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 Pediatric Nutrition
Pediatric Nutrition
7th Edition
By the American Academy of Pediatrics Committee on Nutrition
Pediatric
Editor: Ronald E. Kleinman, MD, FAAP
Associate editor: Frank R. Greer, MD, FAAP

Significantly revised and updated by more than 100 authors, the new Pediatric
Nutrition, 7th Edition, provides practicing clinicians with evidence-based
Nutrition
guidance on the full spectrum of childhood nutrition issues.
7TH EDITION
In the new seventh edition is the latest information about nutrient metabolism
and nutrition to support the normal development and health of infants and
children who are well, those born with congenital anomalies or disorders of
metabolism, and those with acute or chronic illness.

Contents include
• The latest evidence-based guidelines on feeding healthy infants and children
• Current policies and practice recommendations from the American Academy
of Pediatrics Committee on Nutrition

7th Edition
• Several new chapters and appendixes, including chapters on school
and child care nutrition, gene and nutrient interaction, and metabolic
programming
• Recent advances and developments on topics that arise frequently in
pediatric practice, including breastfeeding, fast food, vegetarian diets,
persistent newborn diarrhea, preterm infant nutrition needs, chronic obesity,
vitamin supplementation, and more
• Appendixes of more than 50 tables, including dietary allowances, energy
requirements, composition of human milk and infant formulas, MyPlate,
and more
• More than 20 growth charts for very low and low birth weights; full-term
infants, children, and adolescents; those with Down syndrome; and more
• Updated listings of resources for you and your patients, including printed
materials, government agencies, and Web sites

For other pediatric resources, visit the American Academy of Pediatrics online
Bookstore at www.aap.org/bookstore.

AAP
 Contributors

The American Academy of Pediatrics gratefully acknowledges the invaluable as-

sistance provided by the following individuals who contributed to the preparation
of this edition of Pediatric Nutrition. Every attempt has been made to recognize all
who have contributed; we regret any omissions that may have occurred.

Steve Abrams, MD, FAAP Deborah Frank, MD

Jean Ashland, PhD, CCC-SLP Ellen Fung, PhD, RD, CCD
Robert Baker, MD, PhD, FAAP Amy Gates, RD, CSP, LD
Susan Baker, MD, PhD, FAAP Paulette Gaynor, PhD
Jatinder Bhatia, MD, FAAP Mark A. Goldstein, MD, FAAP
Helen Binns, MD, MPH, FAAP Rose C. Graham, MD, MSCE
Margaux E. Black, BA Frank R. Greer, MD, FAAP
Christopher R. Braden, MD Ian Griffin, MD
Carol Brunzell, RD, LD, CDE Cary Harding, MD
Nancy F. Butte, PhD Sandra G. Hassink, MD, FAAP
Ben Caballero, MD, PhD Katherine Hebel, RD, LDN
Jong Chung, MD William C. Heird, MD
Stephanie Cooks, MA, RD David Herzog, MD
Stephen Daniels, MD, PhD, MPH, FAAP Melvin B. Heyman, MD, MPH, FAAP
Ronald W. Day, MD, FAAP Kathleen Huntington, MS, RD, LD
Christopher Duggan, MD Esther Israel, MD
Kamryn T. Eddy, PhD W. Daniel Jackson, MD, FAAP
Richard A. Ehrenkranz, MD, FAAP Susan L. Johnson, PhD
Nancy Emenaker, PhD, MEd, RD Katherine M. Joyce, MPH
Phil Farrell, MD, PhD, FAAP Doron Kahana, MD
Drew Feranchak, MD Bittoo Kanwar, MD
Eileen Ferruggiaro, RD, PhD Martha Ann Keels, DDS, PhD, FAAP
Marta Fiorotta, PhD Jae Kim, MD, PhD, FAAP
Jennifer Fisher, PhD Ronald E. Kleinman, MD, FAAP

vii

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 viii Pediatric Nutrition, 7th Edition

Pamela Kling, MD, FAAP Theresa Nicklas, DrPH

Nancy Krebs, MD, MS, FAAP Kate E. Nyquist, MD
Michele LaBotz, MD, FAAP Irene Olsen, PhD, RD
HuiChuan Lai, PhD, RD Carol O’Neil, PhD, MPH, RD
Melissa N. Laska, PhD, RD Lois Parker, RPh
Michele Lawler, MS, RD Heidi H. Pfeifer, RD, LDN
Lynne Levitsky, MD, FAAP Moraima Ramos-Valle, MS
Ximena Lopez, MD Sue J. Rhee, MD
David A. Lyczkowski, MD, FAAP Michael J. Rock, MD
Martha Lynch, MS, RD, LDN, CNSC Phil Rosenthal, MD, FAAP
William MacLean, Jr, MD, CM, FAAP Stephanie Lynn Ross
Laurie D. Manzo, MEd, RD Alanna E. F. Rudzik, MSc, PhD
Valérie Marchand, MD Gary Russell, MD
Martin G. Martin, MD, MPP Daniel W. Sellen, PhD
Antonia Mattia, PhD Robert Shulman, MD, FAAP
Shilpa McManus, MD, MPH, FAAP Scott Sicherer, MD, FAAP
Nilesh Mehta, MD John Snyder, MD, FAAP
Robert Merker, PhD Denise Sofka, MPH, RD
Tracie L. Miller, MD Valery Soto, MS, RD
John Milner, PhD Jamie Stang, PhD, MPH, RD
Robert D. Murray, MD Elizabeth A. Thiele, MD, PhD
Brandon Nathan, MD Vasu Tolia, MD
Anjali Nayak, MD Steven J. Wassner, MD, FAAP
Karen Neil, MD, MSPH, FAAP Jaime Liou Wolfe, MD
Daniella Neri, MS, RD, LD Garrett Zella, MD
Josef Neu, MD, FAAP Babette Zemel, PhD
Kenneth Ng, DO

FM_i-xxvi.indd 8 10/4/13 2:30 PM

 Table of Contents

I Nutrient-Gene Interactions
1 Nutrient-Gene Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nutrigenetics (Also Called Nutrigenics). . . . . . . . . . . . . . . . . . . . . . . . . 4
Nutrigenomics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Epigenetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Systems Biology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

II Feeding the Infant

2 Development of Gastrointestinal Function. . . . . . . . . . . . . . . . . . . . . . . 15
Development of Gastrointestinal Function. . . . . . . . . . . . . . . . . . . . . . 15
Infant Nutrient Assimilation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Dietary Fats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Dietary Carbohydrates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Dietary Protein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Vitamins and Minerals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Human Milk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Intestinal Microbiota in the Infant. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3 Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Recent Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Milk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Duration of Breastfeeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Contraindications to Breastfeeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
How to Support Breastfeeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Nutrition of the Lactating Mother. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Growth of the Breastfed Infant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

ix

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 x Pediatric Nutrition, 7th Edition

Expressing and Storing Milk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Special Situations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4 Formula Feeding of Term Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Rates of Breastfeeding and Formula Feeding. . . . . . . . . . . . . . . . . . . . . 61
Indications for the Use of Infant Formula. . . . . . . . . . . . . . . . . . . . . . . 62
History of Infant Formula Development . . . . . . . . . . . . . . . . . . . . . . . 62
Rationale for Development of Current Infant Formulas. . . . . . . . . . . . 63
Available Forms of Infant Formula. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Infant Formula Labels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Safe Preparation of Infant Formula. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Safe Handling and Storage of Infant Formula. . . . . . . . . . . . . . . . . . . . 68
Guidelines for Length of Exclusive Formula Feeding
and Supplementation With Solid Foods. . . . . . . . . . . . . . . . . . . . . . . . 68
Intact Cow Milk Protein-Based Formulas. . . . . . . . . . . . . . . . . . . . . . . 69
Soy Formulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Protein Hydrolysate Formulas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Other Formulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Cow Milk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
5 Nutritional Needs of the Preterm Infant. . . . . . . . . . . . . . . . . . . . . . . . . . 83
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Parenteral Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Parenteral to Enteral Transition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Enteral Feeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Human Milk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Facilitating Lactation and Human Milk Handling . . . . . . . . . . . . . . . 104
Commercial Formulas for Preterm Infants . . . . . . . . . . . . . . . . . . . . . 106
Methods of Enteral Feeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Feeding the Preterm Infant After Discharge . . . . . . . . . . . . . . . . . . . . 109
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

FM_i-xxvi.indd 10 10/4/13 2:30 PM

 Table of Contents xi

6 Complementary Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Nutritional Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Physiologic and Developmental Considerations. . . . . . . . . . . . . . . . . 129
How to Guide Complementary Feeding. . . . . . . . . . . . . . . . . . . . . . . 134

III Feeding the Child and Adolescent

7 Feeding the Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Toddlerhood. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Preschool-Aged Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
School-Aged Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Eating Patterns and Nutrient Needs. . . . . . . . . . . . . . . . . . . . . . . . . . 148
Parenting and the Feeding Relationship . . . . . . . . . . . . . . . . . . . . . . . 152
Special Topics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
The Role of Anticipatory Guidance in Promoting .
Healthy Eating Behaviors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
8 Adolescent Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Factors Influencing Nutritional Needs of Adolescents. . . . . . . . . . . . . 175
Dietary Reference Intakes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Nutrition Concerns During Adolescence . . . . . . . . . . . . . . . . . . . . . . 178
Nutritional Concerns for Adolescent Bone Health. . . . . . . . . . . . . . . 179
Nutritional Considerations During Pregnancy. . . . . . . . . . . . . . . . . . 180
Assessing and Maintaining Adequate Nutrition in Adolescents. . . . . . 181
9 Nutrition in School, Preschool, and Child Care . . . . . . . . . . . . . . . . . . 189
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
The US Nutritional Safety Net. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
The History of School Meals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
New Nutrition Standards for School Meals. . . . . . . . . . . . . . . . . . . . . 191
The Infrastructure of School Food Service. . . . . . . . . . . . . . . . . . . . . . 194
The Economics of the School Meal. . . . . . . . . . . . . . . . . . . . . . . . . . . 195
The Commodity School Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

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 xii Pediatric Nutrition, 7th Edition

The Nutritional Effectiveness of the School Meal Programs . . . . . . . . 197

Nutrition Goals and the National School Lunch Program . . . . . . . . . 197
The Nutrition Potential of the School Breakfast Program. . . . . . . . . . 198
Special Challenges for School Food Service. . . . . . . . . . . . . . . . . . . . . 199
Food Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Competitive Foods in Schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
National Standards for Competitive Foods in Schools . . . . . . . . . . . . 203
Wellness Advisory Committees and School Nutrition Policies . . . . . . 204
Controversies Surrounding School Nutrition. . . . . . . . . . . . . . . . . . . 204
Nutrition Standards in Preschool and Child Care. . . . . . . . . . . . . . . . 209
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
10 Cultural Considerations in Feeding Infants and Young Children. . 219
Importance of Addressing Cultural Influence on Feeding Practices. . . 219
Cultural Diversity in the United States. . . . . . . . . . . . . . . . . . . . . . . . 220
How Is Culture Linked to Health?. . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Cultural Influences on Feeding Practices. . . . . . . . . . . . . . . . . . . . . . . 221
Early Infant Feeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Cultural Influences on Breastfeeding Practices . . . . . . . . . . . . . . . . . . 223
Building Skills in Advising Parents and Caregivers . . . . . . . . . . . . . . . 233
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
11 Nutritional Aspects of Vegetarian Diets. . . . . . . . . . . . . . . . . . . . . . . . 241
Vegetarian Diets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Trends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Additional Implications of Vegetarianism. . . . . . . . . . . . . . . . . . . . . . 244
Nutrient Intake Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Whole Foods Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Nutritional Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Vegetarian Diets for Special Populations. . . . . . . . . . . . . . . . . . . . . . . 255
Vegetarian Diets in Management of the Metabolic Syndrome
and Type 2 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Vegetarian Diets and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

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 Table of Contents xiii

12 Sports Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Fuels for Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Fluids for the Workout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Building Blocks for Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Determination of Optimal Body Weight in Young Athletes . . . . . . . . 281
Vegetarian Athletes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Dietary Supplements/Ergogenic Aids. . . . . . . . . . . . . . . . . . . . . . . . . 287
13 Fast Foods, Organic Foods, Fad Diets, and Herbs, Herbals,
   and Botanicals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Fast Food. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Organic Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Fad Diets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Use of Botanicals by Children and Adolescents. . . . . . . . . . . . . . . . . . 334

IV Micronutrients and Macronutrients

14 Energy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Energy Balance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Components of Energy Expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . 360
Measurement of Energy Expenditure . . . . . . . . . . . . . . . . . . . . . . . . . 362
Energy Cost of Growth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Energy Requirements of Infants, Children, and Adolescents. . . . . . . . 364
Macronutrient Distribution Ranges . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Altered Energy Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
15 Protein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Recommended Dietary Intake for Protein and Amino Acids. . . . . . . . 371
Methods for Determining Protein and Amino Acid Requirements. . . 373
Protein Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Protein Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
Effects of Insufficient and Excessive Protein Intake. . . . . . . . . . . . . . . 383

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16 Carbohydrate and Dietary Fiber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Digestion of Disaccharides and Starches. . . . . . . . . . . . . . . . . . . . . . . 389
Absorption of Monosaccharides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Metabolism of Glucose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Lactose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Starches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Fiber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Glycemic Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Potential Benefits of Fiber Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Potential Adverse Effects of Fiber Intake. . . . . . . . . . . . . . . . . . . . . . . 400
Current Dietary Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . 401
17 Fats and Fatty Acids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Dietary Fats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Fat Digestion, Absorption, Transport, and Metabolism. . . . . . . . . . . . 409
Essential Fatty Acids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Long-Chain Polyunsaturated Fatty Acids . . . . . . . . . . . . . . . . . . . . . . 413
18 Calcium, Phosphorus, and Magnesium. . . . . . . . . . . . . . . . . . . . . . . . . 435
Basic Physiology/Homeostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Calcium Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Phosphorous Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
Magnesium Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
Dietary Sources: Calcium and Phosphorus. . . . . . . . . . . . . . . . . . . . . 443
Dietary Sources: Magnesium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
19 Iron. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Iron Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Nutritional Requirements for Iron. . . . . . . . . . . . . . . . . . . . . . . . . . . 450
Screening for ID and IDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Iron Supplements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

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20 Trace Elements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Zinc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Copper. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
Manganese. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
Selenium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
Iodine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Other Trace Elements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
21.I Fat-Soluble Vitamins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495
Vitamin A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495
Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
Vitamin E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
Vitamin K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510
21.II Water-Soluble Vitamins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Thiamine (Vitamin B1). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
Riboflavin (Vitamin B2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Niacin (Vitamin B3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
Pyridoxine (Vitamin B6). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
Folate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Cobalamin (Vitamin B12). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Vitamin C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
Other Water-Soluble Vitamins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
22 Federal Regulation of Foods and Infant Formulas,
   Including Addition of New Ingredients: Food Additives
   and Substances Generally Recognized as Safe (GRAS) . . . . . . . . . . . 535
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Federal Regulation of Ingredients Added To Food. . . . . . . . . . . . . . . . 536
“Functional Foods” and Provisions for Claims . . . . . . . . . . . . . . . . . . 544
Regulation of Infant Formula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Infant Formula Ingredients, Including New Ingredients. . . . . . . . . . . 546

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Newer Food Ingredients for the General Population. . . . . . . . . . . . . . 554

Biotechnology in the Development of New Food Ingredients. . . . . . . 560
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563

V Nutrient Delivery Systems

23 Parenteral Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Indications for Parenteral Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . 571
Routes of Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Composition of Solutions for Infants and Children . . . . . . . . . . . . . . 573
Ordering Parenteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582
Gastrointestinal and Hepatic Effects of Parenteral Nutrition. . . . . . . . 582
Transition to Enteral Feedings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
24 Enteral Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Indications for Enteral Tube Feedings:
Management of Nutrition-Related Disorders. . . . . . . . . . . . . . . . . . . 591
Enteral Formula Selection for Children 1 to 13 Years of Age. . . . . . . . 597
Enteral Formulas for Use in Children Older Than 13 Years
of Age: Standard Tube-Feeding Formulas. . . . . . . . . . . . . . . . . . . . . . 598
Peptide-Based and Elemental Formulas. . . . . . . . . . . . . . . . . . . . . . . . 598
Oral Supplements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
Blenderized Formulas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
Formula Concentration and Supplementation With Use
of Modular Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
Tube Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
Continuous Versus Intermittent Enteral Feeding . . . . . . . . . . . . . . . . 603
One Final Note of Caution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603

VI Nutrition in Acute and Chronic Illness

25 Assessment of Nutritional Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Assessment of Dietary Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609

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Clinical Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610

Growth Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
Assessment Tools for Anthropometric Measurements by Age Group. . 617
Anthropometric Measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Nutritional Assessment Through the Measurement
of Body Composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
Research Body Composition Assessment Techniques . . . . . . . . . . . . . 626
Clinical Assessment Tools for Body Composition Assessment. . . . . . . 629
Laboratory Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
26 Pediatric Feeding and Swallowing Disorders . . . . . . . . . . . . . . . . . . . 643
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643
Differential Diagnosis of Feeding Versus Swallowing Disorders. . . . . . 643
Summary of Feeding Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
Summary of Swallowing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
Evaluation of Pediatric Dysphagia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654
Dysphagia and the Preterm Infant . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
Assessment and Treatment Updates for Pediatric Dysphagia. . . . . . . . 657
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
27 Failure to Thrive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Ecologic Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Medical Issues in Evaluation and Treatment. . . . . . . . . . . . . . . . . . . . 665
Physical Examination and Laboratory Evaluation. . . . . . . . . . . . . . . . 675
Medical Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677
Nutritional Evaluation and Treatment . . . . . . . . . . . . . . . . . . . . . . . . 677
Psychosocial Issues in Evaluation and Treatment. . . . . . . . . . . . . . . . . 686
Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
28 Chronic Diarrheal Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Introduction and Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Evaluation of the Infant and Child With Persistent Diarrhea . . . . . . . 702
Differential Diagnosis of Chronic Diarrhea . . . . . . . . . . . . . . . . . . . . 705
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714

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29 Oral Therapy for Acute Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
Physiologic Principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
The Search for a More Effective ORS. . . . . . . . . . . . . . . . . . . . . . . . . 719
Early, Appropriate Feeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
Oral Therapy for Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
Common Concerns About ORS Solutions in the United States. . . . . 723
30 Inborn Errors of Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Inheritance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Newborn Screening for IEMs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Signs and Symptoms of IEMs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728
Emergency Therapy of Suspected IEM. . . . . . . . . . . . . . . . . . . . . . . . 729
Nutritional Therapy Using Synthetic Medical Foods. . . . . . . . . . . . . . 730
Other Nutritional Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
Other Therapeutic Modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
31 Nutrition Therapy for Children and Adolescents With Type 1
   and Type 2 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
Guidelines For Nutritional Medical Management of T1DM . . . . . . . 744
Therapy For T2DM and Prediabetes. . . . . . . . . . . . . . . . . . . . . . . . . . 758
Special Situations and Chronic Diseases Associated With Diabetes
Mellitus in Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760
Summary/Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763
32 Hypoglycemia in Infants and Children . . . . . . . . . . . . . . . . . . . . . . . . . 771
Introduction and Definition of Hypoglycemia. . . . . . . . . . . . . . . . . . 771
Clinical Manifestations of Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . 773
Etiology of Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774
Evaluation of Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
Differential Diagnosis of Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . 778
Treatment of Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 786

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33 Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791
Lipoproteins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 792
Types of Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793
Prevention of Atherosclerosis and Prudent Lifestyle and Diet. . . . . . . 795
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 799
34 Pediatric Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805
Adipose Tissue: An Organ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
Genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812
Epidemiology of Pediatric Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . 813
Influence of the Life Cycle on Pediatric Obesity. . . . . . . . . . . . . . . . . 815
Comorbidities of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
Prevention of Childhood Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . 823
Treatment of Pediatric Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833
35 Food Allergy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846
Food Allergens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846
Prevalence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847
Clinical Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 848
Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
Medical Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 857
36 Nutrition and Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
Early Nutritional-Immunologic System Interactions. . . . . . . . . . . . . . 864
Preterm and Low Birth Weight Infants. . . . . . . . . . . . . . . . . . . . . . . . 869

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 xx Pediatric Nutrition, 7th Edition

Micronutrients and Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874
37 Nutritional Support for Children With Developmental
   Disabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883
Growth Abnormalities in Children With Neurologic Impairment . . . 883
Growth Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
Nutritional Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892
Ethical Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
38 Nutrition of Children Who Are Critically Ill. . . . . . . . . . . . . . . . . . . . . . 907
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907
Malnutrition and Metabolic Reserves. . . . . . . . . . . . . . . . . . . . . . . . . 907
Protein Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
Carbohydrate and Lipid Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . 909
Energy Requirement During Critical Illness. . . . . . . . . . . . . . . . . . . . 910
Micronutrients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
Immunonutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
Nutrient Delivery in the PICU – Challenges . . . . . . . . . . . . . . . . . . . 912
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913
39 Nutritional Support of Pediatric Patients With Eating Disorders. . 917
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917
Clinical Features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 918
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 926
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 936
40 HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
Nutrition and the Immune System. . . . . . . . . . . . . . . . . . . . . . . . . . . 939
Nutrition in Pediatric HIV for Children Naive or Resisant to
Antiretroviral Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941

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 Table of Contents xxi

Nutrition in Pediatric HIV With Effective Viral Suppression and

Immune Reconstitution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952
Nutritional Assessment and Interventions. . . . . . . . . . . . . . . . . . . . . . 959
Nutrition in HIV-Exposed, Uninfected Children. . . . . . . . . . . . . . . . 964
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965
41 Nutrition for Children With Sickle Cell Disease and Thalassemia. . 979
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 979
Macronutrient Intake, Requirements, and Energy Expenditure . . . . . 980
Specific Micronutrient Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . 982
Nutritional Status in Subpopulations of SCD and Thal . . . . . . . . . . . 988
Unique Nutritional Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 989
Nutritional Guidelines for SCD and Thal. . . . . . . . . . . . . . . . . . . . . . 990
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 992
42 Nutritional Management of Children With Kidney Disease. . . . . . . 999
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999
Urinary Tract Infections, Vesicoureteral Reflux,
and Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003
Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1004
Kidney Stone Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005
Renal Tubular Defects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
Nephrotic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1008
Glomerulonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009
Acute Renal Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010
Chronic Renal Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1012
Vitamins and Trace Minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014
Children on Dialysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015
Renal Transplantation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015
43 Nutritional Management of Children With Cancer. . . . . . . . . . . . . . 1021
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021
Nutritional Status at Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021
Host-Related Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Therapy-Related Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023

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Nutritional Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024

Nutritional Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1027
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030
44 The Nutritional Aspects of Inflammatory Bowel Disease
   in Pediatric Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1035
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1035
Growth Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1035
Monitoring of Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037
Nutritional Therapy for IBD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1044
Psychosocial Impact of Nutritional Interventions in the Care of Children
With IBD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1048
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1049
45 Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1057
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1057
Nutritional Assessment of the Child With Liver Disease. . . . . . . . . . 1058
Malabsorption in Chronic Liver Disease. . . . . . . . . . . . . . . . . . . . . . 1059
Ascites Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1070
Liver Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1071
Parenteral Nutrition-Associated Liver Disease. . . . . . . . . . . . . . . . . . 1074
46 Cardiac Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1077
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1077
Undernutrition in CHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1078
Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083
47 Nutrition in Children With Short Bowel Syndrome. . . . . . . . . . . . . . 1095
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1095
Intestinal Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1096
Intestinal Physiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1097
Nutritional Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098
Nutritional Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1099
Medical Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1105
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1109

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 Table of Contents xxiii

48 Nutrition in Cystic Fibrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1113

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1113
Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1114
Overview of Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1116
Nutritional Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1117
Specific Guidelines for Nutritional Management . . . . . . . . . . . . . . . 1127
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1137
49 The Ketogenic Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
Physiologic Basis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148
Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149
Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1150
Efficacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1152
Adverse Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1153
The Keto Team. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1154
Calculation of the Ketogenic Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . 1155
Micronutrient Supplementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156
Initiation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156
Maintenance and Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1158
Concurrent Medications and Occult Carbohydrates. . . . . . . . . . . . . 1158
Adjusting the Diet for Optimal Seizure Control. . . . . . . . . . . . . . . . 1159
Discontinuation of the Ketogenic Diet. . . . . . . . . . . . . . . . . . . . . . . 1159
Alternative Dietary Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1160
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161
50 Nutrition and Oral Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167
Dental Caries—an Infectious Disease. . . . . . . . . . . . . . . . . . . . . . . . 1167
Dietary Influences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1168
The Costs Are Enormous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1171
Nutritional Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172
Fluoride: Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172

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 xxiv Pediatric Nutrition, 7th Edition

Fluoride Supplements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173

Fluoride Varnish. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175
Fluorosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176
Fluoride Toxicity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1178
Role of the Pediatrician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1178

VII Nutrition and Public Health

51 Community Nutrition Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1187
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1187
Nutrition Services Provided Through Federal, State,
and Local Health and Nutrition Agencies. . . . . . . . . . . . . . . . . . . . . 1187
Health and Nutrition Agencies: A Nutrition Resource
to Provide Services and Identify Qualified Providers. . . . . . . . . . . . . 1192
Nutrition-Assistance Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1194
Supplemental Food Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1198
Food Distribution Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1200
Where to Seek Nutrition Assistance for Clients. . . . . . . . . . . . . . . . . 1203
Other Federal Agencies Providing Nutrition Services
to Improve Pediatric Health and Well-Being. . . . . . . . . . . . . . . . . . . 1203
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1206
52 Food Labeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1209
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1209
Ingredient Labeling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1209
The Nutrition Facts Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1210
Food Labels for Infants Younger Than 2 Years and Children
Between 2 and 4 Years of Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1213
Nutrition Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1213
Package Dating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1219
Front-of-Package Nutrition Rating Systems and Symbols. . . . . . . . . 1220
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1221
53 Food Safety: Infectious Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1225
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1225
Epidemiology of Foodborne Disease. . . . . . . . . . . . . . . . . . . . . . . . . 1225
Clinical Manifestations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1230
Laboratory Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1230

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Another Random Scribd Document
with Unrelated Content
JEREMY BENTHAM
 His figure as here described is still to be seen in the rooms of
University College, Gower Street, London. It is curious that Dr. Smith
did not go to the mask for a representation of Bentham’s actual face.
That such a mask was made, George Combe testified in the columns
of the London Phrenological Journal a few years after Bentham’s
death. He said that it was in his own possession, and showed that
“the knowing organ was large and the reflective organs only full.”
The mask, he said, was very like the portrait of Bentham reproduced
in Tait’s edition of Bentham’s works. But he does not say whether it
was a death-mask or the life-mask known to have been made by
Turnerelli, an Italian sculptor living in London, in the early part of
this century, and when Bentham was not more than fifty years of
age. He was eighty-five when he died. This plaster mask of Bentham
has been compared carefully with the wax effigy in University
College. The mouth, the cranial arch, the entire upper part of the
face, and the general shape of the head are very like, although in
the wax mask the chin is shorter and rounder, and the eyes, of
course, are open.
The mask of Rossetti was made by Brucciani, after death. Only
three or four copies were cast, and the mould is in the possession of
Mr. William M. Rossetti, through whose courtesy I am able to
reproduce it here, and who writes: “I should say that my family and
myself do not at all like the version of my brother’s face presented
by the mould and cast. In especial, singular though it may sound,
the dimensions of the forehead seem wofully narrowed and belied.
But of course, from a certain point of view, the cast tells truth of its
own kind.”
Mr. Hall Caine, writing of his own copy of the mask, says: “I ought
perhaps to add that it does not give a good impression of Dante
Rossetti. The upper part of the head is very noble, but the lower
part is somewhat repellant.”
A fourth copy belongs to Mr. George F. Watts, the painter, whose
portrait of Rossetti is so well known.
DANTE GABRIEL ROSSETTI
 An anonymous writer in Blackwood’s Magazine for January, 1893,
who seems to have known Rossetti intimately, thus describes the
head and front of the poet: “He was short, squat, bull-doggish; he
belonged to the Cavour type, but the sallow face was massive and
powerful. The impression of solidity is somewhat toned down in
Watts’s portrait, and the face is thinner and more worn than when I
knew him. Sleepless nights and protracted pain may have changed
him in later years and made the ideal Rossetti more manifest. Except
for the meditative, tranquil eye (one thought of the ox-eyed Janus),
there was nothing ideal about him. He was intensely Italian, indeed,
but it was the sleek and well-fed citizen of Milan or Genoa that he
recalled, not the slim and romantic hero of Verdi or Donizetti.”
Cavour, according to George Eliot, who once got a glimpse of him
in an Italian railway station, was a man pleasant to look upon, with a
smile half kind and half caustic. He gave her the impression that “he
thought of many matters, but thanked Heaven and made no boast of
them.” Elsewhere she said: “The pleasantest sight was Count Cavour
in plainest dress, with a head full of power, mingled with bonhomie.”
Mr. O. M. Spencer, in Harper’s Magazine for August, 1871, devotes
much space to the personal appearance of Cavour, who was,
according to this authority, “of medium stature, with a tendency to
corpulency; quick and energetic in his movements, with a forehead
broad, high, and spacious; his eyes were partially closed by
weakness and still further concealed by spectacles; his mouth not
well formed and somewhat voluptuous, over which played an ironical
smile, the joint offspring of mirth and disdain. Nevertheless, the tout
ensemble of his countenance was expressive of benignity. Simple in
his manners, though dignified in his bearing, he would have been
recognized anywhere as a sub-alpine country gentleman, familiar
with the usages of the court. Though of an irascible, phosphoric
temperament, he rarely or never lost his self-control. Generous in his
enmities and liberal in his friendships, he was chary of his confidence
and exclusive in his intimacies. It may be that he was devoid of faith
and affection, but he certainly loved Italy, and believed in his own
mission.”
The death-mask of Cavour, and that of Pius IX., I found lying
peacefully side by side in a little plaster-shop in Rome in the autumn
of 1893. The Pope was assuredly not devoid of faith and affection;
and if he loved Italy less, it was only because he loved the Church of
Rome more.
COUNT CAVOUR
PIUS IX.
 Pius IX., we were told, at the time of his death in 1878, was a hale
and vigorous septuagenarian, with a fine presence, a rich and
melodious voice, a facile utterance, which rose at times to
eloquence, and a benign countenance. For three days the body of
the Pope lay in state in the Chapel of the Holy Sacrament in St.
Peter’s, and an eye-witness of the ceremonies wrote: “The face,
perfectly visible, seemed unchanged from what it had been in life,
and the expression was one of absolute peace; the calmness,
indeed, was almost like that of sleep. A slight flush, even, was on
the cheek, and a smile seemed to hover about the lips. The white
hair peeped from under the mitre, and in the crossed hands, covered
with red gloves, lay a crucifix suspended from a chain about his
neck.”
Signor A. Gallenza, in a volume entitled The Pope and the King,
spoke of the pontiff’s face in death as “handsome and dignified, with
something like sternness in the lofty brow, strangely contrasting with
that set smile so winning in the living man himself, but which was
merely the result of a muscular contraction, a dimple which even
death could not smooth.”
Henry Crabb Robinson wrote from Italy in 1831: “I occasionally
saw Leopardi, the poet, a man of acknowledged genius and of
unimpeachable character. He was a man of good family and a
scholar, but he had a feeble frame, was sickly and deformed.”
Leopardi’s life was very unhappy. His bodily infirmities humiliated
him, and domestic trials greatly affected his spirit. He seems to have
inspired very little tenderness even in the heart of his own mother,
and he died as miserably as he lived, longing for the eternal rest
from pain and neglect. His contemporaries have left almost nothing
on record concerning his personal appearance, but the few existing
portraits of him, and particularly this cast of his dead face, certainly
show sweetness mingled with strength. Mr. Howells, in his Modern
Italian Poets, quotes Niebuhr as saying of the young Leopardi:
“Conceive of my astonishment, when I saw standing before me, in
the poor little chamber, a mere youth, pale and shy, frail in person
and obviously in ill-health, who was by far the first, in fact the only,
Greek philologist in Italy.”
GIACOMO LEOPARDI
JOHN BOYLE O’REILLY
 The best and most sympathetic portrait of John Boyle O’Reilly is
the following, to be found in the life of that gentleman written by his
friend, Mr. James Jeffrey Roche: “Recalling him as he then was
[1870], the abiding memory of him is that of his marvellously sweet
smile, and his strikingly clear and frank gaze; the beauty of his face
lay chiefly in his eyes. The official advertisement of his escape says
that those eyes were brown, and prison descriptions are generally
more accurate than flattering. Almost anybody looking at him less
closely, would have said that his eyes were black. As a matter of
fact, they were hazel, but his dark skin and jet-black eyebrows and
hair gave an impression of blackness to the large, well-formed eyes
beneath. They were very expressive, whether flashing with some
sudden fancy or glowing with a deeper burning thought, or sparkling
with pure boyish fun. There was another expression, which they
sometimes wore at this period of his life, and which may be
described for lack of a better word, as a hunted look—not frightened
or furtive, but an alert, watchful expression, which made it easy to
understand how he could have deliberately armed himself with the
firm intention of surrendering his liberty only with his life.... No
portrait ever made of him does justice to that which was the great
charm of his countenance—its wonderful light and life. His eyes had
the depth and fire and mobile color of glowing carbuncle. For the
rest he had the rich brown complexion, so familiar in after-years; a
small black mustache, only half concealing his finely-cut mouth, and
revealing a set of perfectly white, regular teeth. His form was slight,
but erect and soldier-like. He carried his head well raised, and a little
thrown back. He was a man whom no one would pass without a
second glance.”
It is rather a curious fact that the men most interested, naturally,
in the study of the human face, and in its portrayal with chisel or
pencil, are the men most poorly represented in this collection; Sir
Thomas Lawrence being the only painter of portraits, and Hiram
Powers, Haydon, and Canova the only makers of masks, whose
masks are here presented. Three views of the life-mask of Sir
Thomas Lawrence were engraved by R. J. Lane, in 1830. They are
contained on one plate, and represent the full face, as well as
profiles looking to the right and to the left. The print is very rare,
and bears the following inscription: “From a plaster cast taken at the
age of thirty-four, in the possession of an attached friend.”
SIR THOMAS LAWRENCE
 Edward H. Baily, the sculptor, is known to have made a cast of
Lawrence’s features after death. “The head was finely shaped and
bald, and it bore a striking resemblance to that of Canning, although
the face lacked something of Canning’s elevated expression.” This
death-mask is here presented.
Lawrence is said to have been a beautiful creature in his boyhood,
with bright eyes, and long chestnut hair. In later life we are told that
“although not tall—he was under five feet nine inches—his beautiful
face, active figure, agreeable manners, and fine voice were not
thrown away upon either lords or ladies, emperors or kings.” Opie
said of him once, “Lawrence made coxcombs of his sitters, and his
sitters made a coxcomb of him.” And George IV., the Sir Hubert
Stanley of fine manners, pronounced him “a high-bred gentleman.”
This is praise indeed! Another, and perhaps not so exalted an
authority, said, “Lawrence’s appearance was exceedingly graceful
and gentlemanly. His countenance was open and noble, his eyes
were large and lustrous and very expressive.” Dr. R. R. Madden, in
his Memoirs of the Countess of Blessington, quotes a brother artist,
and a friend of Lawrence, as saying of him, “As a man Sir Thomas
Lawrence was amiable, kind, generous, and forgiving. His manner
was elegant but not high-bred. He had too much the air of always
submitting. He had smiled so often, and so long, that at last his
smile had the appearance of being set in enamel.”
The mask of J. M. W. Turner formerly belonged to the late Dr.
Pocock of Brighton, England, and is now in the possession of Mr.
William Ward, of London. It was made, after death, by the late
Thomas Woolner. There are but few portraits of Turner in existence,
the most life-like being an engraving by M. M. Halloway, of a half-
length profile sketch bearing this inscription: “Drawn by me in the
print-room of the British Museum. J. T. Smith.” Unfortunately no date
is attached.
Much has been put on record about Turner’s personal peculiarities
and eccentricities; but little has been said by his contemporaries
concerning his personal appearance. The best picture, although a
slight one, is from the pen of Mr. W. P. Frith: “Turner was a very
short man, with a large head, and a face usually much muffled to
protect it from the draughts for which the rooms [of the Royal
Academy] were celebrated.”
J. M. W. TURNER
 Cyrus Redding, in his Past Celebrities, speaks of Turner’s
“unprepossessing exterior, his reserve, and his austerity of
language.” Wilkie Collins once described him as seated on the top of
a flight of steps, astride of a box, on Varnishing Day at the Royal
Academy, “a shabby Bacchus, nodding like a mandarin at his picture,
which he with a pendulum-motion now touched with his brush, now
receded from.” And Peter Cunningham, in an almost brutal way, set
down Turner as “short, stout, and bandy-legged, with a red, pimply
face, imperious and covetous eyes, and a tongue which expressed
his sentiments with murmuring reluctance.” Sir William Allen,
according to Cunningham, was accustomed to describe the great
painter as a “Dutch Skipper.”
In view of all this, it is not remarkable that Turner had strong
objections to sitting for his portrait. He felt that any familiarity with
his face and figure would affect the poetry of his works in the
popular mind. “No one,” he said, “would believe, after seeing my
likeness, that I painted these pictures.” A contemporary portrait of
Turner, fishing in all his uncouth enthusiasm, with shabby garments,
and a cotton umbrella over his head, is unfortunately too long to be
quoted here.
Hiram Powers died in Florence in 1873, and lies in the Protestant
Cemetery of that city. His mask, after death, was made by Thomas
Ball and Joel T. Hart. Dr. Samuel Osgood said of Powers in 1870: “In
his looks, his ideas, as well as in all his works, he is a man of the
golden mean. There is nothing too much in his make or his manner.
He is a good specimen of a well-formed man, and his own statue
would make a good sign for the front of his studio.” In October,
1847, Mrs. Browning wrote: “Mr. Powers, the sculptor, is our chief
friend and favorite. A most charming, simple, straightforward, genial
American—as simple as the man of genius he has proved himself to
be.... The sculptor has eyes like a wild Indian’s, so black and full of
light—you would scarcely marvel if they clove the marble without the
help of his hand.” “Mr. Powers called in the evening,” wrote
Hawthorne in his Italian Note-book in 1858—“a plain personage,
characterized by strong simplicity and warm kindliness, with an
impending brow, and large eyes which kindle as he speaks. He is
gray and slightly bald, but does not seem elderly nor past his prime.
I accept him at once as an honest and trustworthy man, and shall
not vary from this judgment.”
HIRAM POWERS
 Mr. Preston Powers, who possesses the mask of his father, has
also in his possession a life-mask and a death-mask of Agassiz, and
a death-mask of Sumner; the last two having been made by himself.
Through his courtesy I am enabled to reproduce them all here.
The life-mask of Agassiz was made when the subject was about
forty years of age, and by an artist now unknown. It was given to
Mr. Powers by Mr. Alexander Agassiz at the time of the elder
Agassiz’s death.
E. P. Whipple, in his Recollections of Eminent Men, said of Agassiz:
“You could not look at him without feeling that you were in the
presence of a magnificent specimen of physical, mental, and moral
manhood; that in him was realized Sainte-Beuve’s ideal of a scientist
—the soul of a sage in the body of an athlete. At that time [1845] he
was one of the comeliest of men. His full and ruddy face, glowing
with health and animation, was crowned by a brow which seemed to
be the fit home for such a comprehensive intelligence.” And
Longfellow, in his Journal (January 9, 1847), wrote: “In the evening
a reunion at Felton’s to meet Mr. Agassiz, the Swiss geologist and
naturalist. A pleasant, voluble man, with a bright beaming face.”
Mr. Curtis, in an oration upon Charles Sumner, delivered shortly
after the statesman’s death, said that “his look, his walk, his dress,
his manner, were not those of the busy advocate, even in his
younger years, but of the cultivated and brilliant man of society, the
Admirable Crichton of the saloons.”
Mrs. Jefferson Davis, in her Life of her husband, spoke of Sumner
as “a handsome, unpleasing man, and an athlete whose physique
proclaimed his physical strength.” And Mr. Seward wrote to his wife
in 1856: “Sumner is much changed for the worse. His elasticity and
vigor are gone. He walks, and in every way moves, like a man who
has not altogether recovered from a paralysis, or like a man whose
sight is dimmed, and his limbs stiffened with age.”
At the autopsy it was discovered that the brain of Sumner showed
no trace of the assault from the effects of which he suffered so
terribly.
LOUIS AGASSIZ—From Life
LOUIS AGASSIZ—From Death
CHARLES SUMNER
 Canova must have been a beautiful character. It is not often that
so much good is spoken, even of the dead, as has been spoken of
him since he died; and if the chroniclers are right, he deserved it all.
In personal appearance, however, we read that he was not
particularly attractive. His hair was black and luxuriant, and his
forehead of noble dimensions, but the outline of his features was
neither grand nor extraordinary. The phrenologists gave him a
massive brain upward and forward of the ears, wonderful
constructive talent, with large ideality and strong intellect. He was
very abstemious in his habits, very thoughtful, and a hard worker.
Count Cicognara, in a biographical sketch of Canova, thus described
his face during his very last hours: “His visage became, and
remained for some time, highly radiant and expressive, as if his mind
was absorbed in some sublime conception, creating powerful and
unusual emotion in all around him. Thus he must have looked when
imagining that venerable figure of the pontiff who is represented in
the attitude of prayer in the Vatican. His death was wholly
unattended by the agonies which make a death-bed so distressing,
nor did even a sigh or convulsion announce his dying moment.”
This is the visage which his friends cast in plaster, and it was, no
doubt, the basis of the medallion bust of Canova, in profile, which
forms part of the pyramidal tomb erected by certain of his pupils in
1827, in the church of Sante Maria Gloriosa dei Frari, the pantheon
of Venice. The monument, according to Mr. Ruskin, is “consummate
in science, intolerable in affectation, ridiculous in conception; null
and void to the uttermost in invention and feeling;” and the
medallion represents the great sculptor in all his glorious prime of
strength and beauty.
The death-mask of Canova, as here reproduced, in its peaceful
and quiet repose, is in strong contrast with that of Richard Brinsley
Sheridan, shown upon a subsequent page.
ANTONIO CANOVA
RICHARD BRINSLEY SHERIDAN