Gastro - nutrition Flashcards
Can formula milk be given to breastfed babies?
Should not be given, unless medically indicated (NICE)
In general, an environment for breastfeeding should be encouraged and commercial formula packs should not be distributed.
At what time after birth should breastfeeding be encouraged?
As soon as possible, ideally within the first hour after birth! Same with skin-to-skin contact.
Avoid separating baby and mother for routine checks, unless indicated.
In the future, unrestricted breastfeeding frequency and duration should be encouraged.
What should be done if the infant is not taking sufficient milk from the breast?
Expressed breast milk should be given as supplementation
What are indicators of good attachment and positioning for breastfeeding?
Mouth wide open
Chin touching breast, lower lip rolled down, nose free
No Pain
What are indicators of successful feeding in babies?
Audible and visible swallowing
Sustained rhythmic suck
Relaxed arms and hands
Moist mouth
Regular soaked/heavy nappies
What are indicators of successful breastfeeding in women?
Breast softening
No compression of nipple at the end of feed
Woman feels relaxed and sleepy
What are symptoms of mastitis?
Flu-like symptoms
Red, tender and painful breast
Needs to report to healthcare professional immediately
What advise is given if the patient has mastitis?
Continue breastfeeding + gentle massage to overcome blockage and effectively remove milk.
Analgesia compatible with breastfeeding eg. paracetamol.
Increase fluid intake
What are the advantages of breastfeeding?
Enhances relationship
Reduced gastro-intestinal infections (especially developing countries).
Reduced incidence of necrotising enterocolitis in preterm infants
Ideal nutrition for 4-6 months.
Reduced incidence of obesity, DM and HTN in later life.
There is a reduction in breast cancer in mothers who breast-feed.
When is breastfeeding challenging?
In twins.
Rarely possible in triplets and higher orders.
Milk needs to be expressed from the breast for PRE-TERM babies, until they can suck.
What is COLOSTRUM?
Produced in the first few days of breast-feeding.
Much higher content of IG and protein than milk. It has low volumes.
What are semi-hydrolised milk formulas?
The proteins are partially broken down, which is supposed to help digestion and prevent colic and constipation. However, there is no evidence for that.
Not suitable if cow or goat milk allergy.
Which formula option is given to babies with cow milk allergy?
Hypoallergenic formula which contains completely hydrolysed proteins.
Which proteins are present in cow’s milk formula?
Casein
Whey
1st infant formula is based on whey, as it is thought to be more easy to digest. Baby can drink it even after solid foods are introduced for the first year.
How is mild and severe failure to thrive defined?
Mild = fall across two centile lines due to inadequate weight gain when plotted on centile chart.
Severe = fall across 3 lines.
Which centile weight should always trigger an evaluation?
A weight below the 0.4th centile.
If below 2nd, child may still be normal.
What are the non-organic causes of failure to thrive?
psychosocial and environmental.
Ca. 5-10% with failure to thrive are on a child protection register. A larger proportion may have socioeconomic deprivation.
Often organic is also present with undernutrition.
What are the important aspects of history in failure to thrive?
Dietary (inc food diary)
Feeding
Well? Energy?
Symptoms? (D+V, cough, lethargy)
Premature/IUGR at birth?
FH and growth of members
Development normal?
Psychosocial problems at home?
Which features should examination focus on in failure to thrive?
Signs of organic disease:
Dysmorphia
Malabsorption (distended abdomen, thin buttocks, misery)
Chronic resp disease (chest deformity, clubbing)
Signs of heart failure and nutritional deficiencies
Which investigations may be useful in some children with failure to thrive?
FBC and seru, ferritin for IDA.
Usually secondary to inadequate to Iron intake
What are the causes of failure to thrive?
Inadequate intake
Inadequate retention
Malabsorption
Failure to utilise nutrients
Increased requirements
What are the causes for inadequate intake? (failure to thrive)
Psychosocial
Neglect/abuse
Impaired suck/swallow (cerebral palsy, cleft palate)
Chrohn’s disease, chronic renal failure, CF, liver disease
What are the causes for inadequate retention causing failure to thrive?
Vomiting
Severe gastro-oesophageal reflux
What are the causes of malabsorption leading to failure to thrive?
Coeliac CF Cow's milk protein intolerance Cholestatic liver disease Post-necrotising enterocolitis
Which syndromes lead to failure to utilise nutrients and thus failure to thrive?
Down’s, IUGR, extreme prematurity
Congenital hypothyroidism, storage disorders
Which conditions lead to increased requirements and thus failure to thrive?
Thyrotoxicosis
CF
Malignancy
Chronic infection (HIV, immune deficiency)
Congenital heart disease
Chronic renal failure
What is the commonest cause of failure to thrive?
inadequate food intake
What is the MUST tool?
Malnutrition universal Screening Tool.
For adults.
Recommended by NICE and British Dietetic Association
How can malnutrition in children be screened for?
Mix of:
Weight for height plus Anthropometry (usually mid upper arm circumference - related to skeletal muscle mass <115mm is severe)
Especially useful fr screening in the community.
Laboratory investigations: low plasma albumin, Vitamins and minerals can be low
Dietary Diary
Immunodeficiency (low lymphocyte count)
Impaired cell-mediated immunity
How does marasmus present?
Severe protein-energy malnutrition.
<70% weight for height (more then 3 standard deviations below median)
Wasted, wizened appearance. No oedema. Skinfold thickness and mid-arm circumference markedly reduced.
Often withdrawn and apathetic.
What is kwashiorkor? How does it present?
Severe protein malnutrition. Energy intake relatively well maintained (eg. high starch diet)
Generalised oedema. Severe wasting. Weight may not be severely reduced because of the oedema.
Plus there may be:
Flaky-pain skin rash with hyperkeratosis.
Distended abdomen.
Hepatomegaly (fatty infiltration).
Angular stomatitis.
Sparse, depigmented hair.
Diarrhoea, hypothermia, bradycardia, hypotension.
Low plasma albumin, potassium, glucose and magnesium
What are the signs of overfeeding?
Greater than average weight/height. >8 heavily wet nappies per day. Frequent, sloppy, foul-smelling bowel motions. Extreme flatulence. Large belching. Milk regurgitation. Irritability. Sleep disturbance.
Many of these are symptoms of reflux, milk-protein allergy/intolerance, colic. However, in these conditions the baby is usually NOT overweight
What are the possible symptoms of cow milk protein allergy?
Variety of symptoms, involving different systems, usual onset 1 week after starting feeding
Pruritus
Erythema
Acute angioedema
Oral pruritus
Nausea
Colicky abdo pain
V + D
What are the treatment options for cow’s milk protein intolerance
Hydrolyzed formulas work in 90%
Otherwise formulas that only contain amino acids
90% resolves by 6 years of age. 75% by 3 years
Disadvantages of breastfeeding
Unknown quantity
Transmission of some disease/drugs/contaminants
Less flexible than formula
Risk of breast-milk jaundice
Where to obtain advice regarding breastfeeding
Info pack should be given to her within 24h
Healthcare professional support with first feed
Midwives can always if in hospital
In the community there are community nurses and health visitors
Which foods should be avoided if weaning takes place < 6 months (not necessarily recommended)
Wheat
eggs
fish
High salt, sugar Any honey (risk of botulism)
Which vitamins is formula milk deficient in?
A, C, D and iron
need supplement
When is specialized formula milk indicated (from soya etc)
Cow’s milk protein intollerance
Lactose intolerance
CF
Neonatal cholestatic liver disease
Causes of failure to thrive
Inadequate intake: environmental (availability, abuse)
impaired suck/swallow (eg. cleft lip)
Inadequate retention (vomiting, severe GOR)
Malabsorption (coeliac, CF, cow’s milk intolerance)
Failure to utilize nutrients (syndromes, congenital infection)
Increased requirements (thyrotoxicosis, CF, malignancy, chronic infection, congenital heart disease)
What is meant by the term nutrition
is the intake of food considered in relation to the body’s dietary needs
5 steps for MUST tool (malnutrition universal screening tool)
- get BMI
- note percentage unplanned weight loss
- establish acute disease effect and score
- add scores from 1, 2, and 3 together to obtain risk of malnutrition
- use management guidelines
Recommended intake for infants 6-12 months old
Breast milk is not enough at this point
Wean onto solid foods: fruit, vegetables, cereal, dairy, meat, fish, eggs
If breast milk is the only drink, supplement Vitamins A, C, and D in the diet
How should weaning be begun?
Puried foods
Mix with a little of the usual milk
Increase frequency gradually
Main nutrition still comes from milk at this stage (500-600ml per day)
How to know when baby is ready for weaning?
Shows interest in food Able to sit up Wants to chew and put objects in mouth Able to reach Seems hungry after milk feed
7-9 months nutrition
Introduce a variety of foods, textures and tastes (wheat and range of proteins)
9-12 months nutrition
3 meals a day
Add healthy snacks
Chopped food, mashed and include all groups of food
Avoid these foods during weaning (top 10, you won’t believe number 9!!!)
Salt Sugar Honey Shark, swordfish Raw eggs Whole nuts
