized form, dehydroascorbic acid
Ascorbic acid accelerates hydroxylation reactions in many biosynthetic
reactions, including hydroxylation of proline in the formation of collagen

Symptoms:
Irritability,
Bone tenderness with swelling,
Pseudo paralysis of the legs
Thiamine – B1
Vitamin B1 functions as a coenzyme in biochemical reactions related to
carbohydrate metabolism
Decarboxylation of branched-chain amino acids
Thiamine is lost during pasteurization and sterilization

Cause: alcoholism, bariatric surgery

Symptoms: Anorexia, apathy, vomiting, restlessness, and progress to

dyspnea, cyanosis, and death from heart failure
Riboflavin – B2
Involved in process of electron transport
Deficiency affects glucose, fatty acid, and amino acid metabolism
It is characterized by an angular stomatitis; glossitis; seborrheic dermatitis
around the nose and mouth
Characterized by eye changes that include reduced tearing, photophobia,
corneal vascularization, and the formation of cataracts

Cause: Diabetic subjects, low socioeconomic status, chronic cardiac

disease, phototherapy for hyperbilirubinemia
Niacin
Niacin consists of the compounds nicotinic acid and nicotinamide
Niacin is involved in multiple metabolic processes, including fat synthesis, intracellular
respiratory metabolism, and glycolysis

Symptoms:
Pellagra, or niacin deficiency disease, is characterized:
Weakness
Dermatitis,
Photosensitivity,
Inflammation of mucous membranes,
Diarrhea, vomiting, dysphagia,
Dementia
Vitamin B6
Vitamin B6 refers to three naturally occurring pyridines: pyridoxine pyridoxal, and
pyridoxamine

Metabolic functions of vitamin B6 include:

1. Interconversion reactions of amino acids,
2. Conversion of tryptophan to niacin and serotonin,
3. Metabolic reactions in the brain,
4. Carbohydrate metabolism,
5. Immune development, and the biosynthesis of heme and prostaglandins

Symptoms:
Microcytic anemia, vomiting, diarrhea, failure to thrive, hyperirritability, and seizures
Folate
Folate functions in transport of single-carbon fragments in synthesis of nucleic acids
It is used for normal metabolism of certain amino acids
It converts homocysteine to methionine

Folate deficiency, characterizes by hypersegmented neutrophils, macrocytic anemia, and

glossitis

Conditions with risk of deficiency include pregnancy, alcoholism and treatment with
anticonvulsants or antimetabolites

First occurrence and recurrence of neural tube defects are reduced significantly by
maternal supplementation during embryogenesis
Vitamin B12
Vitamin B12 is essential for normal lipid and carbohydrate metabolism
 In energy production
 In protein biosynthesis and nucleic acid synthesis
Efficient enterohepatic circulation normally protects infants from deficiency
(1months to year)
Dietary sources of the vitamin B12 are animal products only

Most cases in childhood result from a specific defect in absorption:

1. Congenital anemia
2. Juvenile pernicious anemia (autoimmune)
3. deficiency of transcobalamin II transport
Symptoms of B12 deficiency

Neurologic manifestations:

Depression,
Peripheral neuropathy,
Posterior spinal column signs,
Dementia
Eventual coma
Maintenance therapy consists of repeated monthly intramuscular injections of
B12
Fat-Soluble Vitamins
Fat-soluble vitamins generally have stores in the body, and dietary
deficiencies generally develop more slowly

Absorption of fat-soluble vitamins depends on normal fat intake,

digestion, and absorption
Vitamin A
The basic constituent of the vitamin A group is Retinol
Retinol releases after hydrolysis by pancreatic and intestinal enzymes
In the eye, retinol is metabolized to form Rhodopsin; the action of light
on rhodopsin is the first step of the visual process

Symptoms: Xerophtalmia, Night blindness

Vitamin E
Vitamin E acts as a biologic antioxidant

Vitamin E deficiency occurs in children with:

1. Fat malabsorption
2. Secondary liver disease,
3. Untreated celiac disease,
4. Cystic fibrosis,

All the abnormalities are corrected after oral, lipid, or water-soluble vitamin E
therapy
Vitamin D
Cholecalciferol is the mammalian form of vitamin D and is produced by
ultraviolet irradiation of inactive precursors in the skin

Vitamin D deficiency appears as rickets in children and as osteomalacia in

postpubertal adolescents
Minerals

Calcium

Calcium is the most abundant major mineral

99% percent of calcium is in the skeleton

Nonskeletal calcium has a role in nerve conduction, muscle contraction,

blood clotting
Iron
Iron, the most abundant trace mineral, is used in the synthesis of
hemoglobin, myoglobin, and enzyme iron

Heme iron, present in hemoglobin and myoglobin

Nonheme iron exists in the form of iron salts

Treatment of iron deficiency anemia includes changes in the diet to

provide adequate iron and the administration of 2 to 6 mg iron/kg/24 hr
Zinc
Zinc is the second most abundant trace mineral and is important in protein
metabolism and synthesis

Zinc functions as a cofactor for more than 200 enzymes and is essential to
numerous cellular metabolic functions

Dietary zinc is absorbed (20% to 40%) in the duodenum and proximal

small intestine
Zinc
Zinc deficiency dwarfism syndrome was first described in a group of children in the Middle East
with low levels of zinc in their hair, poor appetite, diminished taste, hypogonadism, and short stature

Zinc supplementation reduces morbidity and mortality from diarrhea and pneumonia and enhances
growth in developing countries

Mild zinc deficiency - anorexia, growth faltering, and immune impairment

Moderately severe deficiency - delayed sexual maturation, rough skin, and hepatosplenomegaly

Severe deficiency - dermatitis; growth and immune impairment; diarrhea; mood changes; alopecia;
night blindness; and photophobia
Fluoride
Dental enamel is strengthened when fluoride is substituted for hydroxyl ions in
the hydroxyapatite crystalline mineral matrix of the enamel

Fluoride is incorporated into the enamel during the mineralization stages of

tooth formation and by surface interaction after the tooth has erupted

Fluoride is similarly incorporated into bone mineral and may protect against
osteoporosis later in life

Because of concern about the risk of fluorosis, infants should not receive
fluoride supplements before 6 months of age
End of Lecture 2