Nutrition and Gastroenterology Groups Flashcards
Updated 01/04/2024
How does pasteurization effect the following nutritional components of donated breast milk ?
- Carbohydrates, Protein and Fats
- Inorganic Salt (e.g. Na, K, Cl, Mg, Ca, etc.)
- Fat Soluble Vitamins (K, A, D, E)
- Water Soluble Vitamins
- Beneficial Immune Cells
- Immunoglobulins (IgA, IgM, IgG)
- Lactoferrin and Lysozyme (antibacterial proteins)
- Commensal (or pathogenic) bacteria
- CMV, EBV, HBV, HCV, HIV
- Carbohydrates, Fats, Inorganic Salts = Preserved
- Protein = Declines 13 %
- Fat Soluble Vitamins = Preserved
- H2O Soluble Vitamins = Mild drop of B6, B12 Preserved
- Beneficial Immune Cells = 100 % deactivation
- IgA is 67-100%, IgM is 0% and IgG is 70 % active
- Lactoferrin = 80 % active
- Lysozyme = 75 % active
- CMV, EBV, HBV*, HCV*, HIV* = Denatured
- Commensal (or pathogenic) bacteria = KILLED**
*These viruses are screened for prior to pasteurization, if found = sample discarded. **Some spore forming bacterial pathogens can survive pasteurization, if found in any cx the samples are discarded.
Give 4 conditions being overweight and/or obese predispose a child, and subsequently young adult to ?
- Non-alcoholic Fatty Liver Disease (NAFLD)
- Coronary Artery Disease (CAD) and Stroke risk factors
- Hypertension
- Type 2 Diabetes Mellitus
- Dyslipidemia
- Obstructive sleep apnea
- Osteoarthritis
- Several Cancer (e.g. colorectal, estrogen dependants)
What modalities can determine nutritional status in Neurologically Impaired children, where simple growth chart following is difficult ?
- Dual Eneregy X-ray Adsorption (DEXA) Scans
- Bioimpedence Analysis (BIA)
- Skin Fold measurements (if above are not feasible)
Give 4 Good parental interventions for “picky eaters”
Good Interventions (Do’s)
- Minimize non-water fluid intakes (< 750 mL milk, no juice/formulas)
- 15 minutes warnings for meals (mental preparation)
- Restrict water intake shortly before meals (stomach filling)
- Restrict snack ‘grazing’ behaviours
- Expect only 20 Minutes at the Table
- No distractions at the table (no screens, no books, no TV)
- Do not use dinner time for discipline events of the day
- Consistent timing and attendance of all family members
- Praise good completion of meals/trying new things
Regarding salt intake, what’s the CPS want you to do, policy wise?
- Advocate for legislation on salt content of foods
- Stop marketing high salt foods to children
- Mandatory labelling of high salt foods
- Encourage families to use Nutritional Facts on food
- Educate the public on the salt content in food, and its impact on health
TRUE or FALSE
Food labels with ’% of daily’ values assist consumers to restrict their Na intake to below the Chronic Disease Risk Reduction level (CDRR)
FALSE
The CDRR for Sodium is < 2000g Na/day. Nutrition labels actually use a ‘% of daily’ required intake for sodium of 2300 g.
Which of the following managements for Infantile Colic are evidence based and endorsed by the CPS ?
- Maternal Hypoallergenic Diet (if breastfeeding)
- Hypoallergenic Formula Feeding
- Soy Formula Feeding
- Lactase Supplementation
- Pre-biotics
- Pro-biotics
- Maternal Hypoallergenic Diet - Possible Option
- No difference in colic incidence between EBM/BF vs. Formula
- Some benefit from elimination diet; although
- Hypoallergenic Formula Feeding - NOPE
- Never an option outside of severe CMPA/Metabolics
- Do not switch to this instead of EBM (elimination first)
- Soy Formula Feeding - NOPE
- Only for Galactosemia and Cultural reasons (vs. typical formula)
- Lactase Supplementation* - NOPE
- Pre-biotics** - NOPE
- Pro-biotics** - NOPE
*Evidence suggests no benefit. **Insufficient evidence.
Describe the sequential management for failure to thrive
Failure to Thrive
- Detailed feeding history including psychosocial context*
- Complete physical exam looking for dysmorphic features
- Laboratory Studies including:
- CBC + differential, CRP (or ESR)
- Electrolytes (Na, K, Cl, Mg, PO4, Ca, Mn, Pb + vitamins if concerned)
- Renal and Liver Profiles (BUN, Creat., AST, ALT, ALP, Urinalysis)
- Iron Profile (Total, TIBC, Ferritin)
- Immunoglobulins (IgM, IgA, IgG) and TTG
- TSH
- Consider pursuing additional studies
- uArray and Fragile X (if dysmorphic)
- SweatCl and Fecal Elastase
- Bone Age
- Refer to Feeding Clinic (if persistent without diagnosis)
- Consider Cyproheptadine (appetitogenic) in d/w GI
- Consider G-tube (if feeding is unsafe or nutrition affects underlying illness)
- Never blame parents (people don’t knowingly starve their kids
EPI BULLETS
- 12 % of children are Obese; 18 % are overweight
- 60 % of children drink sugar sweetened beverages (SSBs)
- Sugar Taxation dropped SSB consumption by 20-50 %*
- SSB is directly proportional to mean BMI scores in children
-
CPS wants :
- 20 % tax on sugar, and to use this tax for health promotion campaigns
- To reassess the impact of SSB access restriction routinely
*11 systematic reviews from different countries/states/provinces found this.
What is the iron supplementation plan for babies with birth weights < 2000 g and 2000 - 2500 g?
Why do they need iron ?
At 2 weeks of life
- Start 3 mg/kg/day Elemental Iron x 1 year if < 2000 g BW
- OR*
- Start 2 mg/kg/day Elemental Iron x 6 months if 2000-2500g BW
- Re-assess dose Q3months
Iron defeciencies that remain untreated will significantly impact cognitive development
What is the definition for Pre-Biotic and Pro-biotic ?
Pre-Biotic
Small molecules that modulate the ratios of commensal / pathogenic flora for a overall healthier gut (in the normal patient)
Probiotic
Living organisms of strain shown to be beneficial for the average person’s gut. Their goal is to colonize and shift commensal / pathogenic flora to a favourable ratio, through innoculation.
What are the beneficial, and negative, aspects of caffeine?
Benefits
- Counteracts sleep deprivation (not cognition loss though)
- Improves muscle endurance
- Improves response time
- Associated with healthy / normal social behaviours (vs. EtOH)
Adverse
- Exacerbates underlying arrythmiae (particularly with overdose)
- Increases T4 production
- Amplifies the stimulation from ADHD medications
- Exacerbates anxiety disorders
- Poor for renal and liver dysfunctional disorders (no explanation)
- Can result in withdrawal if routinely taken
When is the physiologic nadir for an infant’s iron?
6 Months
What are the CPS’ seven principles of nutrition that should be promoted, for a child between 6 - 24 months?
It’s worth noting that these 7 principles have subexplanations that interlock with eachother to create actually 8 principles. This will be reviewed I’m sure.
- Exclusive Breastfeeding until 6 Months*
- Vitamin D for Breastfed/Breastmilk kids (400 IU or 800 IU northern)
- Introduce Complimentary foods no later than 9 months**
- Responsive Feeding (i.e. recognising and respecting hunger and satiety)
- Iron Rich foods once solids are introduced
- Safety (Supervise eating, properly store, no undercooked or unpasteurised)
- Quality (No added salt, sugar. No juice or low fat foods, milk <750 mL/day)
- Regular Food Scheduling and Parents Rolemodel etiquette
*The immune group wants to permit the introduction of allergenic foods as early as 4 months for the best outcomes. This contradicts this CPS statement, so you need to evaluate for Allergy Risk before approving/disproving this practice.**New foods should be introduced gradually and should not result in no breastfeeding.
What is the mechanism for Fluoride in Dental Carries Prevention ?
Topical Fluoride acts in the following ways
- Inhibits plaque production
- Inhibits demineralisation of enamel
- Optimizes Remineralisation of enamel
EPI BULLETS
- 85 % of Canada resides in urban settings
- 40 % of Pre-schoolers are anemic (usually Fe defeciency)
What is the daily iron requirements for the following ages:
- 0 - 6 months
- 6 - 12 months
- 1 - 8 years old
- 9 - 13 years old
- 14+ y.o.
Endorsed Daily Iron Requirements by Age
- 0 - 6 m.o. = 1 -2 mg/kg/day
- 6 - 12 m.o. = 11 mg/day
- 1 - 3 y.o. = 7 mg/day
- 4 - 8 y.o. = 10 mg/day
- 9 - 13 y.o. = 8 mg/day
- 14+ y.o. = 15 (fem.) and 11 (male) mg/day
The CPS versus APA steps away from specific numbers for adequate intake. CPS says exclusvie breast feeding is sufficient until 6 months, then push iron rich solids. Do not screen. Do encourage balanced diets (limit milk)
EPI BULLETS
- Fluorosis rates have increased from 13.5 % to 41.4 % since the introduction of Fluoronated tap water
- 80 - 90 % of Fluorosis cases are mild, with < 20 % severe*
- The Chronic Disease Reduction Rate (CDRR) = 0.7 mm Fluorine
- Systemic (ingested) fluorine does NOT prevent carries
*Severe Fluorosis is identified as requiring cosmetic or reconstructive therapies
What is the caloric value, and suggested component of a child’s daily energy intake, for :
Protein
Carbs
Fat
-
Protein
- 1 g protein = 4 kcal
- Should only be 10 - 30 % of daily energy intake
-
Carbs
- 1 g carbohydrates = 4 kcal__
- Should be 50 - 65 % of daily energy intake
-
Fat
- 1 g Fat = 9 kcal
- Should be 25 - 30 % of daily energy intake
What psychosocial factors does global warming have on children ?
- Housing loss or stressors on:
- Prairie wildfires
- Recession of northern land with permafrost thawing
- Flooding along waterways
- Air pollution increasing family disease burden
What is the Upper Limit for daily caffeine use ?
2.5 mg/kg/day
To give you some perspective here is the content for common drinks:
- Energy drinks (8 oz) = 95 mg
- Instant coffee (8 oz) = 76–106 mg
- Brewed coffee (8 oz) = 118–179 mg
- Black tea (8 oz) = 43 mg
- Green tea (8 oz) = 30 mg
- Regular cola beverage (12 oz) = 36–46 mg
- Chocolate milk (8 oz) = 8 mg
- Hot chocolate (8 oz) = 5 mg
( As a 90 kg man, I should have 225 mg; so ~ 2 cups of coffee )
EPI BULLETS
- 7 % of annual live births are preterm.
- Human Milk Fortifier has decreased Surgical NEC by 94 % and All NEC by 63 % - for babies < 1250 g.
- Vancouver has the only centralised Human Milk Bank in Canada, while depositories exist throughout the country.
- There is no increased risk for allergic reaction to Donor BM compared to EBM and/or formula.
Which of the following conditions have shown evidence of benefit from Probiotic therapy ?
- Neonatal Sepsis
- Anti-biotic Associated Diarrhea
- Clostridium difficile colitis
- Infectious Diarrhea
- Traveller’s Diarrhea
- Cow’s Milk Protein Allergy
- Irritable Bowel Syndrome (IBS)
- NICU enteral feeding tolerance/growth
- Infantile Colic
- Functional GastroIntestinal disorders
- Necrotizing Enterocolitis
- Atopy (asthma, allergic rhinitis, eczema, IgE GI-inflammation, allergies)
- Mild Respiratory / ENT infections
- H. pylori treatment
-
Neonatal Sepsis - YES
- LBW and Prem babies with sepsis have reduced mortality
-
Necrotizing Enterocolitis - YES
- Improvement in babies > 1000 g, when coupled w/ breastmilk.
-
Anti-biotic Associated Diarrhea - YES
- Some benefit from L. bacillus
-
Clostridium difficile colitis - Chronic YES, Acute NO
- No benefit in acute treatment. Did drop recurrence by 50 %
- H. pylori - YES with routine therapy
-
Atopy - sort of
- There is recommendation for the prevention of eczema, not other atopic diseases.
-
Infectious Diarrhea - Depends
- Yes for viral aetiology if treated within 48 h of symptoms onset.
- No evidence for bacterial/parasitic diarrheas.
-
Some evidence on prevention, consider if recurrent
* Functional GI Disorders - Depends - Consider only if there is pain associated with the condition
- Traveller’s Diarrhea - Equivocal
-
Irritable Bowel Syndrome (IBS) - Equivocal
- Some noted symptomatic improvements, but call GI for each case
- CMPA - insufficient evidence
- Infantile Colic - Equivocal
- Mild Respiratory / ENT infections - Equivocal
Nutrition is generally adequate intake:expenditure
if this is not achieved, how does this impact the growing child ?
- Activity related injuries (dislocations, tendon injuries, fractures …)
- Short stature
- Delayed puberty
- Loss of muscle
- Menstrual dysfunction (reflects poor nutrition, doesn’t cause injury)
These are all pathologic things we see in eating disroders - because they are the reflection of an abnormal intake:expenditure ratio which is essential for ED Dx
EPI BULLETS
- 53 % of Canadian schools have health food committees (2013)
- High fat/sugar childhood diet is 1/α to IQ (602 patient cohort study)
- School Nutrition Programs (SNPs)* have been shown to:
- Decrease BMI
- Increase Access to Healthy food
- Decrease access to junk/bad food
- + / - improve school performance**
*Precendence for policy changes is the Arkansas Act 1220. **Studies are mixed results for this measurement, so the CPS won’t claim better performance
EPI BULLETS
- 3.5 % of global intellectual delay is from Lead Poisoning
- 3 % of US children have lead levels > 5 ug/dL (safe limit)
- Half-life of lead is about 45 days
- Risk for lead poisoning peaks at 2 - 3 y.o.
What micronutrient deficits are associated with most anti-epileptic medications ?
- Folate deficits
- Cobalamine (B-12) deficits
- Common and Trace elements (Ca, PO4, Mg, Mn, Zn, Cu)
- These must be checked routinely to screen for nutritional deficits*
- Deficits are associated with hyperhomocystenemia, cardiovascular disease and bone disease.*
What growth parameters should always be documented at each visit/encounter?
- Weight
- Height/Length (limb measurements for disabled isn’t required)
- BMI
- Ideal Body Weight (< 2 y.o.)
EPI BULLETS
- See the attached photo for GMFCS Definitions
- GMFCS 1 - 5 (without a feeding tube) have a hazard ratio* of 2.2 for complications, if their weight < 20th %ile
- GMFCS 2 - 4 have a hazard ratio of 1.5 for death if < 20th %ile
Hazard ratios are the current chance of an event occuring, if a given exposure. Risk Ratio is over a standardized period of time.
What the risk factors for reduced Bone Mass ?
Reduced Bone Mass Risk Factors
1. Chronic inflammation
2. Reduced physical activity/muscle mass
3. Intrinsic Pubertal delay
4. Nutritional deficiencies
5. Medications
