Paediatrics JC120: The Child Is Too Thin: Nutrition And Growth, Nutritional Deficiency States Flashcards

1
Q

How to know baby is thin?

A
  1. Physical examination
    - ***Muscle wasting over buttock + Lack fat deposits
    - Buccal muscles not reliable for assessing muscle wasting / nutritional deficiencies (∵ frequently used for feeding)
  2. Growth parameters / dimensions
    - Body proportion (compare with self)
    - ***Growth record (compare with past)
    - Comparison with other babies
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2
Q

Concept of Relativity in Early growth

A
  1. Relative to ***peers (age / sex-appropriate)
  2. Relative to ***other growth parameters
    - Weight
    - Height
    - Head circumference
  3. Relative to previous growth parameters
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3
Q

Best nurture environment for children

A

Nutrition is the basis (Balance + Sufficient)

Child growth:
- Dynamic + Interactive process
- Relative to norms
- Foundation of health + development

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4
Q

Key determinant of growth

A

Depends on **stage of life + **age of child
- Fetal / Infancy: **Nutrition most important
- Primary school: **
Hormone (GH, Thyroid, Sex hormone)

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5
Q

***Key milestones of child growth (記)

A

Birthweight: 3.2 (female) - 3.4 kg (male)

Weight:
- Double by 4 months
- Triple by 10 months

Height:
- 50% adult height by 3 years
- 75% adult height by 9 years

Head circumference:
- 85% adult HC by 3 years

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6
Q

***Key Child Growth Indicators

A
  1. Underweight
  2. Stunting
  3. Wasting
  4. Failure to thrive
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7
Q

Z-score

A
  • Statistical measurement of a score’s relationship to the mean in a group of scores
  • Z-score of 0 —> score same as mean
  • Z-score:
    —> can be +ve / -ve —> indicate above / below the mean + by how many SD

WHO global database on child growth + malnutrition

  1. Underweight
    - Z-score cut-off point of < -2 SD to classify low ***weight-for-age
  2. Stunting
    - Z-score cut-off point of < -2 SD to classify low **height-for-age
    - Stunting rate under 5 yo —> **
    key health indicator
    - more likely to have impaired ***cognitive development
  3. Wasting (relative comparison between body weight and body height)
    - Z-score cut-off point of < -2 SD to classify low ***weight-for-height
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8
Q

Failure to thrive

A
  • A medical diagnosis
  • Failure of expected growth in children <3 yo
  • Downward crossing of 2 percentile lines in weight over 6 months

Causes:
1. Processing of nutrition
- Inadequate intake
—> Maternal factor
—> Baby’s factor
- Abnormal digestion / absorption
—> Primary
—> Secondary
- Inability to utilise
—> Genetic
—> Metabolic
- Excessive loss

  1. Excessive increase in calorie requirement (High metabolic rate)
    - Chronic / Recurrent infection
    - Chronic respiratory insufficiency
    - Congenital / Acquired heart disease
    - Malignancy
    - Chronic anaemia
    - Toxins
    - Drug excess
    - Endocrine disorders

(Genetic causes (SpC Revision):
Prenatal onset of growth retardation
- Russell-Silver syndrome
- Fetal alcohol syndrome

Postnatal failure + Developmental delay
- Williams syndrome
- Prader-Willi syndrome
- Costello syndrome)

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9
Q

Inadequate calorie intake

A

Maternal factors:
1. Failed breastfeeding
2. Wrong formula
3. Poor preparation (misconception / tradition)
4. Inappropriate feeding technique

Baby’s factors:
1. **Congenital anomalies e.g. cleft palate
2. **
CNS disorders e.g. swallowing problem
3. **Distress e.g. due to cardiopulmonary conditions
4. **
GI problems e.g. vomiting, GER

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10
Q

Abnormal digestion / absorption

A

Primary malabsorption:
- Uncommon (e.g. Cystic fibrosis)

Secondary malabsorption:
- **Post-GE (common) —> secondary dissaccharidase deficiency —> milk intolerance
- **
Necrotising enterocolitis (NEC)
- **Short gut syndrome (due to post-surgical resection)
- **
Food allergy / intolerance

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11
Q

Inability to utilise (Defective use of calories)

A
  1. Genetic diseases (syndromal)
  2. Metabolic disorders
    - ***Inborn errors of CHO metabolism, aminoacidopathies, mitochondrial disease
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12
Q

Process involved in nutrition uptake

A
  1. Coordinated of sucking + swallowing
  2. Gastric emptying
  3. Intestinal motility
  4. Secretions (salivary, gastric, pancreatic, hepatobiliary)
  5. Enterocyte function: Enzyme synthesis, absorption, mucosal protection
  6. Metabolism of products of digestion + absorption
  7. Expulsion of undigested waste products

In-utero:
- Fetal GI tract is exposed to constant passage of fluid containing a range of physiologically active factors:
1. Growth factors
2. Hormones
3. Enzymes
4. Immunoglobulins
—> play a role in **mucosal differentiation + **GI development + ***swallowing / intestinal motility development

At birth:
- Gut of newborn baby: take up task of ***passing, digesting, absorbing large quantities of intermittent boluses of milk

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13
Q

Gut hormones

A

GI peptides
- found in venous cord blood at birth in levels ~ to those of fasting adults

Fetal distress:
- number of gut peptides are elevated —> account for passage of meconium (meconium stained liquor: MSL —> aspiration —> acute respiratory distress)

Enteral feeding:
- levels of gut hormones ↑ rapidly (∵ nutritional uptake)
—> **Motilin (↑ gut motility)
—> Neurotensin
—> **
GIP (Gastric inhibitory peptide: stimulus to insulin release)
—> Gastrin (Intestinal mucosal + pancreatic growth)
—> ***Enteroglucagon (Tropic change to gut mucosa, Intestinal mucosal + pancreatic growth)
—> Pancreatic polypeptide (Intestinal mucosal + pancreatic growth)

Influenced by:
1. **Choice of Breast / Formula feed
2. **
Enteric intake (induce epithelial hyperplasia + stimulate microvillous enzymes production)
3. ***Early enteral feeding (enteral feeding strongly encouraged to promote GI function + differentiation)

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14
Q

Pancreas

A

Pancreatic function
- relatively deficient at birth
- mature levels of pancreatic enzymes not achieved until late infancy

Pancreatic amylase activity
- ↑ after 4-6 months

Lipase:
- do NOT approach adult efficiency until about 6 months

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15
Q

Protein digestion in early infants

A

Early infancy compared to adults
1. Gastric acid
- lower than adult

  1. Trypsin
    - activity reduced
  2. Chymotrypsin
    - low levels
  3. Pancreatic proteases
    - low levels
  4. Intestinal mucosal peptidases
    - adequate
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16
Q

Carbohydrates digestion in early infants

A

Early infancy compared to adults
1. Salivary amylase
- low levels —> compensating mechanisms: ***stay active in stomach (food in stomach for longer period)

  1. Pancreatic amylase
    - very low levels —> compensating mechanisms: ***breast milk amylase
  2. Disaccharidases
    - adequate levels —> compensating mechanisms: ***fermentation + absorption in large intestine
17
Q

Fat digestion in early infants

A

Early infancy compared to adults
1. Pancreatic lipase
- very low levels —> compensating mechanisms: **lingual, **gastric, ***breast milk

  1. Bile acids
    - low levels —> compensating mechanisms: bile salt stimulated ***lipase activity
18
Q

Motility: Upper GI

A
  1. Esophageal motility
    - ↓ in newborn
  2. LES
    - primarily above the diaphragm
  3. LES pressure
    - less for first few months —> ***regurgitation
  4. Gastric emptying
    - may be ***delayed
19
Q

Motility: Intestinal

A
  1. Intestinal motility
    - more disorganised
    - more frequent ***regurgitation
  2. Prolonged transit time in upper intestines
    - may ***improve absorption of nutrients
  3. **Rapid emptying of ileum + colon
    - may reduce time for water + electrolyte absorption + ↑ risk of **
    dehydration
20
Q

Maturation in first year

A
  1. LES tone
    - ↑ after 6 months —> ↓ reflux in most infants
  2. Pancreatic amylase
    - ↑ by 6 months
  3. Gastric acid + pepsin activity
    - don’t reach adult levels until 2 years
  4. Lipase
    - reach adult level by 2 yo
  5. Fat absorption
    - not approach adult efficiency until ~6 months
  6. Lactase activity
    - ***retention of lactase activity until 3-5 yo
21
Q

Kidney

A
  • Limited ability to concentrate urine in first year (∵ immaturities of nephron + pituitary gland)
  • Potential ***renal solute load determined by:
    —> Nitrogenous end products of protein metabolism, Na, K, P, Cl

Renal solute load of different feedings (Low to High):
Human milk (easier to handle, less burden to kidneys) < Milk based formula < Isolated Soy protein based formula < Evaporated milk formula < Whole cow milk (***High renal solute load —> may overload premature kidney)

22
Q

**Failure to thrive due to **↑ calorie requirement

A
  1. Chronic / Recurrent infection
    - UTI
    - TB
  2. Chronic respiratory insufficiency
    - Bronchopulmonary dysplasia (BPD)
    - Cystic fibrosis
  3. Congenital / Acquired heart disease
  4. Malignancy
  5. Chronic anaemia
  6. Toxins
    - Lead
  7. Drug excess
    - Thyroxine
  8. Endocrine disorders
    - Hyperthyroidism
23
Q

Breast feeding

A

Suckling
—> Hypothalamus
—> Pituitary gland
—> Prolactin + Oxytoxin
—> Myoepithelial cells
—> Lactation

24
Q

Breast milk contents

A

Nutrients:
- Energy (67 Kcal/100ml)
- CHO: Lactose, Oligosaccharides
- Protein: Lactoferrin, α-lactalbumin, β-casein, lysozyme, cytokines, Ab
- Fat: LC-PUFA (DHA, AA, EPA)
- Micronutrients + Trace metals
- Cells: Macrophages, Neutrophils, Lymphocytes

25
Q

***Long-term + Short-term effects of breast feeding

A

Benefits to baby:
1. Nutritional value: **best composition with high bioavailability
2. **
Reduced obesity + overfeeding (∵ tailor-made for baby at different stages of life)
3. **Protect against infection + allergy
- matches with sequence of postnatal development of immune system (will alter its content to support immunological needs)
- help adaptation of GI tract in the switch from fetal to postnatal life
4. **
Less contamination, readily available
5. ***Enzymes, hormones, immune factors

Benefits to mother:
1. **Involution of uterus
2. Better physical shape
3. **
Reduce neoplasm (esp. breast cancer)
4. ***Improves psychosocial wellbeing
5. Less postnatal depression

Benefits to family
1. **Maternal-infant bonding (attachment)
- less school withdrawal, behavioural problem, child abuse
2. **
Contraceptive effect (for birth control)
3. ***Most economic + effective way of feeding

Benefits to society
1. Less medical consultations
2. Less hospitalisation
3. Less medical expense related to infections

26
Q

Protective properties of breast feeding

A

3 overlapping groups of bioactive agents:
1. **Direct acting antimicrobial agents
2. **
Anti-inflammatory agents
3. ***Immunomodulating agents

—> Protection against infections + atopy

27
Q

Health risk of NOT breastfeeding

A

Baby:
1. DM
2. Obesity
3. Recurrent otitis media
4. Asthma / pneumonia hospitalisation
5. Death in first year

Mother:
1. Breast cancer
2. Type 2 DM

28
Q

Disadvantages of breastfeeding

A
  1. ***Physical exhaustion of mother (frequent, on demand feed)
  2. ***Emotional stress on mother
  3. Sleeping quality (mother) impaired
  4. Infections: virus (e.g. HIV, CMV, HTLV) (***Hep B is OK!!!)
  5. ***Transmission of undesirable drugs (e.g. chemo, RT, psychiatric drugs) —> need adjustment (do NOT just stop medication)
  6. Inborn error of metabolism (may require special diet)
29
Q

WHO recommendation

A
  • Accurate information + Support of family, health care system, society at large
  • Exclusive breastfeeding up to **6 months of age —> continue breastfeeding along with complementary foods up to **2 yo + beyond