2.1 Healthy nutrition & obesity

Question 1

when is usage of formula milk indicated?

Answer 1

• Metabolic conditions requiring specialised formula: Galactossaemia, maple syrup urine disease (build-up of branched-chain amino acids and toxic ketoacid by-products in blood and urine), phenylketonuria
• Requiring formula in addition to breastmilk for a limited period: Very low birth weight, very premature, at risk of short-term metabolic problems (e.g. with diabetic mothers)
• Maternal HIV infection in certain circumstances
• Maternal active HSV infection if lesions are present on the breast
• chemotherapy

Question 2

Mother-to-child transmission (MTCT) of HIV can occur via breastmilk, in utero (rare), or at the time of birth (also rare):
• Heavily influenced by breastfeeding practices → _________________ increases the rate of HIV MTCT; ______________ reduces MTCT significantly
• _________________ carries the highest risk of MTCT, while EBF is protective against transmission

However, avoiding breastfeeding to avoid HIV transmission is likely associated with increased all-cause mortality (from any cause → including infections):
• With modern prevention of MTCT (PMTCT) interventions (lifelong ART and ART during the MTCT risk period for all pregnant and breastfeeding women with HIV), transmission rates of HIV are much lower → no need to avoid breastfeeding
• For HIV-positive mothers who still choose to avoid breastfeeding, the choice of replacement feeds should be influenced by acceptability, feasibility, affordability, sustainability, safety Aspect Factors affecting transmission

Answer 2

prolonged breastfeeding;

formula feeding;

Mixed feeding (breastfeeding + formula feeding);

Question 3

What are the maternal factors affecting transmission of HIV through breastmilk?

Answer 3

• RNA viral load in milk
• RNA viral load in plasma
• Clinical or immunologic (CD4 count) disease progression
• Breast health (subclinical/clinical mastitis, abscess, cracked nipples)
• Local immune factors in breastmilk
• Consistent compliance with PMTCT interventions

Question 4

What are the infant factors affecting transmission of HIV through breastmilk?

Answer 4

• Duration of breastfeeding
• Mode of breastfeeding
• Morbidity leading to less vigorous suckling, milk stasis, and increased leakage of virus across milk ducts

Question 5

What is the WHO recommendation for HIV positive mothers?

Answer 5

EBF for the first 6 months of life (for HIV-positive mothers) then continue non-exclusive breastfeeding for the first 12 months:
• Abrupt weaning is not advisable → breastfeeding should only stop once a nutritionally adequate and safe diet without breastmilk can be provided
• For known HIV-infected infants: EBF for the first 6 months with continued breastfeeding as per recommendations for the general population

Question 6

What are the abilities that baby need for eating solid foods?

Answer 6

1. Stay in a sitting position and hold their head steady (head control)
2. Coordinate their eyes, hands, and mouth so they can look at the food, pick it up, and put it in their mouth
3. Swallow food (babies who are not ready will push their food back out)

Question 7

what kinds of supplementation do children who are brought up as vegetarians need?

Answer 7

Additional iron, vitamin B12, and high calorie foods (as vegetables are bulky, high in fibre and relatively low in energy)

Question 8

what kinds of supplementation do children who are brought up without fish in their diet need?

Answer 8

Omega-3 supplementation

Question 9

what are the nutritional interventions needed in a resource poor setting?

Answer 9

• Routine vitamin A supplementation
• Intermittent iron supplementation and deworming (minimising blood loss due to intestinal parasites)
• Zinc supplementation for management of diarrhoeal diseases
• Fortification of foods: at a national level (e.g. iodinisation of salt) or household level (e.g. with micronutrient powders/sprinkles)

Question 10

what is the definition of obesity in the uk?

Answer 10

overweightness and obesity are defined as the 85th and 90th percentiles as compared to the rest of the population

Question 11

what is the definition of obesity by the international obesity taskforce?

Answer 11

obesity is defined as a childhood percentile corresponding to BMI of 25 or 30 at age 18

Question 12

What are the complications of obesity?

Answer 12

The main complication of childhood obesity is its maintenance into adulthood (50 – 60% of obese children → significant proportion develop metabolic syndrome):
• Orthopaedic problems
• Asthma (reversible bronchospasm)
• Sleep apnoea (common; up to 50%)
• Polycystic ovarian syndrome
• Liver disease (steatohepatosis)
• Cardiovascular disease
• Psychological problems (e.g. bullying, low self-esteem)

Question 13

How should childhood obesity be managed?

Answer 13

• Behavioural change interventions: encourage healthy diet and more physical activities (should involve the whole family where possible)
• Pharmacologic management (e.g. metformin, orlistat) in unusual circumstances
• Surgical management in exceptional cases
• Assessment and management of complications