Engidaw Ambelu

1. Melese A(MD)

2.  Introduction
Nutrition is the process of taking in food and using it for
maintenance, growth ,metabolism and repair.
Nutrient is a substance in food used by an organism to make
energy,grow,develop and reproduce.
Macronutrients are nutrients that are needed in large amount. These
are carbohydrate,protien and fat.
Micronutrients are those required in very small amount. these are
vitamins and minerals.

3.  Essential nutrients are nutrients that are not produced by the body.
so they should be supplemented from food.
 Non essential nutrients are those can be produced by the body.
• Infants and children have a genetic potential for physical, mental, and
emotional growth. Optimal nutrition is required to achieve this growth.
•Both inadequate intake and excess intake are described as
malnutrition.
•An optimal feeding should contain five food types .
Carbohydrates,protiens,fats and oils,vitamins and minerals, and water.

4. Water
 Water is essential for existence.
 Water comprises ~ 50 to 60% of body weight in
young adults and 70 to 75% of body weight in
infants.
 Water is taken as food and fluid and also
produced in the body during metabolism of
nutrients.

5.  Human needs for water are related to caloric
consumption, to insensible loss and to specific
gravity of urine.
 The daily consumption of fluid by the healthy
infant is equivalent to 10-15% of body weight
compared with 2-4% in the adult
 Evaporation from the lung and skin accounts for
40-50% of intake and renal excretion for 40-50%
of intake.

6. Energy The 3 components of energy expenditure in adults
are
 Basal metabolic rate
 The thermal effect of food (energy required for digestion
and absorption)
 Energy for physical activity
 Additional energy intake and expenditure are required to
support growth and development for children
 Energy is measured in Joules or calorie
 Kilocalorie
 The amount of heat necessary to raise the temp. of 1 kg
of water from 14.5 to 15.5 C or by 1c
 1Joule= 4200 calories , 1kcalorie= 1000calories

7.  The nutrients that provide energy intake in the
child's diet are
 Fats contribute ∼ 9 kcal/g
 Carbohydrates contribute ∼ 4 kcal/g
 Proteins contribute ∼ 4 kcal/g)

8. Energy expenditure in children
1- Basal metabolism 50%
2- Physical activity 25%
3- Growth 12%
3- Fecal loss 8%
4- Thermic effect of food 5%

9.  Energy requirement based on age
 0-6mn 108kcal/kg/day
 6-12mn 98kcal/kg/day
 1-3 yr 102kcal/kg/day
 4-6yr 90kcal/kg/day
 7-10yr 70kcal/kg/day
 11-14yr male 55kcal/kg/day
female 45kcal/kg/day
 15-18 male 47kcal/kg/day
female 40kcal/kg/day

10. Fat The main dietary sources of fat include
 Animal products (meat, butter, milk, cheese, egg yolk)
 Vegetable oils, margarine and fried foods
 Dietary fats are composed of a various mix of
saturated fats, monounsaturated fat, PUFA,
trans fat, and cholesterol.

11.  Function of fat in the body
 Energy-dense macronutrients
 Cholesterol moieties are precursors for cell
membranes, hormones, and bile acids
 Fat intake also facilitates absorption of the fat-
soluble vitamins a, d, e, and k
 Dietary intakes of mono- and polyunsaturated
fats have been associated with positive health
outcomes.

12.  Humans are incapable of synthesizing the precursor
ω3 (α–linolenic; ALA) and ω6 (linoleic; LA) PUFAs
and are dependent on dietary sources for these
essential fatty acids
 Essential fatty acid (EFA) deficiency can be
associated with desquamating skin rashes, alopecia,
and growth deficits
 Essential fatty acids are present in breast milk, are
often supplemented in infant formulae, and are
required for normal growth and development

13. Protiens
 Protein intake is required to supply nitrogen and
amino acids for the synthesis of constituent
proteins and other nitrogen-containing
compounds such as polypeptide hormones.
 Are major structural component of all cells in the
body.
 Functions as enzymes, in membranes, as
transport carriers, and as some hormones.

14.  Amino acids are categorized in to 3
 Indispensable/essential AA humans depend on
dietary sources to meet adequacy and prevent
deficiency
 Threonine, valine, leucine, isoleucine, lysine,
tryptpophan, phenylalanine, methionine, and histidine
 Conditional essential/indispensable AA are
essential only at certain life stages
 e.g. in infants cysteine, tyrosine perhaps arginine
 Despensable/ nonessential AA available in foods
 Alanine,Aspartic acid, Asparagine, Glutamic acid, Serine

15. Carbohydrates
 Dietary carbohydrates include
 Monosaccharides (glucose, fructose)
 Disaccharides (sucrose, lactose)
 Oligosaccharides and polysaccharides (starch)
 The primary function of carbohydrates is to serve as
an energy source for all cells, with the central
nervous system and erythrocytes depending most on
glucose as an energy substrate.

16. vitamins
 Are important micro nutrints.
 Classified as :
- water soluble-vB complex & c
- fat soluble vitamins-vitamin A,D,E,K(adek)
vitamin A

17. Annimal Sources
Source (per 100gm) vit.A(mic.gm)
 Fish liver oil 145,000
 Liver, ox 840
 Butter, cow’s 730
 Kidney, ox 300
 Egg, hen 200
 Chicken 85
 Milk, whole cow’s 40
 Milk, gout 25

18. Plant source
Source (per 100gm) vit.A(mic.gm)
 Carrot, raw 1100
 Mango 400
 Lettuce 325
 Sweet potato, raw 510
 Avocado, raw 90
 Tomatoes, raw 75
 Papaya, raw 75

19.  Functions of vitamin A
 -vision
 -cell differentiation
 -bone growth
 -reproduction
 Clinical manifestations of vitamin A deficiency.
 -night blindness
 -conjuctival xerosis (the earliest lesion)
 -bitot’s spot-foamy,bubbly,or cheesy accumulation
 -xerosis of the cornea
 -corneal ulcer
 -keratomalacia

20. Bitot’s spot

21. Vitamin D
 Forms of vitamin D

 Vitamin D2
 Available as irradiated ergosterol
 Serves as dietary and therapeutic source
of vit D

22.  Vitamin D3
 Naturally present in human skin as 7-
dehydrocholestrole activated photochemically
to cholecalciferol and transferred to the liver
 In the liver by 25-hydroxylase to 25-
OH cholecalciferol then
 In the renal cortical cells by1,25 hydroxylase
to 1,25
dehydroxycholecalciferol

23.  Functions of 1,25-dehydroxycholecalciferol
 Facilitates intestinal absorption of calcium and
phosphorus
 Reabsorption of phosphorus in the kidney
 Control serum ca and P together with
parathyroid hrn and calcitonin.

24. Clinical feathers of vitamin D
deficiency
 Craniotabes - softening of the cranial bones, can
be detected by applying pressure at the occiput
or over the parietal bones -earliest sign of rickets
 Rachitic rosary -the beads of a rosary as the
examiner's fingers move along the costochondral
junctions

25.  Growth plate widening is also responsible for the
enlargement at the wrists and ankles
 Harrison groove horizontal depression along the
lower anterior chest

26.  Large anterior fontanell
 Caput quadratum
 Pigeon chest
 Delayed eruption of temporary teeth
 Bow leg or knock knee
 Greenstick fracture
 Rachitic dwarfism
 Hypotonia
 Sweating
 Delayed tooth eruption

27.  Serum Ca= normal or low
 Serum Phosphorus= low
 Serum alkaline phosphatase= increased
 Serum 25-OH cholecalciferol decreased

28. Radiology
 Generalized decrease in the skeletal
radiodensity
 Widening, capping and fraying at the end distal
of the bones, best seen at the end of radius and
unla

30. Differential diagnosis
Craniotabes -hydrocephalus
-osteogenesis imperfecta
-immidiate post natal period
Costochondral beading - scurvy
-chondrodystrophy

31.  Vitamin D adminstration
-Stoss dose of vit D 300,000-600,000 IU IM in 2-
4 doses over one day or,
Daily intake of 2000-5000IU of vit D for 4-6 wks
-Both should be accompanied by adequate
administration of Ca and P
-After treatment continue with the daily
requirement i.e 400IU of vit D daily

32.  Most cases of nutritional rickets can be
prevented by universal administration of a daily
multivitamin containing 200–400 IU of vitamin D
to children who are breast-fed
 Adequate sunlight exposure

33. Feeding in infancy
 Breast milk is the best food for the newborn
 It should be started immediately after birth with in
one hour of life
 It should be given exclusively for the first 6 month
of life even water need not to be added
 It contains all the nutrients required by the infant

34.  The suckling newborn stimulates the mother's
pituitary to release prolactin and oxytocin, which
in turn stimulate the production and let-down of
breast milk (milk ejection reflex), respectively
 Composition of breast milk varies at diffent stages
after birth
 Colostrum is milk produced during the 1st week
after birth, yellow & thick and contains more
antibodies and WBC , secreted in small amount,
contains more protein than mature milk

35.  Mature milk is secreted after the colostum thinner &
watery but contains all the nutrients required by the
baby
 Foremilk is milk secreted at the start of feeding it is
watery rich in proteins, vitamins, minerals and water
 Hind milk thicker richer in fat content

36.  For effective breast feeding there should proper attachment
and positioning with effective suckling
 Positioning
 Supporting babies whole body
 Neck and back on same plane with neck slightly extended
 Babies entire body facing mother
 Babies abdomen touching mothers abdomen
 Attachment
 Babies moth wide open
 Lower lip turned outwards
 Chin touching nipple
 More areola visible on above than below
 Effective suckling
 Slow, deep suckling with pause in between

37. Optimal breast feeding practices
 Have written breast feeding policy that is routinely
communicated to all health care staff
 Counsel mother and discuss about feeding of the
newborn during pregnancy
 Start breast feeding with in 1 hr of birth
 Teach mother on breast feeding practices
 Exclusive breast feeding for the first 4-6mns
 Breast feeding should be given 8-12 times per day
including night feeds

38. Optimal breast feeding……….
 It should be on demand and frequent
 Empty one breast before switching to the other
 Increase breast feeding during illness
 Continue breast feeding for a total of 24 months
 Start complementary feeding at 6months
 Don’t give artificial teats or pacifiers
 No supply or advertizing of breast milk substitutes to
mothers always tell about priority of breast milk

39. Advantages of breast feeding
 Increases mother to infant bonding
 Protects infants from infection
 Lactational amenorrhea for the mother means of
family planning
 If started immediately after birth facilitates uterine
contraction expulsion of placenta and prevent PPH

40.  Natural food for full-term infants and is the
appropriate milk for the 1st year of life
 Always available at the proper temperature and
requires no preparation time
 Fresh and free of contaminating bacteria
 Associated with fewer feeding difficulties incident to
allergy and/or intolerance to bovine milk which
include diarrhea, intestinal bleeding, occult melena,
“spitting up,” colic, and atopic eczema

41.  Human milk contains bacterial and viral antibodies,
including relatively high concentrations of secretory
immunoglobulin A, that prevent microorganisms from
adhering to the intestinal mucosa
 Macrophages in human milk may synthesize
complement, lysozyme, and lactoferrin
 Lactoferrin an iron-binding whey protein has an inhibitory
effect on the growth of E. coli in the intestine
= lower incidence of diarrheal disease, otitis media,
pneumonia, bacteremia and meningitis than formula fed
infants

42.  Supply all the necessary nutrients except fluoride
and vitamin D
 Iron content is low, but most normal term infants
have sufficient iron stores for the 1st 4–6 mo of
life. Human milk iron is well absorbed
 The vitamin K content also is low and may
contribute to hemorrhagic disease of the
newborn

43.  The only disadvantage of breast feeding is transmission of
maternal infection to the newborn
 HIV in case of maternal HIV infection follow countries policy
for breast feeding
 HTLV infection is a contraindiation for breast feeding
 HBV materal infection baby should receive Ig and HBV
vaccination immeditely after birth
 CMV May be found in milk of mothers who are CMV
seropositive
Causing symptomatic illness in term infants is
uncommon
 HSV If active lesion on breast don’t feed

44. Cow’s milk
 Associated with milk protien allergy
 Occult blood lose in the stool
 3 times higher in protein , 2 times in Na, iron and
linoliec acid are lower
 High ratio of casein to whey protein
 Total amount of fat is equal with BM 3.5mg/dl
 Calorie is comparable 67 calories/dl
 Higher calcium and phosphorus in cows milk
=> Should be avoided in the 1st yr of life

45.  Complementary feeding should be started at 4-6 mn
 Initially with semi solid foods
 One food at a time
 Include all the five nutrition components
 Weaning cessation of breast feeding should be at 24
months
 If not possible it can be as early as 12mns

46. QZ
 1. why infants &children have additional energy
expenditure?
 2. which nutrients have the highest energy density?
 3 .what are the 3 categories of amino acids?
 4. the earliest lesion of vitamin A deficiency is _?
 5. list criteria of optimal breast feeding practice
 6. list advantages of breast feeding

47. ???

48. Thank you !!!