Nutrition Flashcards
What are the normal length/height increases in children
- Infant Length ○ 2.5 cm/month x 6 months ○ 1.3 cm/month 7 mon - 1 yr - Toddler ○ 7.6 cm/yr till 10 years - Teenage Boys ○ Greater than 10 cm/year peak velocity - Teenage Girls 9 cm/yr of peak velocity
What is the normal weight gain in children
- Birth 0 - 3 months ○ 25-35 g/day - 3-6 mon ○ 15 - 21g/day - 6 - 12 month ○ 10 - 13 g/day - Triple weight by first birth day - Quadruple weight by 2 yrs - 2 yr - adolescence ○ Increase ~ 2 kg/yr - Adolescence ○ Peak weight velocity = 3 kg/6 month
List different ways to measure body composition (6)
○ Bioelectrical impendence analysis ○ Total body potassium ○ Isotope dilution ○ Hydrodensitometry ○ Dual-energy x-ray absorptiometry Hand dynamometry
What are clinical determinants for initiating nutrition assessment (7)
- Height < 10% for age
- Weight for Age < 3rd or 5th % on CDC/WHO growth
curve - Weight for Height/length < 3rd or 5th % on
CDC/WHO curve - Change in > than 2 SD on growth curve over 3 -6
month period - Greater than 5% weight loss from usual body
weight
-BMI > 85th %ile, with at least 1 parent who is
overweight or obese
- Weight for Age < 3rd or 5th % on CDC/WHO growth
Indications for PN: (6)
○ Compromised gut integrity (resection, high-output fistula, complete obstruction, paralytic ileus or ischemia)
○ Malabsoprtion
○ Severe short bowel syndrome
○ Intractable vomiting or diarrhea
○ Inability to obtain enteral access
Can break into
1. Primary (gut failure, NEC, severe motility disorders, inability to obtain enteral access)
2. Supportive (post op pts, burns, liver failure, renal failure, severe viral gastro, oncology and BMT pts, IBD, trauma)
3. Supplemental (Nutritional failure, feeding intolerance)
Signs of Essential Fatty Acid Deficiency (EFAD) (6)
- Growth failure
- Flaky dry skin
- Alopecia
- Thrombocytopenia
- Increased infections
- Impaired wound healing
Symptoms of Copper Deficiency
- Anemia
- Neutropenia
Hypercholesterolemia
- Osteopenia
-Pigmentary changes in hair
-Neurological abnormalities
-brittle/kinky hair
-diarrhea
Clinical symptoms of Vit E deficiency
- neuropathy- spinaocerebellar syndrome, ataxia, hyporeflexia, loss of proprioceptive and vibratory sensation
- skeletal myopathy
- pigment retinopathy
- brown bowel syndrome (intestinal lipofuscinosis)
- hemolytic anemia (in prems)
- congenital hemolytic disorders may be associated with vit E plasma levels - increased oxidative stress and antioxidant consumption
Where are water-soluble vitamins absorbed?
-Proximal jejunum except for vit B12 (TI)
How do you interpret MMA levels
- MMA necessarily for human metabolism and energy production
- Vit B12 promotes methylmalonyl CoA to succinyl Coenzyme A
- if low B12 - MMA conc rise in blood and urine
- MMA levels may rise before anemia and neuropathy
- because B12 bound to proteins and not biologically active - MMA may be better measure of bioavailable B12
- High MMA in neonates = may suggest methylmalonic acidemia
9 Trace minerals required for humans
- Iron
- Iodine
- Zinc
- Copper
- Chromium
- Manganese
- Selenium
- Colbat
- Molybdenum
Fat Soluble Vitamins
- Vit A (retinol and B-carotenes)
- Vit D (cholecalciferol)
- Vit K (phylloquinones and menaquinones)
- Vit E (tocopherols)
Water Soluble Vitamins - Non-B-Complex
-Ascorbic acid (vit C)
Water Soluble Vitamins -
B-Complex
Energy Releasing:
- Thiamine (Vit B1)
- Riboflavin (Vit B2)
- Niacin (Vit B3)
- Pantothenic acid (Vit B5)
- Biotin (Vit B7)
Hematopoietic:
- Folic Acid (B9)
- Vit B1 type 2
Other:
- Pyridoxine (Vit B6)
- Pyridoxal
- Pyridoxamine
Vit A
- Absorption
- Dietary Source
- Function (4)
- Assessment
Absorption - Upper SI
Dietary source - green leafy veg, carrots, liver, fish oil, kidney, dairy projects, eggs
Function:
- Retinal for low light and coloured vision
- Carbohydrate transfer to glycoprotein
- Epithelial integrity
- Cell proliferation
Assessment
- Serum retinol
- Serum-retinal binding protein
Vit A Toxicity (8)
- Alopecia
- Ataxia
- Muscle and bone pain
- Cheilitis
- Conjunctivitis
- Headache
- Hepatotoxicity/cirrhosis
- Hyperlipidemia
Vit A Deficiency (4)
- Night blindness
- Xerophthalmia - dryness of conjunctiva and cornia
- Bitot’s spots - build up of keritin on conjnctiva
- keratomalacia - dry eyes
Vitamin D:
- Absorption
- Dietary source:
- Function
- Assessment of Status
Absorption - Duodenum and distal SI
Dietary source: fortified milk, liver, oils, sunlight, egg yolk
Function:
- regulates Ca2+ and P levels through absorption and renal excretion
- Bone mobilization
Assessment:
- Serum 25OH Vit D
- Serum PTH
Vitamin D Deficiency
-Causes - fat malabsorption, breast feeding w/o supplements
- Rickets/osteomalacia
- Dental caries
- Hypocalcemia/hypophosphatemia
- Increased ALP, phosphaturia, aminoaciduria
Vitamin D Toxicity
- Hypercalcemia - N/V, weakness, fatigue, diarrhea, anorexia, headache, confusion, pyschosis and/or tremor
- hypercalcuria
Vitamin E
- Absorption
- Dietary Source
- Function
- Assessment of Status
Absorption - Non-saturable passive diffusion in jejunum
Dietary Source- oil-containing grains, plants and vegetables
Function
- Cell membrane antioxidant
- Free radical scavenger
- Inhibits polyunsaturated fatty acid oxidation
Status - Alpha-tocopherol
Vitamin E Deficiency
Causes- fat malabsorption, chronic Abx therapy
- coagulation/increased PTT
- abnormal bone matrix synthesis
Vitamin E Toxicity
- Impaired neutrophil function
- Coagulopathy
- Thrombocytopenia
- Cerebral hemorrhage
Vit B12 Steps for Absorption
i. Oral ingestion of B12 from diet: liver, kidney, beef, fish, milk, eggs
1. B12 is released from dietary proteins through mastication
ii. Stomach
1. Gastric acid releases B12 from dietary proteins
2. Salivary R protein (haptocorrin) binds free B12 (in mouth and in stomach at acidic pH)
3. Gastric Parietal cell secretion of IF
iii. Duodenum
1. Pancreatic proteases (Trypsin) hydrolyzes B12 from salivary R protein
2. B12 binds IF (from parietal cells)
iv. Ileum
1. IF-B12 complex binds cubulin-amnionless complex receptor on enterocyte
2. Receptor-mediated endocytosis and fusion with lysosomes,
3. Lysosomal degradation of complex releases B12 and it is packaged with transcobalmin inside ileal cell
v. Enterohepatic circulation
1. Transverse basolateral membrane enters portal circulation
Reasons for Vit B12 Deficiency other than lack of intrinsic factor
- Xerostomia (lack of R protein production)
- ileal resection (area where B12 is absorbed)
- ileal inflammation (UC or Crohns which would decrease the number of cobalamin receptors)
- atrophic gastritis (lack of acidic pH for binding to R factor)
- gastrectomy (cobalamin cannot bind Rfactor)
- Pancreatic insufficiency (low pH so IF cannot bind)
- Decreased intake in the diet-Vegan
- Small bowel overgrowth (bacteria use up vit B12)
- Celiac
- genetic mutation lacking cubulin amnionless receptor
Nutritional Deficiencies in pts with extensive ileal resection/SBS
- Vit D (abs at duodenum and ileum, but poor digestion from lack of bile acids)
- Vit A (abs at jejunum, but poor digestion from lack of bile acids)
- Vit E (abs at jejunum, but poor digestion from lack of bile acids)
- B12
- fats specifically long chain fatty acids
- (essential fatty acid deficiency)
- Ca (as a consequence of fat malabsorption)
- Mg as a consequence of fat malabsorption (Mg abs in jejunum and ileum)
- trace elements like iron, zinc, and selenium occur with increased fecal losses
Prevention of Refeeding Syndrome
Start low and slow: ie not more than 15-20 cal/kg or around what patient is currently on
Supplement Phosphorus
Supplement K
Supplement with a multivitamin (including thiamine)
Not more than 100g carbs
Monitor daily lytes
Avoid IV fluids / TPN
Managing Refeeding Syndrome nutrients
Intake of glucose represses gluconeogenesis, which may result in hyperglycemia, osmotic diuresis and dehydration
Limit initial feeding in terms of volume and energy content to provide around 75% of requirements in severe cases <7 yr - 60kcal/kg/day 7-10yr - 50 kcal/kg/day 11-14 yr - 44kcal/kg/day 15-18 yr - 40 kcal/kg/day
use energy density of 1kcal/mL to minimize fluid load
Na 1 mmol/kg/day
K 4 mmol/kg/day
Mg 0.6 mmol/kg/day
PO4 1 mmol/kg/dayIV and up to 100 mmol/kg/day orally in children > 5 yr
Thiamine, riboflavin, folic acid, ascorbic acid, pyroidoxine and FSV must be supplemented
GIR recommendations
Infants: 8 – 12 mg/kg/min (max 12.5 mg/kg/min)
Toddlers: 7 mg/kg/min
Adolescents: 4 mg/kg/min
Avoid excessive protein in initial refeeding phase
Acidosis, azotaemia, hypertonic dehydration, hypernatraemia
Infants: 0.5 – 1 g/kg/day Rehabilitation 1.2-1.5 – 2.0-2.5g/kg/day Children: 0.6 – 1 g/kg/day Rehabilitation 1 – 7 yrs = 1.2 – 1.5g/kg/day 8 – 18 yr = 0.8 – 1 g/kg/day
Parenteral lipid intake should not exceed
Infants: 3 – 4 g/kg/day
Older infants: 2 – 3 g/kg/day
Close monitoring for Daily body weight Daily u/o Optimization of fluid balance Vitals Glucose, lytes (Na, K, U, Cr, PO4, Mg, Ca), albumin, protein, Liver Enzymes, CBC
Causes of Thiamine deficiency outside of ETOH
Thiamine is absorbed in the jejunum:
-Severe malnutrition and refeeding (anorexia nervosa)
-In undeveloped countries risk of infantile beriberi since mother’s diet consists of mostly rice
(deificient in thiamine) and breastmilk will thus be deficient.
-Inflammation of the jejunum (crohns)
-Small bowel resection
-Long term TPN (when thiamine is not added)
Clinical Manifestations of Thiamine deficiency
-Calf tenderness
-hyporeflexia
-severe lethargy
-irritability
-restlessness
(think Ber1 ber1 to remember that is is vit B1)
Wet Beriberi: cardiac involvement (dilated cardiomyopathy, cardiac failure)
Dry Beriberi: primarily nerve damage, Wernicke encephalopathy, Korsakoff psychosis, parenthesis, weakness, ophthalmoplegia, nystagmus
How does MTX result in folate deficiency
MTX: inhibits the enzyme dihydrofolate reductase and therefore depletes the folic acid pool
What is the Pr, CHO and Fat sources for Neocate
Protein : 100% AA
Fat: 5% MCT 95% LCT, safflower oil, coconut soy
CHO: corn syrup
What is the Pr, CHO and Fat sources for Alimentum
Protein: casein hydrolysate
Fat: 33% MCT, safflower oil, soy oil
CHO: lactose free, corn free, sucrose modified tapioca, starch
What is the Pr, CHO and Fat sources for Pregestimil
Protein: casein hydrolysate
Fat: 55% MCT, corn oil, safflower oil, soy oil
CHO: corn syrup, gluten/lactose/galactose free
Trace elements in PN?
- Iron
- Zinc
- Copper
- Chromium
- Iodine
- Manganese
- Selenium
Signs of Ca deficiency
- osteomalacia
- tetany
- arrhythmias
Signs of Magnesium deficiency
- weakness
- twitching
- teatny
- arrhythmias
- hypocalcemia
Signs of Zinc deficiency
- growth retardation
- delayed sexual maturation
- hypogonadism
- alopecia
- acro-orificial skin lesions
- diarrhea
- mental status change
- abnormalities of the immune system
- poor wound healing
Signs of Phosphorus deficiency
- weakness
- fatigue
- leukocyte and plt dysfunction
- hemolytic anemia
- cardiac failure
- decreased oxygenation
Signs of Chromium deficiency
- glucose intolerance
- peripheral neuropathy
- encephalopathy