Module 19: Paediatric Nutrition

Question 1

Learning Objectives:

1. To understand the benefits, epidemiology and physiology of breastfeeding
2. To know how to manage the infant with suboptimal breastfeeding
3. To know how to manage the introduction of solid foods
4. To know basic nutritional management for the best growth and neuro- developmental outcomes in children
5. To recognise and be able to manage gastrointestinal dysfunction and disease states.

Answer 1

Okay

Question 2

What are the benefits to breast feeding?

For the Mother?

Answer 2

Decreases risk of:
1. Breast Cancer
2. Ovarian Cancer
3. Postnatal Depression
4. Type 2 Diabetes
5. Post Partum Bleeding.

Other benefits:
Lactation amenorrhea and delayed ovulation
Postpartum weight loss

Question 3

What are the Immunological benefits of Breast Milk?

What are the cognitive and neural benefits of breast milk?

Answer 3

IMMUNOLOGICAL

1. Cellular (T and B lymphocytes)
2. Humoral
3. IgA

reduced morbidity:
1. Pneumonia
2. Diarrhoea and vomiting
3. Upper respiratory tract infection and ear infection
4. Chronic and inflammatory bowel disease
5. SIDS
-Breast feeding is protective against SIDS, and this effect is stronger when breastfeeding is exclusive

COGNITIVE AND NEURAL BENEFITS:
Longer breastfeeding = better cognitive and motor development in 2-3 year old children (dose-response relationship)

Better academic scores, improved cognitive ability.

1. Obesity
2. Hypertension
3. Serum Cholesterol
4. Type 2 Diabetes
5. Socioeconomic
6. Convenience
7. Environmental
8. Tooth development
9. Sleep apnea

Question 4

Breast Feeding epidemiology and goals:

Exclusive breast feeding to 6months of life, solid intro after 6mo with continued breastfeeding up to AT LEAST 12 months.

What are 8 factors found to promote and encourage continued breastfeeding?

Answer 4

1. A mothers strong intention and desire to breast feed
2. Support context
3. Positive Role models
4. Previous experience
5. High socioeconomic class
6. Higher maternal education levels
7. Prenatal education
8. Early intervention

Question 5

The Physiology of Breast Feeding:

Hormonal control. Which 2 hormones play a big role?

How much Milk is required?

Frequency of feeding:

Answer 5

Prolactin: Stimulates milk production, prolactin doubles with sucking . Sleep and sexual intercourse also stimulates
Stress Inhibits.

Oxytocin for let down: stimulated by sucking or nipple stimulation.
After this its removal of milk which maintains supply. The more the mother empties, the more that is produced.

babies feed better when mum is in reclined position.

How much Milk is required?
Volume: 750-800ml milk daily for first 4-5 months.

Frequency of feeding:
Newborns will feed 2-3 hourly in the first week, due to fast gastric emptying time.
-Gastric emptying time is faster in breastfed infants
-their intake is 30-90 ml
-There are approximately 6-9 feeds per day

Neonate is expected to lose weight in first week <10% and will gain weight by day 12.

By 4 weeks the infant settles into a routine of 3-4 hourly feeds/
By 4-8 months the infant won’t require an overnight feed.

Question 6

Dysfunctional Suck:
Signs include

The breast feeding Exam:
Key areas to assess

Answer 6

-Weak suck
-very strong suck
-excessive clicking
-poor use of lips and tongue
-poor rooting and sucking reflex

Poor Swallow:
Signs include:
-Excessive choking, gagging, and coughing throughout the feed- vagal nerve involvement.
-Dribbling during the feed - vagal nerve involvement

Key areas:
-Spinal, extremities, cranial
-TMJ, Jaw muscles
-neck muscles
-Neuro eg rooting + sucking reflexes
-tongue use and suck

The upper cervical, shoulder + TMJ
Look and feel for
-deviation or poor mouth opening
- The TMJ is usually secondary to neck
AS occiput- The jaw deviates away from the side of dysfunction.
Shoulder subluxation- fussy when feeding lying on involved side.

Question 7

Common breast feeding Problems

What are signs of enough milk supply?

What are some methods to increase milk supply?

Answer 7

6-8 wet nappies
-2 bowel motions a day
-good skin colour and muscle tome
-content infant
-increase in weight, growth and head circumference

Methods to increase milk supply?
1. Express milk supply
2. Herbs such as fenugreek is known to increase milk supply.
3. Calcium can relax the ducts to provide a faster let down.
4. Prolactin (hormone that cause milk production) is increased with suckling, sleep and sexual intercourse, and decreased with stress.
5. The let down is also increased by suckling and nipple stimulation.
6. Motillium
7.Vitamin D – 10,000 to 20,000 IU per day
8. Overactive letdown can be a problem for some. Remove the infant from the breast and wait for flow to slow down. Express some milk early in the let down.

Question 8

Blocked ducts

It could be a persistent or recurrent problem
May lead to mastitis, breast abcess, + breast feeding sensation.

What are the symptoms of plugged ducts?

What are history indicators of plugged ducts

What is the management?

Answer 8

Symptoms of plugged ducts:
1. tender lump in the breast
2. an area of bluish color to the skin over the tender
area
3. breast itself may feel hot.
4. white bleb at the end of the nipple on the breast
with a plugged duct
5. pain in the nipple or brief and shooting pains in
the breast.

History indicators of blocked ducts:
1. Early and/or extreme post-partum engorgement
2. High milk supply
3. A mother who has returned to work or school and
is pumping while separated from her infant
4. Past history of recurrent plugged ducts and/or
mastitis with other children

Management:
1. education RE baby led breastfeeding, avoid rules about feeding, recognise hunger, fully empty the breast
2. Ensure correct latch
3. Breast massage (nurse before and after)
4. hot compresses
5. hot showers and baths
6. Analgesics
7. family support
8. therapeutic ultrasound:

Question 9

What are the causes of Mastitis?

Whats the symptoms and diagnosis?

How about Prevention and Management?

Answer 9

1. Mastitis is an inflammatory condition of the breast, which may or may not be accompanied by infection. (WHO 2000)
2. Breast abscess, a localised collection of pus within the breast, is a severe complication of mastitis (WHO 2000)
3. Occurs in 2-33% of breastfeeding women (Barbosa, 2003)
4. Commonest in the second and third week postpartum (WHO 2000)
5. 74% to 95% of cases occur in the first 12 weeks (WHO 2000)
6. 19% recurrent

Breast inflammation
 redness, warmth and tenderness
 localized, segmental, or total breast inflammation
(Barbosa, 2003, Featherston 2006)  feels unwell, tires easily, afebrile
* Acute
 unwell,
 myalgia, needs to go to bed) * Hyperacute
* Mild
*
 myalgia, headache or vomiting, rigors. (Barbosa, 2003, Featherston 2006)
Mastitis is defined as any inflammation of the breast present for more than 24 hours, and accompanied by any degree of systemic illness.

PREVENTION AND MANAGEMENT:
2 CAUSES: MILK STASIS AND INFECTION

The two principle causes of mastitis are milk stasis and infection. 1. Milk Stasis
* Milk stasis occurs when milk is not removed from the breast efficiently.
* Causes include
 poor attachment of the infant
 ineffective suckling,
 restriction of the frequency or duration of feeds  blockage of milk ducts. (WHO 2000)
* Poor attachment as a cause of inefficient milk removal is now seen as a major predisposing factor for mastitis (WHO 2000)

2. Infection
   * Many healthy breastfeeding women have potentially pathogenic bacteria in their breast milk.
   * Increasing bacterial counts did not affect the clinical manifestation of mastitis; thus bacterial counts in breast milk may be of limited value in the decision to treat with antibiotics as results from bacterial culture of breast milk may be difficult to interpret.

Question 10

TONGUE Tie AFFECT ON Breast Feeding?

2-10% of infants have a tongue tie

Answer 10

• Tongue-tie may prevent the infant from taking enough breast tissue into its mouth to form a teat
  1. may affect latch
  2. some can latch but less efficient.
  3. may affect milk transfer ands infant growth
  4. may reduce stimulation of breast and reduce supply.
  5. may cause painful, damaged nipples
• Tongue tie is a congenitally short or contracted frenulum.
• It has been shown to negatively affect breastfeeding
• Surgical correction has few side effects and can increase the duration of breastfeeding.

Question 11

Introduction of Solids:

What are the cues that the baby is ready for solids or not?

Answer 11

1. Good head control and able to sit up with support
2. Watching and leaning forwards when food is around
3. Reaching out to grab food or spoons to put in their mouth
4. Opening their mouth when food is offered.
   Summary: Are feeding cues present in the:- eyes, body,
   arms/hands, mouth
   Cues that a baby is NOT ready for solids
   - the body cues above are not present
   - there has been digestive difficulties and these remain

Question 12

Timing of foods and allergy

Questions:
1. Is there benefit in restricting introduction of some foods to prevent later allergy?
2. Does early introduction of foods increase or decrease the risk of allergy?
3. Does later introduction of foods increase or decrease the risk of later allergy?

Answer 12

“ current evidence suggests that this is most likely to be between 4 and 6 months of life and that delayed exposure beyond this period may increase the risk of food allergy, coeliac disease and islet cell autoimmunity. “

Question 13

Diet essentials for Neurodevelopment

Answer 13

1. Lots of fruit and vegetables
2. Lots of water
3. Eat low GI foods (wholegrains, legumes, corn, sweet potato, fruits and vegetables).
4. Avoid sugar
5. Avoid processed foods
6. Identify any food sensitivities
7. Some meat, chicken, fish
8. Avoid additives (colourings, preservatives)
9. Use supplements-common (fish oils, probiotics)
10. Use food diaries (insert in appendix) Monitor gut function.

Question 14

Vitamin B12
Cyanocobalamin

What are some sources of B12?

Newborn infants have limited endogenous stores and are at risk for vitamin B12 deficiency if they are predominantly breastfed, with a poor maternal vitamin B12 status and intake.

Answer 14

1. Milk
2. Eggs
3. Meat
4. some mushrooms

Typical manifestations usually start between 4 and 10 months of age and include
1. growth faltering
2. developmental regression
3. tremors
4. hypotonia
5. lethargy
6. irritability
7. feeding difficulties
Megaloblastic anemia is not always present.

Question 15

Vitamin C
Cannot be synthesised by humans
Low levels of VitC including scurvy can occur following infections

A child with what type of condition is most likely to present with Vit C deficiency

Answer 15

Scurvy?

Clinical symptoms can develop only after 30- to 40 days of consuming a diet that is void of vitamin C.

• The earliest symptoms of vitamin C deficiency are fatigue and refusal to walk.
• Dermatologic findings include
  1. petechiae centered on hair follicles
  2. hyperkeratosis
  3. coiled hair
  4. hematomas
  5. ecchymosis
  6. poor wound healing
  7. edema
• Oral manifestations occur only in patients with teeth and include bleeding and hypertrophic gums.
• Musculoskeletal findings include
  1. joint pain
  2. hemarthrosis
  3. muscle pain

Question 16

Vitamin A

Vitamin A plays a critical role in vision, immunity, and cell differentiation and growth.

Answer 16

Subclinical Vit A deficiency
1. Increased mortality
2. Increased diarrheal diseases
3. Decreased antibody production in
measles

Question 17

Vitamin D The hormone

Diet alone only provides 100 to 200 IU of vitamin D per day. Exposure to sunlight, in contrast, produces 10,000 to 20,000 IU when 30% of the body surface area is exposed to sunlight 15 to 30 min a day

Functions
1. Calcium balance and bone mineralisation
2. Regulation of cell differentiation, proliferation, and apoptosis
3. Involved in colorectal cancer, prostate cancer, multiple sclerosis, type 1 diabetes, cardiovascular diseases, and tuberculosis
4. Immune system and inflammation
Sources
1. Nutritional sources:- fatty fish (salmon, mackerel, sardines, cod liver oil), some types of mushrooms
2. UVB-dependent endogenous production
3. Suppléments.
UVB rays that are most efficient in producing vitamin D are available when the sun is most perpendicular to the earth’s surface—between 10 AM and 3 PM

Answer 17

La la

Question 18

Vitamin D and the Immune System

• Enhances the antimicrobial effects of macrophages and monocytes
• Low serum 25(OH)D levels have been associated with
  1. upper respiratory tract infections (URTI), including
  influenza,
  2. chronic obstructive pulmonary disease
  3. allergic asthma
  4. tuberculosis

2014 guidelines now recommend minimum Vitamin D level of 75 nmol/L

Vitamin D supplementation- how much?

Question 19

Vitamin D supplementation- How much?

Answer 19

Vitamin D supplementation

Amaintenancedoseofupto1000IU/daymaybe adequate, however some individuals will require higher doses.

The Endocrine Society in 2011 proposed the following
1. Infants and children aged 0–1 yr require at least 400 IU/d (IU = 25 ng) of vitamin D and children 1 yr and older require at least 600 IU/d to maximize bone health.

Question 20

Vitamin D and pregnancy
A woman’s vitamin D requirements increase during pregnancy.

• Helps prevents low birth weight.
• Insufficient vitamin D during pregnancy may disrupt calcium homeostasis leading to
  intrauterine growth retardation and premature labour.
• Required for proper foetal tooth development and proper foetal bone development.
• Reduces the risk of diabetes mellitus type 1, multiple sclerosis, manic depression and anxiety neurosis in offspring.
• Maternal vitamin D insufficiency during pregnancy is significantly associated with offspring language impairment. Maternal vitamin D supplementation during pregnancy may reduce the risk of developmental language difficulties among their children.
• In animal studies offspring of vitamin D deficient mothers have higher offspring blood pressure and altered brain and kidney development.
• Preeclampsia risk increases

Answer 20

ya its obviously important

Question 21

What are the signs of Rickets?

Answer 21

1. Genu varum(bowing of the legs)
2. Genu valgum (knock-knees)
    due to the lack of structural support as the child learns to walk.
3. Widening at the end of the long bones is most commonly manifested in the wrist. The
4. Rachitic rosary is a term used to describe the beading along the anterior chest wall and is a result of the hypertrophy of the costochondral joints.
5. Bone pain

Question 22

Vitamin D and Allergy

• VitaminDsupplementationforpregnantwomen, breastfeeding women, and infants may not decrease the risk of developing allergic diseases such as

Answer 22

1. atopic dermatitis (in pregnant women),
2. allergic rhinitis (in pregnant women and infants),
3. asthma and/or wheezing (in pregnant women, breastfeeding women, and infants),
4. food allergies (in pregnant women

Question 23

Folic Acid

Answer 23

• Increased folic acid levels have been linked with

1. Fetal loss
2. Immune dysfunction by dysregulation of natural killer cells
3. Increased tumorgenesis
4. Acceleration of leukemias, colorectal and prostate cancers
5. Premature ovarian failure
6. Autism

The replacement of folic acid with 5-methyl-THF in prenatal vitamins should be strongly considered as universally beneficial.

More ingestion of leafy greens like kale, spinach, arugula and swiss chard that provide natural folate forms, including 5-methyl-THF, should be encouraged

Question 24

Vitamin K

The Canadian Paediatric Society suggests that oral vitamin K should be given to newborns whose parents decline IM vitamin K as a 2-mg dose at birth and at weeks 1 and 6.

Answer 24

Oral regimens have proven efficacy in the prevention of late VKDB and are used in Europe, such as the weekly administration of 1 mg of vitamin K for 12 weeks or 2 mg at weeks 1 and 4.
* However, oral vitamin K is not effective in the prevention of late VKDB in patients with liver disease or malabsorption.

• Six deaths were reported, all from intracranial haemorrhage in infants with late VKDB.
   Three of these infants were delivered at home, were not given vitamin K due to parental refusal and were exclusively breast fed; one of whom had cholestasis.
   The remaining three were delivered in hospital and received intramuscular prophylaxis:
   two had confirmed liver disease and did not receive the recommended dose;
   the other did not have liver disease and had received recommended prophylaxis but was exclusively breast fed.
• One death occurred in 1993, 1998, 2010 and 2014 and two in 2000.

Question 25

Iron

Iron functions:
1. provide energy
2. blood formation

Causes of IDA: Iron Deficiency Anemia
Occurs when iron is deficient or poorly absorbed.
 Usual diet pattern is iron lost from excessive cow’s milk consumption.
 To prevent IDA the AAP recommends no cow’s milk before 12 months of age.
 Children ages 1-5 should consume no more that 680 grams of cow’s, soy or goats milk per day, because these are low in iron and displace iron rich foods, and lead to iron loss in the intestines (Brown 2008).
Other bowel disease should also be considered.
* 2% of adolescent girls have IDA due to growth spurt and menstrual blood loss.

By 4 months of age, neonatal iron stores have been reduced by half, and exogenous iron is required to maintain haemoglobin concentration during the rapid phase of growth between 4 and 12 months.

Breastfed babies absorb iron 2-3 more times efficiently.

WHAT ARE THE SIGNS OF IDA?
1. Blue sclera
2. Koilonychias
3. Impaired exercise capacity, weakness, fatigue
4. Increased lead absorption
5. Increased susceptibility to infection.
6. Abnormal developmental performance
7. Poor growth

Answer 25

Basically Iron is bloody important and we should be supplementing it to bugs after they come off breast

Iron and impaired cognition, otherwise they get dum, behavioural issues, and motor effects also, AND behavioural issues!

Question 26

Calcium

• Calcium is required to enhance bone mineral deposition.1-6
• Very low calcium intake can contribute to rickets in infants and children 1-3
• it is a combination of vitamin D status, physical activity and genetics
• 99% of total body calcium is found in the skeleton, with only small amounts in plasma & extracellular fluid.3
• Serum calcium is maintained at constant levels by Parathyroid hormone and calcitonin.1-3
• Calcium absorption relies heavily on Vit D levels.1-3
• It is currently recommended that we have a dietary Calcium intake of:
• 300mg/d for infants
• Between 500-800mg/d for children
• Between 800-1000mg/d for adults
• 1100-1200mg/day for pregnant and lactating women.1-3
• That is however being questioned – Newer research is suggesting more like 500mg/day.1-2

Answer 26

Good to know

Question 27

Is Dairy- PREVENTION of Osteoporosis???

You have been brainwashed!

Dairy has been suggested to cause more harm than good
* Consuming dairy at the recommended quantities raises health concerns. It has been linked to: 1-3
 Increased risk of cancers
 Increased autoimmune diseases
 Ear infections and allergies in children  Heart disease
 Diabetes

Answer 27

• In a 12-year Harvard study of 78,000 women, those who drank milk three times a day actually had higher risk of hip and forearm fractures than women who consumed one glass of milk or less per week. 4
• A 1994 study of elderly men and women in Sydney, showed that higher dairy product consumption was associated with increased fracture risk. Those with the highest dairy product consumption had approximately double the risk of hip fracture compared to those with the lowest consumption. 5
• The countries with the highest rates of osteoporosis (US, England, Sweden & Finland) are the ones where people drink the most milk and have the most calcium in their diets. 1-2
• “The connection between calcium consumption and bone health is actually very weak, and the connection between dairy consumption and bone health is almost nonexistent.” Amy Lanou1-2
• 27 out of 37 studies found no relationship between dairy or dietary calcium intake and measures of bone health.
• In those remaining, effects were very small.1-2

Bioavailability of dietary
calcium & calcium balance
* Whilst dairy is high in calcium, only approximately 30% of calcium is actually absorbed. The rest is excreted through the urine.1-3
* Calcium is more highly absorbed from beans and most greens (up to 60%) than from milk.1-3
* Factors affecting calcium absorption:
 Vit D is essential for Ca uptake.
(Milk in USA is supplemented with Vit D.)1-2
* Factors increasing excretion – Dairy is high in:
 Animal protein – acidifying =↑ ph =↑Ca
in urine
 Doubling protein intake produces 50% ↑ urinary Ca.
 Sodium - ↑ urinary Ca.1-2

Question 28

Iodine

The evidence currently available indicates an increased risk of ADHD in the offspring of mother with abnormal serum thyroid hormone concentrations during early pregnancy; ADHD has been described in cases of
1. hyperthyroidism
2. iodine deficiency
3. maternal hypothyroxinemia
4. mild thyroid-hormone insufficiency

Answer 28

Iodine supplementation to breastfeeding mothers is more effective than direct supplementation to the infant

Severe maternal hypothyroxinemia in early gestation has been consistently associated with offspring autistic symptoms

Question 29

The social cost of neurotoxicants

• The magnitude of IQ losses attributable to lead, pesticides, and other neurotoxicants was in the same range as, or even greater than, the losses associated with medical events such as preterm birth, traumatic brain injury, brain tumours, and congenital heart disease
• Loss of cognitive skills reduces children’s academic and economic attainments and has substantial long-term economic effects on societies.4
• Each loss of one IQ point has been estimated to decrease average lifetime earnings capacity by about €12 000 or US$18 000 in 2008 currencies.96
• The most recent estimates from the USA indicate that the annual costs of childhood lead poisoning are about US$50 billion and that the annual costs of methylmercury toxicity are roughly US$5 billion.97
• In the European Union, methylmercury exposure is estimated to cause a loss of about 600 000 IQ points every year, corresponding to an annual economic loss of close to €10 billion.
• In France alone, lead exposure is associated with IQ losses that correspond to annual costs that might exceed €20 billion

Answer 29

CONCLUSIONS AND RELEVANCE
In this study, maternal exposure to higher levels of fluoride during pregnancy was associated with lower IQ scores in children aged 3 to 4 years.
These findings indicate the possible need to reduce fluoride intake during pregnancy.

• Higher concentration of maternal urinary fluoride was associated with more ADHD-like symptoms in school-age children.
• Findings are consistent with the growing body of evidence suggesting neurotoxicity of early-life exposure to fluoride.

 The recent epidemiological results support the notion that elevated fluoride intake during early development can result in IQ deficits that may be considerable. Recognition of neurotoxic risks is necessary when determining the safety of fluoride-contaminated drinking water and fluoride uses for preventive dentistry purposes.

Question 30

DHA and the developing Brain

Answer 30

• Affects neurotransmitter pathways, synaptic transmission, and signal transduction.

Metabolites of DHA are bioactive molecules which protect tissues from oxidative injury and stress.

Question 31

The enviroment, toxins and organic food

In the past 50 years, tens of thousands of new chemicals have been synthesized, and millions of new chemical products have been released into children’s environments
* Currently >80,000 chemicals are registered for commercial use in the United States. (Landrigan, 2011)
Very few have been tested for their health effects

Answer 31

*Prioritize consumption of fresh or frozen fruits and vegetables *Avoid processed meats, especially maternal consumption during pregnancy.
*Avoid microwaving food or beverages (including infant formula and pumped human milk) in plastic, if possible.
*Avoid placing plastics in the dishwasher.
*Use alternatives to plastic, such as glass or stainless steel, when possible. *Look at the recycling code on the bottom of products to find the plastic type, and avoid plastics with recycling codes 3 (phthalates), 6 (styrene), and 7 (bisphenols) unless plastics are labeled “biobased” or “greenware ” * Encourage hand-washing before handling foods and/or drinks, and wash all fruits and vegetables that cannot be peeled

Question 32

Salicylates
For example, citrus fruit, berries, tomato sauce and mint flavouring.

Salicylates are natural chemicals made by plants. They are found in fruits and vegetables and help protect plants against disease and insects. Salicylate extracts have been used medicinally for thousands of years. Salicylic acid, more commonly known as aspirin, relieves pain and inflammation and lowers fevers.

Answer 32

1. Avoid the skin of fruits
2. Avoid processed foods
3. Avoid unripe fruit

Of the top five foods found to be most effective in inhibiting growth of cancer cells, the top four are low in salicylates (Brussels sprouts, cabbage, garlic and shallots or scallions)

Question 33

Nitrates, nitrites and nitrosamines

In 2015, the International Agency for Research on Cancer specifically classified processed meat (which includes meat that has been salted, cured, or otherwise altered to improve flavor and preservation) as “carcinogenic to humans”

and there is convincing evidence linking consumption of processed meats with colorectal cancer

High maternal intake of nitrite-cured meats has also been linked to an increased risk of childhood brain tumors in the offspring, especially tumors of the astroglia

Used in bacon, ham, corned beef, saveloys and hot dogs, devon, salami-type sausages and some luncheon rolls. Not permitted in organic foods.
Effects:
headaches, irritable bowel symptoms, itchy rashes, asthma, children’s behaviour problems, difficulty falling asleep and frequent night waking
(Fedup.com.au)
nitrates or nitrites cannot be used in food produced specifically for infants or young children

Answer 33

ya

Question 34

Pestisides are bad news

Chronic exposure in adults: (Forman, 2012)
 respiratory problems, memory disorders, dermatologic conditions, depression,
 neurologic deficits including Parkinson disease, miscarriages, birth defects, and cancer.

Prenatal exposure:
 adverse birth outcomes (decreased birth weight and length, smaller head circumference)  lower mental development index scores at 24 months of age
 attentional problems at 3.5 and 5 years of age

Link between insecticides, with acute lymphocytic leukemia and brain tumors

Question 35

Bisphenol A

Answer 35

Found in:
1. polycarbonate plastic
2. resin that is used as linings for most food and beverage cans
3. dental sealants (Von saal 2005)
4. toys, water supply pipes, medical tubing, and food container linings

Effects
1. Reduced fertility
2. altered timing of puberty
3. changes in mammary gland development
4. development of neoplasias
5. trigger the conversion of cells to adipocytes
6. disrupt pancreatic β-cell function in vivo
7. affect glucose transportation in adipocytes
* BPA exposure in utero has been associated with
1. adverse neurodevelopmental outcomes
2. decrements in fetal growth
3. childhood obesity
4. Low grade albuminuria

Question 36

Bisphenol S (BPS) - even worse than BPA

Answer 36

• In recent years, bisphenol analogues such as bisphenol S (BPS) have come to replace
  bisphenol A in food packaging and food containers
• Unfortunately, little or no research was done to determine the safety of these BPA-free products before they were marketed to the public as a healthier alternative.
• The latest studies have shown that some of these bisphenol analogues may be even more harmful than the original BPA in some situations.

1. It was found that BPS works via different pathways than BPA while causing equivalent obesogenic effects, such as activating preadipocytes, and that
2. BPS was correlated with metabolic disorders, such as gestational diabetes, that BPA was not correlated with.
3. BPS was also shown to be more toxic to the reproductive system than BPA and was shown to hormonally promote certain breast cancers at the same rate as BPA.
   * Therefore,astrongargumentmaybemadetoregulateBPSinexactlythesame manner as BPA.

Question 37

Mercury toxicity
* Mercury is a major neurotoxin that can affect development.
* It is third most common neurotoxin after lead and arsenic, and the most toxic

Advice regarding fish intake:

Answer 37

Classic triad:
1. erethism(bizarrebehavior,eg,excessiveshynessoraggression)
2. tremor
3. gingivitis.

Advice regarding fish intake
- women who might become pregnant, and who are pregnant, nursing mothers, and young children, do not consume fish such as shark, swordfish and tilefish, which generally contain high levels of mercury.
- However, they should consume fish (1 to 2 servings per week), that is low in methyl mercury content.

Question 38

Strategies to improve child’s eating behaviour

(Don’t use food to sooth a child- will make them fat)

Children tend to require up to 15 exposures of a new food before it is “trusted” and thus tasted and a further 10 to 15 exposures to bring about a liking of the food

Using food to soothe emotions and “make things better” has been found to be associated with increased BMI in 3– 34-month-old children and eating more food in the absence of hunger in 3- to 4- year-old children, behaviours that have been linked to becoming overweight

Question 39

Obesity

The five main areas of health affects:

Social/psych
Metabolic/systemic
Anatomic/orthopaedic
Degenerative
Neoplastic co-morbidities

MANAGEMENT:
DIETARY RECOMMENDATIONS

Answer 39

Social and psychological
* increase probability risk of:
- depression, suicide
- academicdifficulties,vocationallimitations,
- socialchallenges

Anatomic issues
Sleep apnoea occurs in 7% of obese children.
Other anatomic morbidities:
- GERD, GERD associated asthma
- pseudotumor cerebri, venous insufficiency
- venous thrombosis, skin infections and ulcers
- stress incontinence

Metabolic and systemic effects
1. Increased risk for glucose intolerance and Diabetes
2. Elevated levels of cholesterol and triglycerides
3. High blood pressure (Porter 2004).
High blood pressure linked to poor concentration and behaviour.
4. Fatty liver disease (nonalcoholic steatohepatitis
5. Gallstones
6. reproductive dysfunction
7. Nutritional deficiencies

Orthopaedic issues
➢ fractures, musculoskeletal discomfort, impaired mobility, and lower limb malalignment
➢ tibia vara (Blount’s disease or adolescent bowing of the legs) ➢ slipped capital femoral epiphyses. (from Tan 2010) ➢advancedboneage, tallerforage,usuallymatureearlier.
➢ Injuries are more common in obese children

Degenerative conditions
* axial arthritis
* vertebral disc disease
* spondylolisthesis
* left ventricular hypertrophy
* atherosclerotic cardiovascular disease * right-sided heart failure

Dietary Recommendations
MAIN CONCEPT: Educate parents and children on the benefits of a whole-foods diet, full of variety and organic, clean living
 Creating a new perspective on lifestyle will be more beneficial long-term than attempting a short-term “diet” to lose weight

Exercisewithoutdietcontrolordietwithoutincreased exercise almost always results in failure

Question 40

Supplements for neuro-development and function

• is a natural substance thought to inhibit the build up of certain amino acids in the body and enhance the immune response in children with ASD.
• It is a derivative of the amino acid, glycine.
• It is found in foods, such as beans, grains, and liver.
  May increase brain tissue oxygenation and energy transmission
  Start with 60mg/day and increase to 500 mg/day
• Use for autistic disorders, especially language (occ imp behaviours or sezuires
• 1-4 weeks to notice changes.
• rarely, dramatic imp within first day

Answer 40

beans, grains, liver

Question 41

Constipation

Is a reflex act in first year of life- Emptying of rectum depends on pressure receptors in rectal muscle filling up. If it doesn’t empty leads to drying of stool and failure to initiate reflex.

What is some differential diagnosis for constipation?

Answer 41

Any definition of constipation is relative, dependent on stool consistency, stool frequency, and difficulty in passing the stool.
 A normal child may have a soft stool only every 2nd or 3rd day without difficulty; this is not constipation.
 A hard stool passed with difficulty every 3rd day should be treated as constipation.
* Constipation may arise from defects either in filling or emptying the rectum

Differential diagnosis for constipation:
1. Intussusception

2. Mechanical:
    intestinal atresia,
    imperforate anus,  anal stenosis
3. Hirschsprungs (The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby’s colon)
    can be undetected in first 4 weeks
    some infants have less severe obstruction
    episodes of constipation, abdominal distention and vomiting
4. Anal fissures
   An anal fissure is a small tear in the thin, moist tissue (mucosa) that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. Anal fissures typically cause pain and bleeding with bowel movements.

Non organic
1. Spinal cord lesions, subluxation
(interference of spinal arc)
2. Voluntary inhibition – too busy, embarrassed, behavioural.
3. Diet:
 lack of roughage
 too much protein
 decreased water intake
 lack of fruit
 lack of vegetables
 too much processed foods

Question 42

What is Chiropractic management of Constipation?

Answer 42

Chiropractic management

Spinal subluxation

1. Most commonly sacral segment, particularly S2 and S3, along with entire sacral subluxations are involved
2. BAS and unilateral anterior sacral subluxations are usually associated with food allergies

Adjusting frequency needs to be aggressive over the first three to four weeks in children to establish pain free regular defecation

Infants may respond rapidly, however severe cases may take up to three months for subluxation stabilisation

• Restrict activities which impact on sacrum such as 1. Trampoline use
  2. Bouncing down stairs on bottom

If breastfed:
 address mother’s diet if breastfed
 remove all dairy and soy products for a trial three week period whilst adjusting

If formula fed:
 Constipation in the artificially fed infant may be caused by an insufficient amount of food or fluid.
 Simply increasing the amount of fluid
 Add brown sugar to the formula
 Need to change formula if bottle fed e.g. change to Goat’s milk formula , HA, Allerpro or prescription formula

Abdominal massage
Anal stimulation

Management goals
* Aim is to establish and maintain pain free bowel motions every one to two days in children
* Usually as a result of subluxation correction and dietary changes infants will have a bowel motion with every feed when breast fed or one to two daily if bottle fed without straining
* Use suppositories if three days between bowel motions in children – available from Chemist

Herbal options?
The older child or if infant is on solids
* Reduce fat or protein
* Increase“bulk”
* In the older infant, better results are obtained by adding or increasing the amounts of cereal, vegetables, and fruits.
* Eliminate dairy and soy or other allergens
* Prune juice
* Enemas and suppositories
* Milk of magnesia (doses of 1–2 tsp)
* ABO blood type diet
* Avoid processed foods
* Fruit – kiwi fruit has laxative effects (Rish, 2002)
* Vegetables
* Water.
* Vitamin C
* Vitamins e.g. - Folic Acid, B vitamins
* Minerals: e.g. calcium, iron, potassium, sodium, magnesium salts
* AloeVera(juiceconsumedorally)

Question 43

CMP and constipation
* ThetrialshowedthatremovalofCMP from the diet of children with Chronic Functional Constipation significantly increased the number of bowel motions and improved constipation, suggesting that CMP played a role in CFC for these children

• Allparticipantsinthisstudy experienced resolution (greater than 8 bowel motions per fortnight) of constipation on soy milk compared with the 68% that resolved on soy milk in the study by Iacono and colleagues

Supplements: Gut care for kids (metegenics)
Aloe vera juice (metegenics)

Answer 43

Paediatric constipation: An approach and evidence-based treatment regimen

• Constipation can be associated with food allergy, particularly to cow’s milk.
• A dietary history is essential and should include the mother if the child is still being breastfed.
• Cow’s milk protein can be found in breast milk, formula and dairy- containing solids.
• Allergy testing is not recommended to diagnose suspected cow’s milk allergy in children with constipation, as it is usually not IgE mediated.
• A one-month trial of avoiding cow’s milk and soy protein may be indicated in children with intractable constipation.
• Up to 50% of patients referred to a paediatrician for constipation will regain normal function and be off laxatives in six to 12 months

Question 44

The most common argument put forth in favour of milk consumption is that it is a good source of calcium that builds strong bones in young people and prevents osteoporosis in the elderly

What do you have to say about this?

Answer 44

• Clinicalresearchcontradictsthese claims.
• Instead,studiesofchildrenandadults reveal that exercise, reduced sodium, and reduced animal protein intake have significant positive effects on bone density.
• Consumingsubstantialamountsof fruits and vegetables, particularly kale, broccoli, other leafy greens, and beans will ensure calcium intake adequate to protect bones
• While extensive research underscores the exaggeration or falsity of milk’s health benefits, other studies establish a strong link between dairy consumption, particularly of saturated fats found in cheese and high-fat milk, and serious medical conditions, including
   increased risks of heart disease,  prostate cancer,
   pancreatic cancer,
   breast cancer,
   ovarian cancer,
   diabetes, and
   multiple sclerosis

Question 45

Encopresis
sometimes called fecal incontinence or soiling, is the repeated passing of stool (usually involuntarily) into clothing. Typically it happens when impacted stool collects in the colon and rectum: The colon becomes too full and liquid stool leaks around the retained stool, staining underwear.

Subtypes:
1. Encoparesis with constipation and overflow incontinence
2. Encoparesis without constipation and overflow incontinence

*
Can usually trace back to events in early toilet training that caused unpleasant or painful bowel motions.

Diagnosis
Encopresis and bacterial overgrowth
* Children with Fecal impaction (FI) and encopresis had a higher prevalence of small intestinal bacterial overgrowth (SIBO), elevated basal methane levels, higher methane production. (2010, Leiby)

 Retentive encopresis
 chronic constipation, fecal impaction, and overflow incontinence  65-95% of cases
 Nonretentive encopresis
 without constipation and overflow incontinence.

MANAGEMENT?
BEHAVIOURAL?

Dietary methods and other interventions?

Prognosis is not great as 30% Go on to develop constipation and related symptoms as an adult.

Answer 45

Correlations:
a) Constipation during infancy
b) Low muscle tone, and poor coordination
c) slow intestinal motility
d) atypical attention span
e) male gender.
f) oppositional and conduct disorders, obsessive-compulsive disorders, g) cognitive delays and learning disabilities.
Other risk factors:
1. high-fat diet
2. high intake of sugary fluids (such as soda pop, juices)
3. low intake of dietary fiber
4. low activity level
5. chronic and/or recurrent stress
6. specifically an unstable or unpredictable daily routine

MANAGEMENT:
Key areas of MX:
1. Acute treatment of bowel impaction 2. Nutritional changes.
3. Bowel training.
4. Behaviour management.
5. Family support. 6. Medications

Toilet sitting regimen: (Brooks,2000)
1. try, child sitting on toilet 10-15 minutes
after a meal
2. rewards for compliance
3. power struggles to be avoided.
4. keep records of BM, and soiling.
5. star charts

Dietary methods and other interventions
Use of high fiber diets, increase water
Eliminate dairy
Fiber
Increase fluids
Eliminate food that constipate:
 dairyproducts,bananas,caffeine-containingfoodsanddrinks,whiterice and white bread, and apple sauce or other products containing apple peelings.
Allergy and stool tests
Pro-biotics
Aloe vera
pawpaw cream for anal fissures

Question 46

CASE STUDY:

Chronicrecurrentdiarrhoeaoccurring8-9timesaday
* Runnypoorlyformedstools
* Mostlyunawareofbowelaction
* Constantnappyrash
* Nappyrequiredallday
* Noabdominalpain
* Bowelmotionscanaffectsleep
* Nomedicationused
* Nodietaryrestriction
* RecentlytestedforCoeliac’sandlactasedeficiencyvia biopsy
* CurrentlyunderPaediatricGastroenterologistatRCH

Prenatal history
* Steroids used during pregnancy due to previous premature delivery
* Otherwise unremarkable
Perinatal and neonatal history
* Born at 40 weeks gestation
* 4 hour labour
* No assistance required
* Spontaneous onset of labour
* Seizure at birth – small brain haemorrhage diagnosed
* Hirschsprung disease diagnosed at birth
disease is a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby’s colon

INFANCY:
Half large intestines removed at 5 months of age- IV Abs used
* Unwell due to bowel leak post surgery at 5 moa requiring IV Abs
* Repeat bowel operation at 6 months of age

EENT
* Grommets inserted at 18moa
* Adenoids removed at 18 months of age
* Approx 10 courses of anti-biotics regarding middle ear infections
* No recent ear problems

GI:
* Given 10 day course of anti-biotics 6 months ago regarding diarrhoea
* Significant improvement in bowel function noted
* Anti-biotics repeated 4 weeks later with moderate
* Anti-biotics repeated 4 weeks later with minor improvement noted

Gross motor
* Walked 22 months of age
* Crawled normally prior to walking
* No concerns regarding balance
* No concerns regarding co-ordination

EXAMINATION:
* Abdominal
 Liver 7 cm ( normal 4.2 cm)
 Spleen palpable 2 cm below left margin (abnormal)
* Oral – unremarkable

Neurological:
* Neurological
 Upper and lower extremity muscle stretch
reflexes all graded +3
 Cranial nerves unremarkable
 Scapulohumeral reflex negative neutral, positive on right in right rotation, flexion and left lateral flexion

Motionpalpation–
 decreased S3 flexion – PI S3
 decreased upper cervical right lateral flexion and left rotation – AIRP C1

Whats working diagnosis?
Ie subluxations present?

Issues
* Gastroenterologisthasputthediarrhoeadowntobeingaresultofthelargebowelresection Is this correct?
What is the key fact from the history which suggests this is incorrect?
Response to anti-biotics indicates bowel flora is important factor regarding the diarrhoea

How would you manage?

Answer 46

Working Diagnosis
* PIS3subluxationcomplex
* AIRPC1subluxationcomplex

Chiropractic Management:
Referral for stool analysis

Course of weekly chiropractic adjustments over period of 4 to 6 weeks.

Supplement with probiotics

Treatment of large bowel amoebiasis: wormer- worms/ parasite made use of weak intestinal flora due to AB.

• Patient having 2-3 formed bowel motions per day after 4 adjustments
• Continue chiropractic visits and adjustments as required every 1- 2 weeks
• Repeat stool test after three months treatment
• A patient can have a number of interrelated diagnoses
   Dysbiosis as a result of anti-biotic treatment  Hirschsprung disease
   Subluxation
• Viscero-somaticreflexeswillresultinrecurrentsubluxationsuntilgut environment is normal
• A comprehensive case history will usually give you the answers

DDX:
Post infectious sec. lactase deficiency Irr. Bowel syndrome
Celiac disease
Lactose intolerance
Excessive fruit juice Giardiasis
Inflammatory bowel disease

Question 47

Why must we be careful that a child is not constipated for long?

Answer 47

Stasis allows proliferation of bacteria, which may lead to enterocolitis ( Clostridium difficile, Staphylococcus aureus, anaerobes, coliforms) with associated sepsis and signs of bowel obstruction.

• Early recognition of Hirschsprung disease before the onset of enterocolitis is essential in reducing morbidity and mortality.

Question 48

Abdominal Pain in Children

Appendicitis- what can cause it?

How does it present?

How would you examine it?

Answer 48

• begins with luminal obstruction; inspissated fecal material, lymphoid hyperplasia, ingested foreign body, parasites, and tumors have been implicated.
• the final common pathway of which involves invasion of the appendiceal wall by bacteria.
• more common in developed countries with refined, low-fiber diets than in developing countries

How does it present?

1. The illness typically begins insidiously with generalized malaise and anorexia
   escalates rapidly with abdominal pain followed by vomiting
2. often the first symptom and begins shortly (hours) after the onset of illness.
3. initially vague, unrelated to activity or position, often colicky, and periumbilical in location

Next 12-24 hr leads to involvement of the adjacent parietal peritoneal surfaces
 somatic pain localized to the RLQ
 pain more steady and more severe and is exacerbated by movement.

Nausea and vomiting
- in more than half
- follows pain by several hours

In appendicitis:
- abdominal pain is constant (not cramping or relieved by defecation),
- emesis may become bile stained and persistent
- clinical course worsens rather than improves over time. - pain precedes vomiting
* Fever is typically low-grade unless perforation has occurred.
* Most patients demonstrate at least mild tachycardia.
* If the appendix is retrocecal, the pain will be lateral or posterior and may mimic the symptoms associated with septic arthritis of the hip or psoas abscess.

EXAMINATION:
Palpation:
 Localized abdominal tenderness is the single most reliable finding.  McBurney’s point
 rigidity of the overlying rectus muscle.

Rebound tenderness
 finger percussion better for diagnosis of peritonitis
Psoas sign
 typically positive in cases of a retrocecal appendix

Perforation: * rates as high as 82% for children<5yr and approaching100% in infants.
DDX: Intussusception, UTI