Unit 2 (Lectures 11-14) Flashcards
What do centiles show?
number of children EXPECTED to be below that line
e.g. 50% below the 50th centile line and half above OR 91st centile: only 9% of children would be expected to be heavier/taller
- half fall between 75th and 25th centile - -1 and + 1 Z scores (=25th to 75th centile)
Baby weight loss
- normal after birth (3-5 days)
- 80% will regain by 2 weeks of age (indicates feeding is effective and going well)
- > 10% weight loss may indicate feeding problem or illness
- regardless of % weight loss (consider overall picture to understnand baby health
Hydrocephalus
fluid on the brain and rapid head growth in babies is a symptom
BMI
Reflects how heavy a child is, relative to their height
- higher bmi = higher bmi in adulthood
- rapid growth and tracking 98th centile (>2) are at risk of LT health problems & more likely to be obese in childhood, adolescence and adulthood.
How does Iron deficiency affect overall health?
- Delays/impairs growth
- Fatigue
- increased susceptibility to infection
How does calcium deficiency affect overall health?
- Delays/impairs growth
- reduced blood clotting
- heart and nerve function
- reduced bone health
How to measure growth of infants and children
Weight:
Clinical electronic scales
*if under 2 - mum can hold baby
Length:
Length board
Rounded to nearest 0.1cm (3 measurements)
under 2: lying
older than 2 : stand (standiometer)
Head circumference only taken up to 1 year of age
When do we measure weight and length?
-Important in 1st week of life - gives estimate of good breastfeeding
-Concerns around weight gain or growth
-At routine checks
1,2,4,6,9,12,18,24 months
*Should measure more than 2 weeks apart after 6 months
(measure too often can be misleading)
Growth reference
How certain children grew in a particular place and time
E.g. study
Growth standard
How healthy children SHOULD grow under optimal environmental and health conditions
i.e. a single international standard representing the best physiological growth for children from birth to 5y and to establish the breastfed infant as the normative model for growth and development
WHO childs growth standards:
Represent the best description of physiological growth and should be applied to all children everywhere, regardless of ethnicity, socio-economic status and type of feeding
Attained for:
- Weight for age
- Length/height for age
- Weight for length/height
- Body mass index for age
When should additional measurements be taken?
If weight is below the 0.4th centile or above the 99.6th centile.
very rapid weight gain or loss (>10%)
Discuss the general guidelines for growth over this newborn period.
- Most babies lose weight after birth (in the first 3-5 days)
- but 80% will regain by 2 weeks of age
- Infants recover birth weight usually by 10 to 14 days which indicates feeding is effective and going well
“Growing normally”
Growth ‘tracks’ parallell to one of the centile lines (with little deviation)
Further investigation required to identify the cause if…
Growth ‘tracks’ up or down signifficantly
Consistent changes in centile position
Height: 1 or more centile space
Weight: 2 or more centile spaces
Between Height & Weight: 2 or more centile spaces
Growing on 5th centile for weight
Growing on 95th centile for height
How often should older children and adolecents be measured to track growth patterns?
once a year
How often should infants&todlers be measured to track growth patterns?
1st week of like (0years old)
Month: 1,2,4,6,9,12 (1 year old), 18, 24 (2 years old)
Why do the length/height percentiles change at 2 years of age and what is the important message to caregivers about this change?
<2 years are measured lying down (supine) on a length board
> 2 years are measured standing with stadiometer -> spine is compressed -> height is slightly less than their lying down length – the centile lines shift down slightly at age 2 to allow for this different type of measurement.
*What is the most important is to check, whether the child continues to FOLLOW THE SAME centile after this transition
Concerns around delays in motor skill development.
Discuss milestone achievements
There are time widows of development that certian skills must be learned in order for subsequent learning to occur
however,
Wide and variable window of achievement for each milestone in young children.
If still concerned, refer to WHO guidelines of milestone achievement
Pull-self to standing window
by 12 months
i.e. if stood at 11 months = normal
Walking alone window
by 18 months
i.e. if walked at 16 months = normal
Sit on chair - grasp object window
6 months
Stand alone
14 months
(15 for walking)
What is an allergy?
A reaction to harmless to environmental substances
E.g. dust mites, pets, pollen, insects, mould, medication, food
What is the prevalence of allergies?
1 in 5 will develop in their life time
Eczema: 1 in 10
Food: 5-10% children, 2-4% adults
Atopic disease
Genetic tendency to develop allergic disease.
lgE antibodies are produced after exposure to environmental allergens
Present with one or more of: asthma, allergic rhinitis (hayfeever, congunctivitis; nose/eyes) eczema or hives (urticaria/sskin)
*If have one, more likely to develop another
What is a food intolerance?
vs food allergy
Intolerance: usually in older children and adults
- delayed reaction after ingestion of large amount of the food
- can be related to reduction in digestive enzymes i.e. lactase
e.g. lactose, FODMAP foods, fructose
caused by abdominal pain, bloating, gas, diarrhoea/constipation
Food allergy: an immune mediated hypersensitivity reaction to a food.
40% increased risk of developing food allergy if have eczema (atopic disease)
resources for families
- YUM cook book (DF, GF)
- Ascia
- Paediatrics society
- Formula companies for videos and recipe books
Adverse food reactions
can be food, chemicals in food
Immune mediated or non-immune mediated
Non-immune mediated adverse food reaction
Reactions to non-protien substances e.g. cho, chemicals, food additives, toxins, irritants
Reactions are usually delayed (up to 20 hours after food is eaten)
Symptoms: diarrhoa, nausea, cramping, headache
Diagnosis: typically eliminaition and reintroduction
DOES NOT INVOLVE THE IMMUNE SYSTEM
DOES NOT PRODUCE IgE ANTIBODIES
IgE mediated food allergy
Quick response (within 1h)
- hives, swelling, breathing difficulty, vomiting, floppy/pale
- associated with anaphalaxis
Diagnosis: with clinical symptoms i.e. how quickly did it start and what were the sympyoms? and +ve SPT or seum IgE antibodies test (blood test)
e.g. egg
Most common food allergies (big 9)
responsible for 90% of food allergies
milk, eggs, peanuts, tree nuts, milk, wheat, soy, fish, shellfish, sesame are
Cows milk, egg, wheat, soy are grown out of by 5 years old
Peanut and tree nuts, fish and shelfish usually persist (75-90%)
Two ways to test IgE mediated food allergies
- Skin prick test (SPT): IgE antibody specific response (weal diameter (< 3mm))
- Serum specific IgE blood test (measures IgE when mixed with allergens in laboratory)
Non-IgE mediated food allergy
commonly due to cows milk or soy
occur within first year of life then resolve in early childhood
delayed onset (2-48h)
gi system response e.g. reflux, diarrhoea, blood/muscus in stools, excessive crying and abdominal pain
difficult to test becuase haven’t build antiboties to the food
diagnosis done on clinical symptoms
Prevention of food allergy
From 6 months to 12 months all allergen foods should be introduced into the infants diet (one at a time , 1-2 days apart to detect problem foods)
and offered regularly (once tolerated)
Eating a healthy and balanced diet before pregnancy, while pregnant and breastfeeding.
Keeping skin well moisturised
What did the LEAP 2015 study show? (peanuts)
Earlier introduced peanut - lower the risk of peanut allergy
continued exposure keeps tollerance to peanuts
What did the PETIT 2017 and STAR 13 study show? (egg)
early introduction of egg from 4-5m to 12 months decrease egg allergies
What did the health nuts study 2017 show? (cows milk)
Introduction to cows milk in first 3 months reduced risk of cows milk allergy and sensitivity
What did the ABC study in 2020 show? (cows milk)
Introduction to cows milk within first 3 days of life (due to LBS) followed by exclusive breastfeeding = increased risk of cows milk protein allergy.
Does being born on a farm increase or decrease risk of food allergy
decrease (less exposure to pullition)
Extensively hydrolysed and amino acid formulas
Made with cows milk then extensively hydrolysed to brreakdown proteins into small peptides (via heat)
*not suitable for infants with severe cow’s milk PROTIEN allergy or anaphylaxis to cows milk
AA: further broken down of peptides into singular amino acids
*smaller molecules which are less reactive.
Infant milks for IgE and Non-IgE mediated cows milk protein allergy
*if react to cows milk - will also react to other mammals milk (e.g. goat/sheep)
lactose free is also not suitable as baby is reacting to PROTIEN in the milk (not the lactose) - lactose intollerance is RARE
if react to cows milk - also react to soy
- not given soy formula (esp under 6m old)
extensivley hydrolised *not suitable for infants with severe cow’s milk PROTIEN allergy or anaphylaxis to cows milk
rice milk formula: good if have corn allergy as corn is in aa and extensively hydrolised formula
Amino acid formula: needed when anaphilactic,
Advice
- Continue breastfeeding
- Inform on milk free diet, food substitutes
- How to read food labels for allergens
- Encourage and explain introduction of other allergens (introduce early to reduce the risk if allergy)
- Add formula to foods to get used to flavor when mum returns to work
- Vitamin D supplementation (oral drops) (may benefit if EB and live south of nelson and in winter)
- Eczema management e.g. creaming, hydrocortisone
Closely monitor growth
How to read food labels for allergens
Contains = avoid
May contain: may be okay, depends on severity of allergy
Advice in todler years
- Continue to breastfeed until around 2 years
- Continue on formula when mum working, but add calcium with FORTIFIED soy/oat milk
- Advice on managing daycare and anaphylaxis plan from specialsit
- Advice on family meals - meals to be dairy, egg, peanut, GF due to other family members
Monitor growth
Alternative milks and yoghurts
Milk: *Check calcium 120mg/100ml
- Soy (good protien, fat, energy) - Oat (good energy, some protien) - Rice (good energy, 300ml/day max) - Almond/coconut/cashew (low wenegy, protien, fat = last resort) Yoghurt: soy, coconut, cashew
Alternative Cheese and egg
DF cheese: none have calcium - useful for social activities e.g. pizza night
Eggs:
chia or linseeds & water
mashed banana or apple sauce
When should complementary feeding begin?
Introduce soil foods around 6 months - not before 4 months and preferably while still breastfeeding
And in age-appropriate form e.g. smooth peanut butter and cooked egg BEOFRE 12 months old (incl high risk infants)
Eczema skin treament
Apply moisturiser at least twice a day
Avoid products containing food protiens and products (Smearing food on skin with eczema may increase risk of developing allergy to that food)
3 serves of Omega-3 fatty acids (oily fish) per week possible reduce eczema in early life during pregnancy and breastfeeding
Reintroduction to egg: The egg ladder
Step 1: well cooked e.g. biscuts or egg pasta
Step 2: lightly cooked e.g. pancakes or scrambled egg
Step 3: raw e.g. mayonaise or raw cake mix
Genetic explinations for food allergies
If parent has an atopic disease, 40% of offspring will be affected (high risk infant if both parents)
Environmental explanations for food allergies
- Hygiene hypothesis: less exposure to infections in early life, increases chance of allergies developing due to suppressed natural development of immune system (critical window utero-5y)
- Food skin exposure: food-based skin products
- Food processing methods: roast vs boiled peanuts
- Delayed intro to allergenic foods: beyond 12 months old, egg, peanut, tree nuts
Dual-allergen exposure hypotheses
becoming allergic by skin exposure (in the absence of protective oral exposure as oral is more protective to form a tolerance
Skin exposure = failure to establish tolerance
If breast feeding is not possible what is the recommended formula?
cows milk
Baby lead weaning
Alternative approach to introducing complementary foods.
- Finger foods (not puree) as first foods
- Babies feed themselves (not -spoon fed)
- not reccomended by MOH
How to safely practice baby-led weaning
- Ensure baby can sit up unassisted, pick up food and bring to their mouth
- Offer soft foods which are able to be squashed to the roof of mouth with tongue
For reducing of BLW concerns, offer iron-rich foods daily, follow advice on reducing choking risk
What did the BLISS study show for baby-lead weaning?
Positive: Lower food fussiness and greater enjoyment of food
no difference in choking or iron status
Discretionary foods
High in energy, saturated fat, salt, sugar
little nutirional value
contributes to 13% of todlers total energy intake and 9/10 consumed dicretionary foods
MOH servings for todlers
Vege: 2-3
Fruit: 1/2
Grains: 4
Legumes, nuts(unsaturated oils/spreads) , fish, egg, meat: 1
milk products: 1-1.5
Should toddlers drink whole blue cows milk or ‘toddler milk’ (cows milk based formula, fortified with iron, iodine, Vit D and C)
whole blue cows milk - important as provides energy, protien, calcium, riboflavin, and vit B12
(Not reccomended to use reduced fat milk as have high energy requirements)
*no more than 350ml / day as it is low in iron and displaces nutrient-rich foods in the diet
‘Toddler formula’: Not recommended by MOH because it adds to their preference towards milk over nutrient rich foods.
Optimal nutrition from a variety of healthy foods is important to set up healthy eating behaviors.
*22% of total energy intake is from toddler milk
Problematic as consumption of veg becomes lower
Fruit juice allowance: 120ml / day
However, Clinical setting: e.g. iron concerns it is short term beneficial to boost iron status
Issues around toddlers and 1/3 consuming above upper limit (1000mg/d)
May influence preferences for salty foods into adulthood.
High sodium intake is a risk factor for cardiovascular disease
What does the ‘Atopic March’ reffer to?
Excema
Progression of atopic diseases (i.e. excema) to other atopic diseases.
