Classification System
Low Birth Weight (LBW) <2500 grams or 5.5 pounds
Very Low Birth Weight (VLBW) <1500 grams of 3.3 pounds
Extremely Low Birth Weight (ELVW <1000 grams or 2.2 pounds
Classification System
Small for gestational age (SGA) Birthweight less than the 10th %tile
Appropriate for gestational age (AGA) Birthweight between 10th and 90th %tile
Large for gestational age (LGA) Birthweight greater than the 90th %tile
Infant Growth
Occurs in genetically predetermined way Can be compromised by nutritional status calorie or nutrient undernutrition or
imbalance.Undernutrition:
First affects weight gainIf severe enough, affects linear growth
Growth
After birth genetic influences are target seeking
Catch Up Growth: Grow faster to get closer to genetically determined size Usually shift growth channels by 3 to 6
monthsLag Down Growth:
Usually shift growth channels by 13 months
Rules of Thumb
Weight: 4 months:Double birth weight 12 months: Triple birth weight then 2.3 kg/year until 9 or 10 then adolescent growth spurt
Growth: Height
1 year: 50% increase in height4 years: double birth length13 years: triple birth lengthAdolescence: rapid increase
Adolescent Growth Spurt
2 years later in males than femalesintensity, duration highly variableGrowth continues until after the
epiphysis closesGenerally by 4 years post onset of
puberty
Body Proportions
At birth: Head 1/4 of total length
Leg 3/8 of total lengthWhen growth ceases: Head 1/8 of total
length Leg 1/2 of total length
Collecting and Assessing Food Intake
24-hour recallDiet historyDiet Record 1, 3 and 7 day or moreFFQ
Who should be asked about Diet Intake?
If the subject is a boy < 13 or 14 years of age, the caregiver should be asked.
If a girl under 12 years of age, caregiver.
Why?
After diet has been taken accurately, then analysis is required
How?Food Guide PyramidNutrient analysis using food
composition table/ computer analysisMicaelsen room 104
Red Flags
Anthropometric: ht or wt less than 5th %tile
Infant formula under or over dilutedwhole cow’s milk before 1 yearreduced fat cow’s milk before 2 yearssemi-solid foods before 4 monthsbottle fed to go to sleep
Other Assessments Made
parent’s nutrition knowledgeadequacy of foods offeredparent’s knowledge of community
servicesdelays in feeding skillsbehavior patterns that affect intakemotivation of parent for change
Feeding problem: organic or inorganic
Organic: problem with muscle coordination, development
Inorganic: stress in family, emotionalOccupational therapists, speech
pathologists are trained to make these types of evaluations: if feeding problem exists, you may need to make a referral to determine cause.
Stressors
MovingDeath, divorce,
separationMarriage,
pregnancySerious injury or
illnessLoss of workFamily fights
Money problemsDrinkingTrouble with the
lawOther serious
problems
Parents of Maladjusted Children
Often are:youngermore dependent on relativeunstable mentallyhave marital or other conflictshave a disturbed relationship with
their child
Infant Feeding Choice
Breast feeding best choice but approx. 80 % of infants receive
formula at sometime during first year
types of formulas available: ready to serve concentrated powdered
Formulas: types
Source of Formula and Use Cow’s milk based formulas. Soy based formulas. Specialized formulas.
Cow’s Milk Formulas
2 types: 1. Protein diluted to reach amount in
human milk add back CHO, Fat, vitamins and minerals
2. Casein diluted to reach amount in human milk add back lactalbumin, fat, vitamins and
minerals
Soy Based and Specialized Formulas
Soy protein used as the protein base add back CHO, fat, vitamins, minerals,
and methionine (limiting amino acid) e.g.: Prosobee
Specialized: For special needs e.g.: Lofenalac: used with PKU infants
Low in phenylalanine
Osmolality
Measure of solute in solvente.g.: particles in milkosmolality: osmoles of solute in 1 kg of
solvent osmole: solute that dissociates in solution
to form one mole (Avogadro’s number) of particles.
If too high: water sucked out and causes diarrhea
Osmolality & Renal Solute Load
Human milk: low, less than 300 mosmolar, gut can easily handle Creates Renal Solute Load of 13
mosmol/100kcalCow’s milk: Higher osmolality
Renal Solute Load of 46 mosmol/100kcal Skim milk: RSL of 86 mosmol/100kcal
Formulas: 18-27 mosmol/100kcal
Potential Problems:
Mixing formulas too strong (or weak)Skim milk to infants or children
under 2 yoWhole milk under 1 yo
Nutrient Needs of Children
Energy Needs based on: body size and composition physical activity rate of growth surface area to volume ratio
Infancy more surface area to volume then later in life
More loss of energy to surrounding environment
Energy
Age Energy< 6 months kg x 1086mo-1 year kg x 98
Consider range of intake of intake requirements
Protein
Infant requirements based on amount found in breast milk
Extrapolation from nitrogen balance studies
RDA’sAge Protein<6 mo 2.2 g/kg6-12 months 1.6 g/kg
Fat
No RDA but 40 to 50 % of infant KcalsFat energy spares protein from being
used as an energy source45 to 50 % of infant formulas kcals are
from fat55% of human milk kcals are from fatEssential fat recommendation > 1.2%
of kcals (linoleic and linolenic acid)
When to reduce fat intake in kids?
Fat shouldn’t be a concern until after 2 years of age. Then start incorporating lower fat food
items into the dietreduced fat milk and milk products are okIf these are accepted early, the risk of
chronic disease could be reduced
Controversy: Am Ac of Pediatrics says don’t worry until after puberty: too late
Water
Age Amount3 days 80-100 ml/kg/day10 days 125-150 ml/kg/day3 mo 140-160 ml/kg/day6 mo 130/155 ml/kg/day9 mo 125-145 ml/kg/dayWith BF and formula: none additionally
needed
Iron(Fe)
In the fetus, Fe stores are related to body size, therefore lbw and premature babies are at increased risk for iron deficiency
Human milk: 49% of iron is absorbed, only 1% of cow’s milk Human milk not a very good source of Fe so
after 4 to 6 months, baby may be deficient in Fe. Iron fortified cereals with vitamin C.
Fluoride(Fl)
Major role in tooth and bone development
Adequate intake reduces dental decay Becomes incorporated in tooth and resists
acid breakdown. Acid produced by cariogenic bacteria in mouth.
Supplementation dependent on Fl in water supply.
Fluoride Supplementation
Amount in Water age supplement< 0.3 ppm 2 wk-2 y 0.25 mg/day 2-3 years 0.5 mg/day after 3 y 1.0 mg/day0.3-0.7 ppm 2 to 3 y 0.25 mg/day 3-16 years 0.5 mg/dayover 0.7 no supplementation
Age of Introduction of Solid Foods
Developmental readiness, generally 4 to 6 months depends on oral skills: tongue thrust, munching
pattern, brings objects to mouth palmer grasp develops interest: if child reaches for food
First Foods: iron-fortified cereals for infants6-8 months: strained vegies, fruits, meats,
finger foods
Adding Foods
New foods should be added one at a time, no more than one every three days Check for tolerance
As infant approaches 9 to 12 months, increase in texture to mashed and finger foods can progress
Avoid potential choking foods hot dogs
Feeding Problems
Colic: gas production, and bloating Cause? Not always known: formula fed,
may change formula to casein hydrolysatebut not always successful
Breastfeeding?Foods in the mother’s dietCow’s milk, or items
Spitting up
Normal occurrenceUnless projectile vomiting:
Organic problem: pyloric sphincter closure
What You Should Know About Gastroesophageal Reflux (GER) in Infants and Children - December 1, 2001 - American Academy of Family Physicians
Screening Infants for special needs
Nursing Bottle Syndrome: feeding baby to go to sleep with bottle Increases tooth decay Treatment: don’t put baby to bed with a bottle
Infant Obesity:>95%tile wt for age, Wt for ht Not predictive of obesity in later life Adequate nutrition should be the key: don’t
restrict foods
Neonatal Care
Level 1: uncomplicated births and healthy infants
Level 2: normal infants and expertise in screening and referral of high risk infants care for moderately ill neonates and
convalescing neonatesLevel 3: equipped to cope with most
serious neonatal problems, illnesses, abnormalities
Role of Nutritionist in Neonatal Care
Should be able to screen for various nutrition problems, monitor and assess nutritional progress, develop and implement nutrition
management plans
Failure to Thrive
Failure to regain birth weight by 3 weeks
Wt. loss of >10% of birth weight by 2 wks
Wt dropping below the 3rf %tileDeceleration of growth velocityEvidence of malnutrition
Growth Retardation: 4 Types
1. Small for Gestational age but appropriate growth since intrauterine growth retardation, but
appropriate since then parental height small stature
Growth Retardation
2. Small or appropriate for gestational age but subnormal growth velocity ongoing growth insult examples: poor intake, overdiluting
formula, in appropriate breastfeeding schedule, family stress, poverty
Growth Retardation
3. Depression in growth velocity Some transient growth insult but has
since been alleviatedSeasonal low intake of nutrients due to low
income
Determination of Short Stature
Chronological age: actual ageHeight age: compared to 50%tile on
growth chartBone age: x-ray needed and radiologist
measures the width of growth plate to determine bone age. The thicker the growth plate, the younger the bone age and the longer the time for continued growth
Height Prediction: Is the child exhibiting appropriate growth?Female Childmother ht(cm) + (father ht-13) + 8.5 cm 2
Male Child(mother ht(cm)+13) + father ht + 8.5
cm 2
Height Prediction
Compare this height to age 18 on growth chart to determine % tile.
Compare this %tile to the current %tile of child and see if it compares favorably. If considerably below, cause for further
investigation e.g.: If prediction shows 75%tile and actual is
5%tile, most likely there is some environmental influence.
Development of Food Patterns in Young Children
First 5 or 6 years are important for developing food likes and dislikes
Goals for food pattern development: 1. Children eat in a matter-of -fact
manner 2. Independent eating 3. Introduction of new foods
Ellyn Satter Theory
Caregiver: Gatekeeper: decides what foods are offered
Child: Decides whether to eat, and how much to eat Child then develops their own regulation
of food intakeIf caregiver forces food or withholds food,
child isn’t able to develop their own satiety gauge
Guidance for introducing new foods
Have then explore food first Feel, smell, play with?
Use small portions. Why?
Decision to consume is left up to the childPositive reinforcement when consumption
happens. Guard against negative reinforcement, or
coercing.
New foods
Gradually intro new texturesAdd individual foods first before
mixturesAdd when child most receptive to food
Often in morning when well rested Often not late in the day when they are tired
Be patient with self-feeding efforts Self-esteem
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