Pediatric Nutrition

Question 1

Definitions

Answer 1

Newborn
◦ 0‐2 mos
Infants:
◦ 2 mos‐1 years of age
Toddler:
◦ 1‐3 yrs.
Preschooler
◦ 3‐5 yrs.
Grade‐schooler
◦ 5‐12 yrs.
Teen:
◦ 12‐18 yrs.

American Academy of Pediatrics recommends people be under pediatric care up to the age of 21.

Baby 0‐12 mos

Question 2

Growth

Answer 2

Good nutrition essential for proper growth and development
Physical growth occurs at different rates as infant becomes adult
◦ Childhood and adolescence are periods of rapid growth
◦ Double weight by 4‐5 mos, triple weight by 1 y
◦ i.e. body composition, cognitive and psychosocial development

Question 3

Measures to assess healthy growth in in children

Answer 3

◦ Growth is measured using average daily weight gain and growth charts (male/female)
◦ Growth charts 0‐36 mos: weight/age, length/age, weight/length, head circumference/age
◦ Growth charts 2‐18 yrs: weight/age, height/age, BMI/age
◦ Height and weight measurements follow consistently along or between the
same percentile lines on a growth chart
◦ Exceptions: Growth is more variable during first two years of life and during puberty
◦ Growth charts are not intended to be used as a sole diagnostic instrument.
Instead, growth charts are tools that contribute to forming an overall clinical impression for the child being assessed.

Question 4

Infant Nutrition

Answer 4

Newborns feed every 2‐4 hours, 8‐12 times per day
◦ Formula fed babies a bit less often than breastfed babies
◦ 140‐200 mL/kg/day
◦ Over time ‐ larger amounts consumed, less often feeding
◦ At 3 weeks, 6 weeks and 3 months of age, it is normal for babies to feed more frequently for a few days to meet their growing needs
Weight
◦ Loss 10‐15% in first 3‐5 days is NORMAL
◦ Regain birth weight by 10‐14 days

Additional measures to assess nutritional status, “is my baby eating drinking/eating enough”?
◦ # of wet diapers, “ins and outs”, change in pooping
◦ Infants who do not readily arouse for feeding should be wakened to feed if more than 4 hours have elapsed since the start of the last feeding

Question 5

Breastfeeding Basics

Answer 5

Breast milk:
◦ The Canadian Pediatric Society (CPS) recommends exclusive breastfeeding for the first 6 months
of life.
◦ Optimal milk for infants and is recommended for up to 2 years and beyond
◦ 90% of mothers attempt to breast feed (CAN)
◦ 27% exclusively breastfeed (CAN)
◦ Breast feeding is climate/environment friendly

◦ Colostrum:
◦ Colostrum is the first milk produced immediately after baby is born.
◦ Thick and yellowish, but it can also be thin and watery
◦ Colostrum is rich in proteins, vitamins, minerals and infection‐fighting antibodies that are found only in breast milk
◦ Acts as a natural laxative to help baby pass meconium (greenish‐black, sticky stool)

Question 6

AMERICAN ACADEMY OF PEDIATRICS (AAP),
SUPPORT UNEQUIVOCAL EVIDENCE THAT BREAST
FEEDING PROTECTS AGAINST/REDUCES:

Answer 6

Asthma/Atopic Dermatitis
Gastroenteritis
RTIs
Otitis media
Late‐onset sepsis in preterm infants
Type 1 & 2 diabetes
Sudden Infant Death Syndrome
Lymphoma, leukemia and Hodgkins disease

Question 7

FOR MOTHERS, BREASTFEEDING CONTRIBUTES

TO A NUMBER OF HEALTH BENEFITS:

Answer 7

Decreased postpartum bleeding
More rapid return to pre‐pregnancy uterine size
Reduced risk of type 2 diabetes
Reduced risk of postpartum depression
Decreased risk of some cancers (breast and
ovarian)
Relationship between breastfeeding and
improved bone health and return to pre‐
pregnancy weight require further research

Question 8

TRUE CONTRAINDICATIONS

rbeastfeeding

Answer 8

Infants with galactose 1‐phosphate
uridyltransferase deficiency (galactosemia)
Mother is HIV antibody–positive
Acute H1N1 influenza (resume when afebrile)
Undergoing chemotherapy
Active herpes outbreak on breast
Taking a drug not compatible with
breastfeeding, illicit drugs

Question 9

NOT CONTRAINDICATED IN:

Answer 9

Mothers with HepB
Mothers infected with HepC
Mothers who are febrile
Mothers who have been exposed to low‐levels
of chemical agents
Who smoke tobacco or have the occasional
drink
Babies with jaundice

Question 10

Galactosemia

signs and symp

Answer 10

Galactosemia means “galactose in the blood”
◦ Caused by a mutation in the genes
◦ Hereditary condition is passed from parent to child as an autosomal recessive disease
◦ Galactose‐1‐phosphate uridyltransferase (GALT) enzyme is missing or not functional
Babies with this metabolic condition are not able to metabolize a certain type of
sugar (galactose) found primarily in breast milk, cow’s milk, and dairy products.

Galactose and its byproducts can build up in the tissues and blood in large amounts and cause toxicity and can be life threatening.
Signs and Symptoms:
◦ Initial signs include refusal to eat, spitting up or vomiting, jaundice, lethargy
◦ Later in life signs (even with treatment) include learning disabilities (speech delayed),
neurological impairments (ataxia, tremors), and ovarian failure.

Question 11

Galactosemia Treatment and Management

Answer 11

◦ The only treatment is food avoidance. A person with galactosemia must avoid foods containing
milk and all dairy products, such as:
◦ Cow's milk
◦ Butter
◦ Yogurt
◦ Cheese
◦ Ice cream
◦ Whey
◦ Casein
Child may need supplementation with calcium and vitamin D.
Holistic treatment should involve speech therapy, educational assistance, physical therapy and
behavioural therapy

Question 12

Infant Formula: Take away points

Answer 12

Infant Formulas for Healthy Term Infants Compendium (for professional reference only)

Infant formula is regulated under the Food and Drug Act by Health Canada
Infants that are partially breastfed or not breastfed should receive iron fortified commercial infant formula until 9‐12 months of age.
◦ 3.25% milk may be introduced at 9 to 12 months
◦ Infants drinking soy formula should drink follow‐up soy formula from 12 to 24 months of age.
As pharmacists, you sell and recommend these products. Important for you to know
this topic

Question 13

Commercially available infant formulas

Answer 13

◦ Available as powder, liquid concentrate or ready‐to‐feed
◦ Commercial infant formulas contain 0.67 kcal/mL with 40–45% of calories from carbohydrate,
8–12% of calories from protein and approximately 45–50% of calories from fat.
◦ Micro‐ and macronutrient content differ slightly between products but all are designed to
mimic human milk as closely as possible.
◦ In infants that area at higher risk of infection, immunocompromised, pre‐term or low‐birth
weight who are less than 2 months, use liquid concentrate and ready‐to‐feed formula since
powder is not sterile.
◦ To reconstitute concentrated formula or powder formula, use boiled tap water or sterilized
water. READ LABELS!
◦ Often families will over‐dilute to save $$

Question 14

Many different types:
◦ Cow’s Milk Infant Formula’s for Healthy Term Infants (see slide 24)
◦ Specialized Infant Formulas (see slide 25)
◦ “Organic Formula” receive a certification from the Canadian Food Inspection Agency.
◦ This certification does not represent specific claims of health, safety and nutrition of this product

Homemade infant formulas:

Answer 14

Homemade infant formulas:
◦ Are NOT an appropriate alternative to breastmilk or commercial infant formula
◦ The World Health Organization (WHO) provides homemade infant formula recipes to
be used in extenuating circumstances (i.e. natural disasters)
◦ For those struggling economically, there are various income support programs that
help families access commercial infant formula

Question 15

Plant Based Beverages or Milk

Substitutes

Answer 15

Plant based beverages are not appropriate alternatives to breastmilk, 3.25% milk
or commercial infant formula for children in the first 2 years of life.
◦ Low in protein, fat, calories and iron

Question 16

Vitamin and Mineral Supplementation

Answer 16

Vitamin D Supplementation:
◦ Children get vitamin D from sun, food, formula and supplements
◦ In Alberta, sun exposure (northern hemisphere, long winters) not sufficient to
produce enough vitamin D
◦ 250 mL of breastmilk = 10 IU
◦ 250 mL of infant formula = 100 IU
◦ 250 mL cow’s milk = 100 IU
◦ All fully and partially breastfed babies require a vitamin D supplement of 400
IU/day, not to exceed 1000 IU/day.
◦ Dark‐skinned infants born to dark‐skinned mothers and infants living in
northern climates are at greater risk of vitamin D deficiency

Iron Supplementation:
◦ By 6 months of age, babies need iron from food regardless of if they are on
formula or breastmilk
◦ Offer iron rich foods with foods rich in vitamin C to aid in absorption
◦ Iron fortified baby cereal
◦ Meat and meat alternatives
◦ Can d/c iron supplement if baby takin

Question 17

Use of Prebiotics in Children

Answer 17

Prebiotic: non‐digestable food components that stimulate the
growth and activity of bacteria in the colon
◦ Examples, human milk oligosaccharides, lactulose, inulin
◦ Galactooliogosaccarides (GOS) and polydextrose (PDX) are two prebiotics
found in various infant formulas
◦ Current evidence only supports prebiotic consumption for supporting softer
stools in formula fed infants
◦ Prebiotics have not shown to prevent asthma, diarrhea or “gassiness”
◦ Inconsistent evidence on the benefit of use in atopic dermatitis, food allergy, antibiotic use, colic

Question 18

Use of Probiotics in Children

Answer 18

Probiotic: “live microorganisms” (non‐pathogenic) when administered in
adequate amounts confer a health benefit.
◦ Two most common strains are Lactobacillus and Bifidobacterium
◦ Effects are strain and dose specific i.e. Lactobacillus reuteri DSM 17938
◦ Research must be conducted on each strain and cannot be applied to other strains
◦ Choose a product with an NPN
◦ Risk of opportunistic infections. Caution in the following health conditions:
◦ Infants born prematurely
◦ Immunocompromised
◦ Auto‐immune disorders, cystic fibrosis, cancer
◦ Short‐gut syndrome

Question 19

The following probiotic health claims are not supported at this time (always
check current literature)

Answer 19

Atopic Dermatitis
◦ Insufficient evidence for the prevention or treatment of AD
◦ Some evidence supports the prevention of AD in infancy when mother consumed probiotics during pregnancy

◦ Colic in Formula Fed Infants
◦ Conflicts results from 2 RCTs there fore a firm recommendation cannot be made.

◦ Gastrointestinal Disorders (abdominal pain, stool frequency, bloating)
◦ Studies have not included infants and young children therefore, evidence is not available to make recommendation.
◦ No evidence for the maintenance of gastrointestinal health in formula fed infants.

◦ Improvement to Cow’s Milk Allergy
◦ Studies with small sample size have looked at hydrolyzed casein formula with the addition of LGG show increased
cow’s milk tolerance at 12 mos.
◦ Need studies with larger sample sizes and longer duration of studies to make a clear recommendation.

◦ Infections:
◦ A 2015 Cochrane review concluded that probiotics decreased the need for antibiotics to treat URTIs BUT specific
strains and doses were not provided!
◦ Thus, a public health recommendation cannot be made at this time.
◦ Evidence is inconsistent on probiotics for the treatment of acute otitis media.

Question 20

Synbiotics

Answer 20

◦ Combination of pre‐ and probiotics
◦ Conflicting evidence for use
◦ Strain and dose specific results. Those researched are not available on the Canadian market at this time.
Infants and children generally do not need pre‐ or probiotics if they are consuming breastmilk
and are offered a variety of foods (vegetables, fruits, whole grains, fermented dairy products)

Question 21

Starting Solid Foods in Diet

Answer 21

Most babies are ready to eat foods around 6 months of age
(continue to breast feed or offer infant formula while starting solids)
◦ Signs of readiness include:
◦ Can hold head up
◦ Sits well in high chair
◦ Shows interest in food
◦ Makes chewing motions
◦ Can close mouth around a spoon

Parents/Caregivers chose the food that is OFFERED to baby, baby
chooses HOW MUCH food to eat
◦ Start with 1‐3 teaspoons (5‐15 mL) of food
◦ Give baby 1 new food at a time, wait 2 days before adding next new food
◦ Start with pureed, smooth or mashed food
◦ Change texture as baby grows, i.e. diced, grated
◦ Encourage self feeding as soon as baby is interested

Don’t give babies honey or foods with honey until 1 year of age
◦ Risk of botulinum toxin. Pasteurized honey after 1 year of age.
Offer sips from open cup if baby is thirsty
For children 2 years of age and older, skim, 1% or 2% is recommended
Children that drink plant based milks should be offered a variety of protein rich foods

Question 22

Introduction of Allergenic Foods
Food allergies have increased over time. Canadian Pediatric Society (CPS) states that the
early introduction of commonly allergic foods may be beneficial in prevention. Can
introduce all foods at 6 months.

see slide 41

Answer 22

Common allergenic foods:
◦ Cow’s milk
◦ Egg
◦ Peanut & tree nuts
◦ Wheat
◦ Soy
◦ Shellfish
◦ Fish
Many food allergies resolve spontaneously with age but peanut, tree nut and seafood allergies are
less likely to resolve. nfants at high risk for allergenic disease:
◦ Have a history of atopy (tendency to produce IgE antibodies to allergens)
◦ Having a first degree relative with atopy
◦ Atopic dermatitis, food allergy, allergic rhinitis or asthma

How to introduce allergenic foods:
◦ Ensure texture, size and shape of food is age appropriate
◦ i.e. peanut butter can be thinned out with a liquid or mixed in with another food such as baby cereal.
◦ Introduce commonly allergenic foods one at a time. This way foods that causem eactions can be identified.
◦ Continue to offer allergenic foods a few times a week to maintain tolerance
◦ If a reaction is observed, stop offering the food and consult physician

Question 23

Child Milestones for Eating

Answer 23

18 mos to 3
years (Toddler)
• Holds glass or cup with one hand
• Chews food more, choking still a hazard
• Uses fork and spoon
• Definite likes and dislikes
• Distracted easily at meal time, feelings of hunger are less as growth slows down

3 to 5 y.o.
(Preschool)
• Good at self‐feeding
• Can open fridge
• Can eat hard foods such as popcorn and nuts after the age of 4
• Shows interest in food and where food comes from
• Is influenced by TV, family and friends
•Would rather talk than eat at meal times

Question 24

Choosing a variety of foods from Canada’s Food Guide daily

Answer 24

◦ Eat the rainbow, variety is important
◦ Pick from all “food groups”
◦ Notes:
◦ Choose whole grains and enriched foods
◦ Fruits and vegetables at each meal will help ensure that they are getting enough
◦ Suggest full fat milk products be provided to children under the age of 2
◦ Choose high fibre foods
◦ Limit salt and added sugar intake
◦ Limit processed foods

Question 25

geenral recommendations

Answer 25

Suggest 3 meals a day (including breakfast) and 2‐3 healthy snacks
◦ Snacks are a great way to make‐up for lost food groups during meals
◦ Younger children eat small amounts of food at any one time
Encourage adequate hydration
◦ Water is the best choice. Avoid caffeinated beverages and limit 100% fruit
juice to a maximum of ½ cup daily
◦ Tip: ½ cup juice and top up with water
◦ Fluid requirements will vary on individual, outside temperature and physical
activity
◦ Satiate thirst and drink fluids at meals

Question 26

Ensure adequate intake of specific nutrients such as iron, calcium, vitamin D
◦ Iron:

Answer 26

increase iron if menstruation has begum

dont know doses

Question 27

Vitamins for Children

Answer 27

A well‐planned vegetarian diet is appropriate
for all stages of the life cycle, consult a
Dietician to ensure nutrient requirements are
met.
◦ Vegan diets: ensure adequate intake of vitamin
B12, vitamin D, calcium, omega‐3 fatty acids
(EPA/DHA), iron and zinc
◦ Poverty: ensure adequate intake of vitamin A,
vitamin C, magnesium, calcium, folic acid,
vitamin B12 and vitamin D
Some parents will ask for vitamin
supplementation for their children.
Opportunity to take a diet history.
Popular brands
◦ Flintstones (BAYER)
◦ Centrum for Kids

Question 28

1. Can my child drink energy drinks?

2. My child keeps eating butter noodles three times a day for days and days…help!

Answer 28

1. Can my child drink energy drinks?
2. Not recommended. These drinks are high in sugar, calories and caffeine (exceed max caffeine
   recommendations) .
3. My child keeps eating butter noodles three times a day for days and days…help!
4. This is called a “food jag”. Common behaviour for toddlers and preschoolers
5. Keep offering a variety
6. Encourage participation in meal preparation
7. Combine favorite foods with new foods