Pediatric Nutrition and Nutritional

Disorders
Dr Ibraahim Guled
MBChB,MMED (Paediatrics).
 Outlines
Overview of nutrition in children
Diet of the normal infant
Diet of the normal child and adolescent
Obesity
Pediatric under nutrition
Vitamins
 Overview of nutrition in children
• Nutrition is concerned with how food is used by the
body, interfaces with gastroenterology, metabolism
and endocrinology, and is inseparable from growth
and development.
• Awareness of poor nutrition is critical to the effective
management of many childhood diseases, particularly
those that are chronic, and there is evidence that poor
nutrition in early life plays a part in the genesis of
adult degenerative diseases.
• Nutrition services should be provided by a team that
works together in the clinic, ward and community to
provide nutritional support for children.
 Cont..
• Nutritional requirements of infants and young
children differ from that of adults in a number
of aspects due to energy expenditure (i.e.,
basal metabolism, metabolic response to
food, and physical activity), rate of growth,
new growth, body composition, and
physiological changes (e.g., puberty).
 Cont..
• Due to the high nutritional needs of infants and
young children, there is an increased risk for
nutritional disruptions (i.e., undernutrition and
overnutrition).
• This risk may be compounded by lack of
knowledge or awareness of signs and
symptoms on the part of the caregiver. Regular
well child care visits aid in the prevention and
screening of such disruptions and can alleviate
associated detrimental effects.
 Cont..
• Nutrition can be classified by:
A. Macronutrients
B. Micronutrients
 Macronutrients
1. Carbohydrates
2. Proteins
3. Fats
8
Carbohydrates Digestion

9
Protein Digestion

10
Protein Types & Functions

11
12
 Micronutrients
1. Vitamins
2. Minerals
14
 Diet of the normal infant
• Proper nutrition in infancy is essential for
normal growth, resistance to infections, long-
term adult health, and optimal neurologic and
cognitive development.
• Healthy nutrition is especially important
during the first 6 months.
• Breastfeeding is associated with a reduced risk
of many diseases in infants, children, and
mothers.
 Breastfeeding Initiation
• The mother should be comfortable and the
infant positioned so that nothing interferes
with mouth-to-breast contact.
• The breast from which the infant nurses
should be supported with the opposite hand,
with the thumb and index finger above the
nipple to allow the infant easy access to the
nipple.

17
 Cont..
• The rooting reflex should be explained to the
parents to make initiation of breast-feeding
easier.
• The nipple is stroked against the infant's cheek
nearest the nipple.
• The infant turns toward the nipple (rooting
reflex) and open the mouth, allowing the
introduction of the nipple and areola.

18
 Cont..
• The entire nipple and most of the areola should be
placed in the infant's mouth.
• The infant "latches on" by compressing the lips.
• The mechanics of normal suckling include suction of
4 to 6 cm of the areola, compression of the nipple
against the palate, stimulation of milk ejection by
initial rapid non-nutritive sucking, and extraction of
milk from the lactiferous sinuses by a slower suck-
swallow rhythm of approximately one per second.

19
 Cont..
• The infant may be removed from the breast by
placing a clean finger between the infant's
gums and the areola to release suction.
• The mean feeding frequency during the early
weeks postpartum is 8 to 12 times per day

20
Good positioning

21
Good attachment

More areola above

Mouth wide open ??

Lower lip outward

Chin touching breast ??

22
 Exclusive Breastfeeding
• Definition: Means that the infant receives only
breast milk in the first 6month of life. No other
liquids or solids are given – not even water –
with the exception of oral rehydration solution,
or drops/syrups of vitamins, minerals or
medicines.
• Breastfeeding is the recommended method for
feeding normal infants during approximately
the first 6 months of life.
23
 Cont..
• Adequacy of milk intake can be assessed by voiding and
stooling patterns of the infant.
• A well-hydrated infant voids six to eight times a day.
• Each voiding should soak, not merely moisten, a diaper, and
urine should be colorless.
• By 5 to 7 days, loose yellow stools should be passed at least
four times a day.
• Rate of weight gain provides the most objective indicator of
adequate milk intake.
• Total weight loss after birth should not exceed 7%-10%, and
birth weight should be regained by 10 days.

24
 Cont..
• An infant may be adequately hydrated while not
receiving enough milk to achieve adequate
energy and nutrient intake.
• The characteristics of the stools of breastfed
infants often alarm parents.
• Stools are unformed, yellow, and seedy in
appearance.
• Parents commonly think their breastfed infant
has diarrhea.
25
 Cont..
• Stool frequencies vary; during the first 4 to 6
weeks, breastfed infants tend to produce stool
more frequently than formula-fed infants.
• After 6 to 8 weeks, breastfed infants may go
several days without passing a stool.
• In the newborn period, elevated concentrations
of serum bilirubin are present more often in
breastfed infants than in formula-fed infants .

26
 Breast-milk composition

• Breast milk contains all the nutrients that an infant

needs in the first 6 months of life, including fat,
carbohydrates, proteins, vitamins, minerals and
water.
• It is easily digested and efficiently used.
• Breast milk also contains bioactive factors that
augment the infant’s immature immune system,
providing protection against infection, and other
factors that help digestion and absorption of
nutrients.
28
 Cont..
• Fats : Breast milk contains about 3.5 g of fat per 100
ml of milk, which provides about one half of the
energy content of the milk.
• The fat is secreted in small droplets, and the
amount increases as the feed progresses.
• As a result, the hindmilk secreted towards the end
of a feed is rich in fat and looks creamy white, while
the foremilk at the beginning of a feed contains less
fat and looks somewhat bluish-grey in colour.

30
 Cont..
• Carbohydrates :The main carbohydrate is the
special milk sugar lactose, a disaccharide.
• Breast milk contains about 7 g lactose per 100
ml, which is more than in most other milks, and
is another important source of energy.
• Another kind of carbohydrate present in breast
milk is oligosaccharides, or sugar chains, which
provide important protection against infection

31
 Cont..
• Protein: Breast milk protein differs in both
quantity and quality from animal milks, and it
contains a balance of amino acids which makes
it much more suitable for a baby.
• The concentration of protein in breast milk (0.9
g per 100 ml) is lower than in animal milks.
• The much higher protein in animal milks can
overload the infant’s immature kidneys with
waste nitrogen products.
32
 Cont..
• Breast milk contains less of the protein casein,
and this casein in breast milk has a different
molecular structure.
• It forms much softer, more easily- digested curds
than that in other milks.
• Among the whey, or soluble proteins, human
milk contains more alpha-lactalbumin; cow milk
contains betalactoglobulin, which is absent from
human milk and to which infants can become
intolerant
33
 Cont..
• Vitamins and minerals: Breast milk normally
contains sufficient vitamins for an infant, unless
the mother herself is deficient .
• The exception is vitamin D. The infant needs
exposure to sunlight to generate endogenous
vitamin D –or, if this is not possible, a supplement.
• The minerals iron and zinc are present in relatively
low concentration, but their bioavailability and
absorption is high.

34
 Cont..
• Provided that maternal iron status is
adequate, term infants are born with a store
of iron to supply their needs; only infants born
with low birth weight may need supplements
before 6 months.
• Delaying clamping of the cord until pulsations
have stopped (approximately 3 minutes) has
been shown to improve infants’ iron status
during the first 6 months of life
35
 Cont..
• Anti-infective factors: Breast milk contains many
factors that help to protect an infant against
infection including:
 immunoglobulin, principally secretory immunoglobulin
A (sIgA), which coats the intestinal mucosa and prevents
bacteria from entering the cells;
 white blood cells which can kill micro-organisms;
whey proteins (lysozyme and lactoferrin) which can kill
bacteria, viruses and fungi;
 oligosacccharides which prevent bacteria from attaching
to mucosal surfaces.
36
 Cont..
• The protection provided by these factors is
uniquely valuable for an infant.
First, they protect without causing the effects of
inflammation, such as fever,which can be
dangerous for a young infant.
Second, sIgA contains antibodies formed in the
mother’s body against the bacteria in her gut, and
against infections that she has encountered, so they
protect against bacteria that are particularly likely
to be in the baby’s environment.
37
 Cont..
• Other bioactive factors: Bile-salt stimulated lipase
facilitates the complete digestion of fat once the milk has
reached the small intestine .
• Fat in artificial milks is less completely digested .
• Epidermal growth factor stimulates maturation of the
lining of the infant’s intestine, so that it is better able to
digest and absorb nutrients, and is less easily infected or
sensitised to foreign proteins.
• It has been suggested that other growth factors present
in human milk target the development and maturation of
nerves and retina .
38
 Colostrum and mature milk
• Colostrum is the special milk that is secreted
in the first 2–3 days after delivery.
• It is produced in small amounts, about 40–50
ml on the first day , but is all that an infant
normally needs at this time.

41
 Colostrum
Property Importance
• Antibody-rich • protects against infection and
allergy
• Many white cells • protects against infection
• Purgative • clears meconium; helps prevent
jaundice
• Growth factors • helps intestine mature;
prevents allergy, intolerance
• Vitamin-A rich • reduces severity of some
infection (such as measles and
diarrhoea); prevents vitamin A-
related eye diseases
 Cont..
• Milk starts to be produced in larger amounts
between 2 and 4 days after delivery, making the
breasts feel full; the milk is then said to have
“come in”.
• On the third day, an infant is normally taking
about 300–400 ml per 24 hours, and on the fifth
day 500–800 ml.
• From day 7 to 14, the milk is called transitional,
and after 2 weeks it is called mature milk.
43
 Benefits of breastfeeding
• Infant

• Mother

• Family and community

• Hospital
 Benefits of breastfeeding for the infant

• Provides superior nutrition for optimum

growth.
• Provides adequate water for hydration.
• Protects against infection and allergies.
• Promotes bonding and development.
 Benefits of breastfeeding for the mother

• Protects mother’s health

– helps reduces risk of uterine bleeding and helps the
uterus to return to its previous size
– reduces risk of breast and
ovarian cancer
• Helps delay a new pregnancy
• Helps a mother return to pre-pregnancy weight
Benefits of breastfeeding for the family
• Better health, nutrition, and well-being
• Economic benefits
– breastfeeding costs less than artificial
feeding
– breastfeeding results in lower medical care
costs
Benefits of breastfeeding for the hospital
• Warmer and calmer emotional environment
• No nurseries, more hospital space
• Fewer neonatal infections
• Less staff time needed
• Improved hospital image and prestige
• Fewer abandoned children
 Risks of artificial feeding
 Interferes with bonding

 More diarrhoea and  More allergy and

respiratory infections milk intolerance

 Persistent diarrhoea  Increased risk of

some
 Malnutrition chronic diseases
Vitamin A deficiency
 Overweight
 More likely to die
 Lower scores on
Mother intelligence tests
 May become  Increased risk of anaemia,
pregnant sooner ovarian and breast cancer
 Breastfeeding pattern

• To ensure adequate milk production and flow for 6

months of exclusive breastfeeding, a baby needs to feed
as often and for as long as he or she wants, both day and
night.
• This is called demand feeding, unrestricted feeding, or
baby-led feeding.
• Babies feed with different frequencies, and take
different amounts of milk at each feed.
• The 24-hour intake of milk varies between mother-infant
pairs from 440–1220 ml, averaging about 800 ml per day
throughout the first 6 months.
50
Common Breastfeeding Problems
• Breast tenderness, engorgement, and cracked nipples are
the most common problems encountered by breast-
feeding mothers.
• Engorgement, one of the most common causes of
lactation failure, should receive prompt attention because
milk supply can decrease quickly if the breasts are not
adequately emptied.
• Applying warm or cold compresses to the breasts before
nursing and hand expression or pumping of some milk can
provide relief to the mother and make the areola easier to
grasp by the nursling.
51
 Cont..
• Nipple tenderness requires attention to proper latch-
on and positioning of the infant.
• Supportive measures include nursing for shorter
periods, beginning feedings on the less sore side, air
drying the nipples well after nursing, and applying
lanolin cream after each nursing session.
• Severe nipple pain and cracking usually indicate
improper latch-on.
• Temporary pumping, which is well tolerated, may be
needed.
52
 Cont..
• If a lactating woman reports fever, chills, and
malaise, mastitis should be considered.
• Treatment includes frequent and complete
emptying of the breast and antibiotics.
• Breastfeeding usually should not be stopped
because the mother's mastitis commonly has
no adverse effects on the breastfed infant, and
abrupt weaning may increase the risk of
development of a breast abscess.
53
 Cont..
• Untreated mastitis also may progress to a breast
abscess.
• If an abscess is diagnosed, treatment includes incision
and drainage, antibiotics, and regular emptying of the
breast.
• Nursing from the contralateral breast can be continued
with the healthy infant.
• If maternal comfort allows, nursing also can continue
on the affected side.
• Women with genital herpes can breastfeed.
• Proper hand-washing procedures should be stressed.
54
Contraindication of breastfeeding
• A mother with active TB
• Herpes lesions on mothers breast
• HIV positive mother
• A infant with inborn error of metabolism e.g
Galactosemia, Phenylketonuria.
• A mother on certain medications e.g.
Anticancer therapy, Radioactive Isotope.
 Animal milks and infant formula

• Animal milks are very different from breast milk in both

the quantities of the various nutrients, and in their
quality.
• For infants under 6 months of age, animal milks can be
home-modified by the addition of water, sugar and
micronutrients to make them usable as short-term
replacements for breast milk in exceptionally difficult
situations, but they can never be equivalent or have the
same anti-infective properties as breast milk .
• After 6 months, infants can receive boiled full cream milk .

57
 Cont..
• Infant formula is usually made from industrially
modified cow milk or soy products.
• During the manufacturing process the
quantities of nutrients are adjusted to make
them more comparable to breast milk.
• However, the qualitative differences in the fat
and protein cannot be altered, and the absence
of anti-infective and bio-active factors remain.

58
 Cont..
• Powdered infant formula is not a sterile product, and
may be unsafe in other ways.
• Life threatening infections in newborns have been
traced to contamination with pathogenic bacteria,
such as Enterobacter sakazakii, found in powdered
formula .
• Soy formula contains phyto-oestrogens, with activity
similar to the human hormone oestrogen, which
could potentially reduce fertility in boys and bring
early puberty in girls .
59
60
 Therapeutic Formulas
• The composition of specialized infant and pediatric
formulas is modified to meet specific therapeutic
requirements .
• Therapeutic formulas are designed to treat digestive and
absorptive insufficiency or protein hypersensitivity.
• Semielemental formulas include protein hydrolysate
formulas.
• The major nitrogen source of each of these products is a
casein or whey hydrolysate, supplemented with selected
amino acids.
• These formulas contain an abundance of essential fatty
acids from vegetable oil. 61
 Cont..
• Certain brands also provide substantial
amounts (25% to 50% of total fat) of medium
chain triglycerides, which are water soluble
and are more easily absorbed than long chain
fatty acids; this is a useful feature for patients
with malabsorption resulting from such
conditions as short gut syndrome, intestinal
mucosal atrophy or injury, chronic diarrhea, or
cholestasis.
62
63
 Complementary Feeding
• By approximately 6 months, complementary feeding of
semisolid foods is suggested.
• By this age, an exclusively breastfed infant requires
additional sources of several nutrients, including protein,
iron, and zinc.
• If the introduction of solid foods is delayed, nutritional
deficiencies can develop, and oral sensory issues (texture
and oral aversion) may occur.
• General signs of readiness include the ability to hold the
head up and sit unassisted, bringing objects to the mouth,
showing interest in foods, and the ability to track a spoon
and open the mouth.
64
 Cont..
• Although the growth rate of the infant is decreasing,
energy needs for activity increase .
• A relatively high-fat and calorically dense diet (human
milk or formula) is needed to deliver adequate calories.
• The choice of complementary foods to meet
micronutrient needs is less critical for formula-fed
infants because of the nutrient fortification of formula.
• The exposure to different textures and the process of
self-feeding are important developmental experiences
for formula-fed infants.
65
 Cont..
• Commercially prepared or homemade foods help meet the
nutritional needs of the infant.
• Because infant foods are usually less energy dense than
human milk and formula, they should not be used in young
infants to compensate for inadequate intake from
breastfeeding or formula.
• Oropharyngeal coordination is immature before 3 months,
making feeding with solid foods difficult.
• Vitamin-fortified and iron-fortified dry cereals are often used
as a source of calories and micronutrients (particularly iron) to
supplement the diet of infants whose needs for these
nutrients are not met by human milk after about 6 months of
age. 66
 Cont..
• Introduction of single-ingredient meats (versus
combination dinners) as an early complementary
food provides an excellent source of bioavailable
iron and zinc, both of which are important for the
older breastfed infant.
• Parents who prefer to make homemade infant
foods using a food processor or food mill should
be encouraged to practice safe food handling
techniques and avoid flavor additives such as salt.

67
 Cont..
• Juice frequently is given to infants, although it is not a necessary
"food" for infants.
• If given, juice should be started only after 6 months of age, be
given in a cup (as opposed to a bottle), and limited to 4 oz daily.
• An infant should never be put to sleep with a bottle or sippy cup
filled with milk, formula, or juice because this can result in infant
bottle tooth decay .
• Foods with high allergic potential that should be avoided during
infancy, especially for infants with a strong family history of food
allergy, including fish, peanuts, nuts, dairy products, and eggs.

68
 Cont..
• Grapes, and nuts also present a risk of
aspiration and airway obstruction.
• All foods with the potential to obstruct the
young infant's airway should be cut into sizes
smaller than an infant's main airway.
• Honey (risk of infant botulism) should not be
given before 1 to 2 years of age.

69
Diet of the normal child and adolescent
• Nutrition issues for toddlers and older
children:
• Learning healthy eating behaviors at an early
age is an important preventive measure
because of the association of diet with several
chronic and noncommunicable diseases
(NCDs), such as obesity, diabetes, and
cardiovascular disease, which may account for
approximately 60% of all deaths worldwide.
 Cont..
• These diseases share risk factors that can be modified by
lifestyle changes such as eating less processed food and
increasing physical activity.
• Diets high in fruits and vegetables together with
increased physical activity improve metabolic risk factors.
• The first 1000 days of life are an important time to
engage in healthy nutrition behaviors that will promote
well-being.
• Accelerated postnatal growth in infants and young
children is an important risk factor for obesity;
interventions should be aimed at identifying underlying
causes for early prevention.
 Milk
• The consumption of cow’s milk is ideally not introduced
until approximately 1 year of age when it is better
tolerated.
• Low-fat (2%) or whole milk is recommended until 2 years
or age, after which fat-free or 1% milk is recommended.
• Excessive milk intake (more than 24 oz/day) should be
avoided in toddlers because larger intakes may reduce
the intake of a good variety of nutritionally important
solid foods and also result in iron deficiency anemia;
large intakes also may contribute to excessive caloric
intake.
• THANKS