Nutrition Flashcards
What organism is known to cause disease outbreaks with regards to powdered formula?
Cronobacter sakazaii
previously Enterobacter sakazakii
What are some medical indications for providing artificial nutrition/hydration?
- neurological impairment leading to inability to feed orally and / or risk of aspiration
- malnutrition due to inadequate intake or increased caloric requirements
- malabsorption due to intestinal disease or short gut syndrome
- support of chronic diseases such as cancer or congenital heart disease
What are some beneficial elements within breastmilk?
- Secretory IgA
- Lactoferrin: immunomodulation, iron chelation, antimicrobial action, antiadhesive, trophic for intestinal growth
- κ-Casein: Antiadhesive, bacterial flora
- Oligosaccharides: Prevention of bacterial attachment
- Cytokines: Antiinflammatory
- Growth factors i.e. Epidermal, transforming, nerve
- Enzymes: platelet-activating factor, glutathione peroxidase
In what instances is breastfeeding contraindicated?
- HIV infection in a high resource setting
- Brucellosis infection
- HTLV-1 or HTLV-2 infection
- Infant galactosemia
- the mother is on chemotherapy or radiopharmaceuticals
- If the mother and child are on quinine containing medications and are G6PD deficient
- Active TB without at least 2 weeks of medication
What is the nutritional density of breast milk?
20 kcal/oz
What is the nutritional difference between cow’s milk and human milk?
Human milk has more whey as compared to cow’s milk which has more protein (too much for young infants)
Type of whey is also different, α-lactalbumin vs β-globulin in cow’s milk
What micronutrients are missing or deficient in human milk?
Vitamin K and Vitamin D
Calcium and phosphorus levels are relatively low, but more bioavailable
Iron, zinc and copper are adequate only up to 6 months of age
What are some of the benefits of breastfeeding for baby and for mom?
- reduced instance of SIDS
- reduces rate of AOM, pneumonia, meningitis, diarrhea
- reduces rate of breast and ovarian cancer for mom
- improves bonding between mother and child
- reduces stress in mother and baby
- decreases rate of GERD
- stimulates intestinal growth
- improves cognitive functioning
- helps with post-conception weight loss
How does breastmilk differ when a baby is born preterm rather than full term?
Preterm breastmilk contains more protein, lipids, sodium and free amino acids than it does with a term baby
In what time frame should formula be used?
Ready made: within 48 hours of opening
- within 2 hours of removing from the fridge
- within 1 hour of starting feed
Powered preparations: should be used within 4 weeks
What type of formula is contraindicated in patients with thyroid disease?
Soy formulas (as the phytoestrogens can inhibit thyroid peroxidase)
In what ways does the CPS suggest Paediatricians help improve nutrition in schools?
RIPE
- Restrict on-site access to sugar-sweetened beverages and energy-dense, low-nutrient foods and beverages.
- Increase children’s consumption of nutrient-rich foods via targeted on-site programs.
- Promote healthier food choices as part of the regular curriculum
- Establish a nutrition committee in every school or school board.
What are the top 5 dietary sources of sodium as per CPS?
- Bakery products
- Mixed dishes (anything from 2 or more groups in Canada’s food guide)
- Processed meats
- Cheese
- Soups
What strategies should be used to reduce sodium intake in children?
LLC
Labeling - clearly label foods and flag those known to have more sodium
Limit it - petition manufacturers to reduce general sodium content
Cut down - reduce childhood exposures/choices to high sodium foods
What does the CPS suggest with regards to sugar sweetened beverages?
- Encourage increased taxes to reduce incentives for consumption/purchasing
- Tax revenue can then be used for educational programs and subsidizing fresh fruit and vegetables
- Monitoring should be done to identify the effects of such a tax on rates of obesity, hypertension, diabetes and dental caries
Which enzyme deficiency cannot be identified via stool reducing substances?
Sucrase-isomaltase (as sucrose is a non-reducing sugar)
Which enzyme deficiency cannot be treated via enzyme replacement?
Glucose/galactose malabsorption - only carbohydrate that can be given safely in this instance is fructose
Name 4 conditions with exocrine pancreatic insufficiency
- Cystic fibrosis
- Shwachman- Diamond
- Pearson Bone Syndrome
- Autoimmune polyendocrinopathy syndrome type 1
• Johanson-Blizzard
At what age should birth weight be regained? Doubled? Tripled?
2 weeks
4 months
12 months
Name 3 conditions associated with growth hormone deficiency
- Hall-Pallister syndrome
- Septo-optic dysplasia
- Holoprosencephaly
What nutrients is goat’s milk deficient in?
- FOLATE
- vitamin B12
- vitamin D
- iron
What are some potential causes of folate deficiency?
- Inadequate intake/diet
- Medication i.e. phenytoin
- Poor absorption
- Congenital dihydrofolate reductase deficiency
How much folate does the CPS recommend for women of childbearing age?
- 0.4-0.8 mg of folic acid per day
- For women who are at higher risk should take between 0.8 - 4.0 mg of folic acid (up to 5.0 mg)
- This should be done for at least 3 weeks prior to conception and continued 10-12 weeks postconception
Higher risk: i.e. previous pregnancy with NTD, family hx of NTD, higher risk ethnic group, insulin-dependent diabetes, obesity, sz medications, difficulty with compliance, addiction to EtOH or drugs
What is the treatment dose for folate deficiency?
0.5-1 mg PO daily
Name 6 risk factors for developing iron deficiency
- Preterm delivery - low iron stores at birth
- Birth weight <2500 g - low iron stores at birth
- Low SES, particularly Indigenous communities (10x higher)
- Infants born to mothers with anemia or obesity
- Early umbilical cord clamping
- Male sex
- Exclusive breastfeeding > 6 months
- High cow’s milk intake
- Prolonged bottle use
- Chronic infection
- Lead exposure
- Low dietary intake of iron-rich complementary foods
How much iron is required for preterm infants?
- <2000 g: 2-3 mg/kg/day, until 12 months of age
- 2000-2500 g: 1-2 mg/kg/day, until 6 months of age
*Start routine supplementation at 2-6 weeks of age if predominantly breastfeeding
How much iron is needed to treat iron deficiency anemia?
3-6 mg/kg/day of elemental iron for at least 3 months
What are the characteristics of Marasmus?
THIN and SKINNY
- protein-energy malnutrition AND inadequate calories
- characterized by severe wasting
- most common form of protein-energy malnutrition
What are the features of Kwashiorkor?
ROUND LIKE AN “O”
• insufficient protein consumption, characterized by peripheral pitting edema
• marked muscle atrophy, normal body fat
• dull reddish orange/rust coloured hair and skin
•
What is the WHO framework for treatment of malnutrition?
- Acute stabilization (treat hypoglycemia, hypothermia, dehydration)
- Ongoing stabilization (correct electrolyte imbalance, prevent infection, correct micronutrient deficiencies and start cautious feeding)
- Rehabilitation phase (achieve catch up growth)
- Prevention (improve water, sanitation and hygiene)
What are risk factors for obesity?
- parents who are obese
- type 2 diabetes
- high preconceptual weight
- maternal smoking
- IUGR and catch up growth
- ethnicity (Black > Hispanic > Native > White)
- poor temperament
- poor socioeconomic status
How does the CPS define overweight/obese children (2-5, 5-18 years)?
BMI of:
At risk: >85th %ile, N/A
Overweight: >97th %ile, >85th %ile
Obese: >99.9th %ile, >97th %ile
What are the CPS guidelines for oral fluid replacement in case of uncomplicated GI losses?
- mild dehydration (<5%): replace with 50 mL/kg over the first 4 hours, as well as ongoing losses
- moderate dehydration (<5-10%): replace with 100 mL/kg over the first 4 hours, as well as ongoing losses
- severe dehydration (>10%): replace with IV fluids (20-40 mL/kg/hr)
What screening test should be done for suspected protein-losing enteropathy?
• stool alpha-1-antitrypsin
What diet should be recommended for a child with protein-losing enteropathy?
• diet high in protein with medium chain or short chain fatty acids
What micronutrients are absorped in the various parts of the GI tract?
- Duodenum and proximal jejunum
- Throughout small intestine
- Distal ileum
- Colon
- Duodenum and proximal jejunum: Ca, Mg, P, Fe, folic acid
- Throughout small intestine: MCT and fatty acids
- Distal ileum: Vitamin B12
- Colon: water, electrolytes
What nutritional considerations does CPS advise for paediatric atheletes?
• Athletes should consume proper amounts of calcium (1000-1300 mg/day), vitamin D (600 IU/day) and iron
(8-11/15 mg/day; more for females)
• Fluids
- Before activity: 400-600 mL of cold water 2-3 hours before their event
- During activities: 150-300 mL every 15-20 mins
- After activity: 1.5 L of fluid/kg of body weight lost
- Also eat sodium containing snacks to help stimulate thirst and increase water retention
For non-athletes, routine ingestions of carbohydrate-containing sports drinks can result in consumption of excessive calories, increasing the risk of obesity and dental caries
What recommendations should be made regarding caffeine?
- caffeinated drinks should not be marketed routinely to children
- max daily allowance 400 mg/L (1/2 of cup of coffee)
What are some preventative strategies that can be taken to reduce the risk of dental caries in Canada?
- Prevention of inappropriate infant feeding practices (i.e. Prolonged or frequent bottle-feeding or juice consumption)
- Water fluoridation
- Evidence-based guidelines recommend a biannual varnish application regimen for high-risk populations
- Regular use of fluoride mouth rinses have been shown to reduce tooth decay in older children
What are the 3 main effects of fluoride on teeth?
- Inhibits plaque - may kill/inhibit bacteria and makes them less able to produce acid from carbohydrates
- Inhibits demineralization - fluoride is incorporated into crystals on the tooth surface, making the surface more resistant to acid
- Enhances speed of remineralization of enamel
How much fluoride should be provided for dental health?
If living in a place with water fluoridated >0.3 ppm, none.
If water is not fluoridated, offer:
- none if <6 months
- 0.25 mg if 6 months to 3 years
- 0.5 mg if 3-6 years
- 1.0 mg if >6 years
What are some potential complications of gastro/gastrojejunal feeding tubes?
- obstruction
- dislodgement
- displacement/migration
- advancement
- granulation tissue
- tenderness/pain
What deficiencies are vegans/vegetarians at greater risk for?
Vitamin B12, iron, vitamin D, zinc and fatty acids
What food sources should be suggested to vegans/vegetarians?
- Vitamin B12: plants not a good source (almost exclusively obtained through animal foods), vegans will need fortified foods and supplements
- Iron: cashews, kidney beans, black beans, lentils, oatmeal, raisins, soybeans, sunflower seeds, chickpeas, molasses, chocolate and tempeh
- Fatty acids: walnuts, soy products, flaxseed and canola oils
- Calcium and vitamin D: leafy greens (ideally with low oxalate like broccoli, kale or Chinese cabbage), soy milk, almond milk, fortified orange juice
- Zinc: soy products, legumes, grains and nuts
What are the characteristic signs of vitamin A deficiency?
• Most characteristic and specific signs:
○ Delayed dark adaptation, night blindness, photophobia
○ Corneal and conjunctival epithelial tissues keratinize and become opaque, forming dry, scaly layers of cells (xerophthalmia) forming plaques
○ Bitot spots –> triangular pearly white or yellowish foamy spots on bulbar conjunctiva
- General: FTT, diarrhea, repeat infections, apathy, mental retardation, wide separation of cranial bones at the sutures
- Hyperkeratotic patches on the arms, legs, shoulders and buttocks
- Pyuria and hematuria
What are the signs of hypervitamosis A?
- Fatigue
- Hair loss
- Arthralgia
- Increased intracranial pressure
- Carotenemia (reversible orange colour of the skin)
What deficiency mimicks that of Beriberi?
Thiamine (vitamin B1)
What are the signs of thiamine deficiency?
- Fatigue, apathy, irritability
- Depression
- Drowsiness
- Poor mental concentration
- Anorexia, nausea and abdominal discomfort
- Peripheral neuritis (tingling, burning, paresthesias of the toes and feet, decreased DTR, loss of vibration sense, tenderness and cramping of the leg muscles)
- Heart failure, prolonged QT interval, inverted T waves, low voltage
- Ptosis of the eyelids and atrophy of the optic nerve
- Paralysis of the laryngeal nerve –> aphonia, hoarse voice
- Muscle atrophy, ataxia
- Wernicke encephalopathy (rare)
What are the signs of riboflavin deficiency?
Pellegra
- Dermatitis
□ May be initiated by irritants, i.e. intense sunlight
□ Symmetric, sharply demarcated areas of erythema on exposed surfaces, resembling sunburn i.e. caudal necklace
□ May have glove and stocking appearance (distribution changes)
- Diarrhea
- Dementia: other CNS symptoms - depression, disorientation, insomnia, delirium
What foodstuffs are rich in riboflavin?
Anything with tryptophan!
Meat, fish, poultry, cereals, legumes, green leafy vegetables, milk and eggs
Which vitamin deficiency can lead to listlessness, irritability, seizures, vomiting, FTT?
Vitamin B6 (pyridoxine)
Children taking which medications should also consider supplementing their vitamin B6 intake?
Isoniazid, penicillamine, corticosteroids, phenytoin, carbamazepine
What children are at greater risk of developing vitamin B12 deficiency?
- Those with illnesses affecting absorption at the terminal ileum i.e. Crohn’s disease, short gut syndrome, Celiac disease, any resection
- Pernicious anemia
- Vegans/vegetarians
- those with tapeworms
What are the signs/symptoms of vitamin B12 deficiency?
- Neurologic: parasthesias, impaired vibration sense, ataxia, developmental regression, neurophyschiatric changes, weakness, fatigue
- Hematologic: megaloblastic anemia, pallor
- GI: diarrhea/vomiting
What are the clinical characteristics of vitamin C deficiency (scruvy)?
Think issues with collage synthesis and iron transport
- bleeding and swelling of mucous membranes
- MSK pain
- swelling at knees and ankles
- pseudoparalysis
- subperiosteal hemorrhages
- petechiae and ecchymoses
- General: irritability, fatigue, loss of appetite, low-grade fever
What are the classic signs of Vitamin D deficiency (rickets)?
- craniotabes (“ping pong” skull)
- windswept deformity (valgus/varus deformity)
- flaring of epiphyses
- rachetic “rosary bead” appearance to ribs
- frontal bossing
- signs of hypocalcemia i.e. seizures
What investigations should be ordered for a child with suspected rickets?
- serum Ca (ionized and non-ionized)
- serum phosphate
- PTH
- vitamin D (1,25 hydroxy and 25-hydroxy forms)
- alkaline phosphotase
- creatinine
- standard electrolytes
Which deficiency presents with limb and truncal ataxia, absence/loss of DTR, dysarthria, nystagmus, positive Romberg, poor proprioception/vibratory sense and blindness?
Vitamin E deficiency
Why are preterm infants at greater risk for vitamin E deficiency?
Transfer and stores occur primarily during the last trimester of development
Why are newborns predisposed to vitamin K deficiency?
○ Minimal transplacental passage
○ Limited hepatic storage in the newborn period
○ Low concentration of vitamin K in the breast milk
○ Absence of bacterial intestinal flora to synthesize K2
What is the recommended dose of vitamin K?
Within first 6 hours post-natally
- IM injection x 1
- 0.5 mg if <1500 g
- 1.0 mg if >1500 g
- if family declines, advise re: risks
- if still declines offer 2 mg PO, and repeat at 2-4 weeks and at 6-8 weeks
What are the characteristic features of zinc deficiency?
- symmetrical perioral, perianal and acral rash
- failure to thrive
- reddish/brown hair
- chronic diarrhea
- poor wound healing with yeast superinfection
- conjunctivitis and corneal dystrophy
