nutrient needs: part 2
DESCRIPTION
Nutrient Needs: Part 2. Vitamin K Vitamin D Calcium and Phosphorus Iron Zinc B-12 Flouride. Vitamin K. Vitamin K. 2 forms: K1 or phylloquinone (plant form) and K2 (synthesized by bacteria) - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/1.jpg)
Nutrient Needs: Part 2
• Vitamin K• Vitamin D• Calcium and
Phosphorus• Iron• Zinc• B-12• Flouride
![Page 2: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/2.jpg)
Vitamin K
![Page 3: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/3.jpg)
Vitamin K
• 2 forms: K1 or phylloquinone (plant form) and K2 (synthesized by bacteria)
• Function: cofactor in metabolic conversion of precursors of Vitamin K dependent proteins to active form ( eg: prothrombins, osteocalcin)
![Page 4: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/4.jpg)
Vitamin K
• Lack of specific information regarding an infant’s requirement
• Vitamin K concentration of breastmilk is low and for the breastfeeding infant a deficiency state has been described
• No “gold standard” available
![Page 5: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/5.jpg)
Vitamin K deficiency: Haemorrhagic disease of newborn
• First used in 1894 to describe bleeding in the newborn not due to trauma or haemophilia
• Current Terminology:– VKDB: vitamin K deficiency bleeding
• EVKDB: early• LVKDB: late
![Page 6: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/6.jpg)
Vitamin K Deficiency- definitions – AAP, 2003
Term Age and Incidence
Symptoms
Early vitamin K deficiency bleeding (VKDB)*
First week of life: Unexpected bleeding in previously healthy-appearing neonates
Late VKDB 2-12 weeks of age
unexpected bleeding attributable to severe vitamin K deficiency
* Formerly known as classic hemorrhagic disease of the newborn
![Page 7: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/7.jpg)
Incidence of VKDB
• Early: 0.25%–1.7% incidence• Late:
– No vitamin K prophylaxis: 4.4 to 7.2 per 100,000 births– Single oral vitamin K prophylaxis:1.4 to 6.4 per 100 000
births – IM vitamin K prophylaxis: 0
• Oral vitamin K has effect similar to IM in preventing early VKDB, but not in preventing late VKDB
![Page 8: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/8.jpg)
Vitamin K
• DRI for infants 2-2.5 ug/day• Formula provides 7-9 ug/kg/d• BM contains < 10 ug/L• Hemorrhagic disease of the Newborn…
Vitamin K deficiency• Prophylaxis: 1 mg Vitamin K IM for all
newborn infants
![Page 9: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/9.jpg)
Controversies Concerning Vitamin K and the Newborn: AAP
Policy Statement, 2003
![Page 10: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/10.jpg)
Vitamin K Controversy
• Adequacy of BM• Maternal Diet and Vitamin K content of BM• ? Significance/prevalence of hemorrhagic
disease of newborn• IM injections of all newborns
![Page 11: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/11.jpg)
Danielson et al Arch Dis Child 2004 89:F546-550
• Late onset vitamin K deficient bleeding in infants who did not receive prophylactic vitamin K at birth in Hanoi province– Incidence: 116 per 100,000 births– Higher in rural areas– 9% mortality– 42% impaired neurodevelopmental status at discharge in survivors
![Page 12: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/12.jpg)
Incidence
• Netherlands 2005: 3.2 per 100,000 births• Canada 2004: 0.45 per 100,000 births
– Conclude low incidence associated with current practice of prophylactic Vitamin K at birth
![Page 13: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/13.jpg)
Closing the Loophole:Midwives and the Administration of Vitamin K in the Neonate
• Adame and Carpenter J Pediatr 2009 154:769-771• Case Report of a previously healthy, exclusively breastfed 6
week old infant delivered by a midwife on the south Texas border. Did not receive Vitamin K at birth. Admitted with severe intracranial hemorrhage, cooagulopathy, and seizures, unresponsive, pupils fixed and dialated
![Page 14: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/14.jpg)
Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996.
• Study selection: Six controlled trials met the selection criteria: a minimum 4-week follow-up period, a minimum of 60 subjects and a comparison of oral and intramuscular administration or of regimens of single and multiple doses taken orally. All retrospective case reviews were evaluated. Because of its thoroughness, the authors selected a meta-analysis of almost all cases involving patients more than 7 days old published from 1967 to 1992. Only five studies that concerned safety were found, and all of these were reviewed
![Page 15: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/15.jpg)
Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996.
• Data synthesis: Vitamin K (1 mg, administered intramuscularly) is currently the most effective method of preventing HDNB. The previously reported relation between intramuscular administration of vitamin K and childhood cancer has not been substantiated. An oral regimen (three doses of 1 to 2 mg, the first given at the first feeding, the second at 2 to 4 weeks and the third at 8 weeks) may be an acceptable alternative but needs further testing in largeclinical trials.
![Page 16: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/16.jpg)
Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996
• Conclusion: There is no compelling evidence to alter the current practice of administering vitamin K intramuscularly to newborns.
![Page 17: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/17.jpg)
Cochran Prophylactic Vitamin K for preventing haemorrhagic disease in newborn infants
• Vitamin K deficiency can cause bleeding in an infant in the first weeks of life. This is known as Haemorrhagic Disease of the Newborn (HDN) or Vitamin K Deficiency Bleeding (VKDB).
![Page 18: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/18.jpg)
Cochran
• The risk of developing vitamin K deficiency is higher for the breastfed infant because breast milk contains lower amounts of vitamin K than formula milk or cow's milk
![Page 19: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/19.jpg)
Cochran
• In different parts of the world, different methods of vitamin K prophylaxis are practiced.
![Page 20: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/20.jpg)
Cochran
• Oral Doses:• The main disadvantages are that the
absorption is not certain and can be adversely affected by vomiting or regurgitation. If multiple doses are prescribed the compliance can be a problem
![Page 21: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/21.jpg)
Cochran
• I.M. prophylaxis is more invasive than oral prophylaxis and can cause a muscular haematoma. Since Golding et al reported an increased risk of developing childhood cancer after parenteral vitamin K prophylaxis (Golding 1990 and 1992) this has been a reason for concern .
![Page 22: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/22.jpg)
Cochrane Conclusions, 2000
• A single dose (1.0 mg) of intramuscular vitamin K after birth is effective in the prevention of classic HDN.
• Either intramuscular or oral (1.0 mg) vitamin K prophylaxis improves biochemical indices of coagulation status at 1-7 days.
• Neither intramuscular nor oral vitamin K has been tested in randomized trials with respect to effect on late HDN.
• Oral vitamin K, either single or multiple dose, has not been tested in randomized trials for its effect on either classic or late HDN.
![Page 23: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/23.jpg)
Oral Supplementation with Vitamin K
• Increase in reports of late VKDB• Single oral dose does not provide sustained elevations in
serum Vitamin K to prevent late bleeding• Multidose regimen (1-2 mg given 3X over first 3 months)
has been used in some countries– Some studies report efficacy– Also, reports of treatment failure (eg Germany, Australia,
Sweden)– Disadvantages: reliance on compliance, increased cost,
unreliable infant intake/feeding– AAP recommends contininuation of IM prophylaxis
![Page 24: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/24.jpg)
AAP Recommendations: Pediatrics:Vol112#1 July 2003
1. Vitamin K1 should be given to all newborns as a single, intramuscular dose of 0.5 to 1 mg.
2. Further research on the efficacy, safety, and bioavailability of oral formulations of vitamin K is warranted.
![Page 25: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/25.jpg)
AAP Recommendations
3. Health care professionals should promote awareness among families of the risks of late VKDB associated with inadequate vitamin K prophylaxis from current oral dosage regimens, particularly for newborns who are breastfed exclusively
4. Earlier concern regarding a possible causal association between IM vitamin K and childhood cancer has not been substantiated
![Page 26: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/26.jpg)
Vitamin D
![Page 27: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/27.jpg)
Vitamin D
• Role• Source
– Dietary– sunlight
• Deficiency– Rickets
![Page 28: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/28.jpg)
Role
• Enhances intestinal absorption of Ca• Increase tubular resorption of Ph• Mediation of recycling of Ca and Ph for bone
growth and remodeling• Sterol hormone
– Deficiency: Rickets
![Page 29: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/29.jpg)
Role
• Extraskeletal effects of Vitamin D– Modulates B and T Lymphocyte fx and deficiency
may be associated with autoimmune diseases (diabetes, MS associations)
– Regulation of cell growth (assoc with breast, prostrate, and colon cancer)
![Page 30: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/30.jpg)
Prevalence
• Thought to be disease of past (prior to 1960’s)– Disappeared secondary to recognition of role of
sunlight, fortification of milk, use of multivitamins, AAPCON recommendation for 400 IU supplementation of infants
![Page 31: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/31.jpg)
Prevalence• Increased incidence and case reports 1970’2• No national data in US
– Georgia 1997-99: 9 per million hospitalized children– National Hospital Discharge Survey: 9 per million– Pediatric Research in Office Setting (AAP):23-32
hospitalized cases reported 1999-2000
![Page 32: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/32.jpg)
Prevalence
• Literature Review – 13 articles published between 1996-2001– 122 case reports
![Page 33: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/33.jpg)
Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake
PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910
![Page 34: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/34.jpg)
Vitamin D and Sunlight• Vitamin D requirements are dependent on the
amount of exposure to sunlight.• Dermatologists recommend caution with sun
exposure. – Sunscreens markedly decrease vitamin D production in
the skin – Decreased sunlight exposure occurs during the winter
and other seasons and when sunlight is attenuated by clouds, air pollution, or the environment
– AAP recommends against exposing infants < 6 months to direct sun
![Page 35: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/35.jpg)
Breastfeeding and Vitamin D
• Breastmilk has < 25 IU/L Recommended adequate intake can not be met with breastmilk alone
• Formerly stated that needs could be met with sun exposure, but now, due to cancer concerns recommend against this
![Page 36: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/36.jpg)
Vitamin D Recommendations
• Before 2003 AAP recommended 10 mg (400 IU) per day for breastfeed infants
• 2003: American Academy of Pediatrics recommends supplements of 5 mg (200 IU) per day for all infants as recommended in DRIs.
• 10/14/2008: AAP updates guidelines for vitamin D intake for infants, children, and teens to be published in Nov 5th ed Pediatrics– 400 IU per day intake of vitamin D beginning in first few days of life
![Page 37: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/37.jpg)
Formulas
• if an infant is ingesting at least 500 mL per day of formula (vitamin D concentration of 400 IU/L), he or she will receive the recommended vitamin D intake of 200 IU per day.
• If intake is less than 500 ml recommend additional supplement of vitamin D
![Page 38: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/38.jpg)
Summary of AAP Recommendations
• All breastfed infants unless they are weaned to at least 500 mL per day of vitamin D-fortified formula or milk.
• All nonbreastfed infants who are ingesting less than 500 mL per day of vitamin D-fortified formula or milk.
• Children and adolescents who do not get regular sunlight exposure, do not ingest at least 500 mL per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D.
![Page 39: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/39.jpg)
AAP Recommendations for Vitamin D
• 2008– Intake of 400 IU beginning in first few days of life
• Supplement breastfed, partially breastfed, infants and children consuming less than 1 liter formula or vitamin D fortified whole milk
• Wagner et al: Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents: Pediatrics 2008;122;1142-1152
![Page 40: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/40.jpg)
Vitamin D
• DRI: B-6 months 200 IU, 7-12 months 250 IU• UL: 1000 IU
![Page 41: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/41.jpg)
Calcium and Phosphorus
![Page 42: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/42.jpg)
Basis of recommendations
• Previous RDA of 400-800 mg/d of Ca was based on formula feeding with 25-30% retention
• Breastfed infants retain 2/3 of their Ca intake from breastmilk
![Page 43: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/43.jpg)
CalciumAge DRI mg/d
Birth-6 months 210
7-12 months 270
1-3 years 500
4-8 years 800
![Page 44: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/44.jpg)
Hot off the Presses!
• FNB IOM recommends Calcium intake – B-6 months: 200 mg/d– 7-12 months: 260 mg/d– 1-3 years of age: 700 mg/d– 4-8 years of age: 1000 mg/d
![Page 45: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/45.jpg)
Calcium/Phosphorus content of typical Infant feedings: (mg/dl)
• Breastmilk:– 28/14
• Standard Infant Formula– 49/38
![Page 46: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/46.jpg)
Iron
• Function• Source
– Formula, breast milk, other foods– Bioavailability:
• Breast milk• Soy formula
• Deficiency– Anemia
![Page 47: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/47.jpg)
Anemia• Anemia (low Hct, Hgb: not specific for iron
deficiency)Causes:– Inadequate iron in diet– Loss
– GI bleeding, cows milk proteins, infectious agents– Other
• Genetics• Lead• Other nutrients
![Page 48: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/48.jpg)
Iron
• Biological function– Oxygen transport primarily in hemoglobin– Component of other proteins including
cytochrome a, b, c, and cytochrome oxidase essential for electron transport and cellular energetics
![Page 49: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/49.jpg)
Iron deficiency (ID and IDA)
• Anemia: Hgb <11 g/dl 12-36 months• Iron deficiency Anemia (IDA): anemia due to
iron deficiency• Iron deficiency: Insufficient iron to maintain
normal physiologic functions leading to decrease in iron stores as measured by serum ferritin with or without IDA
![Page 50: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/50.jpg)
• Association between ID and IDA and neurobehavioral development– Lozoff– McCann and Ames– Cochrane review– Carter– Recent sleep studies
![Page 51: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/51.jpg)
Iron Deficiency Anemia
• Impact on social, neurobehavioral and sleep– Peirano et al: Sleep and Neurofunction Throughout Child
development: Lasting Effects of Early Iron Deficiency J Ped Gastroenterology and Nutr 2009 48:S8-S15
– Lozoff et al: Dose-Response Relationships between Iron deficiency with or without anemia and Infant Social-emotional Behavior J Pediatr 2008 152:696-702
![Page 52: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/52.jpg)
Peirano
• Slower neurotransmission in auditory and visual systems
• Different motor activity patterning sleep-waking and sleep state organization
• Alterations in behavioral and cognitive function
![Page 53: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/53.jpg)
Lozoff
• N=77• “Infant social-emotional behavior appears to
be adversely affected by iron deficiency with or without anemia”– Shyness, orientation engagement, soothability
![Page 54: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/54.jpg)
Carter et al: Iron Deficiency Anemia and Cognitive Function in Infancy: Pediatrics 2010 126;2427-e434
• N= 87 (28 IDA, 49 no anemia)• Methods: at 9 and 12 months series of
cognitive, intellegent and behavioral tests administered (Fagan test of infant intellegence (FTII), Emotionality, Activity and Sociability Temperment Survey, and Behavior Rating Scale (BRS))
![Page 55: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/55.jpg)
Carter et al: Iron Deficiency Anemia and Cognitive Function in Infancy: Pediatrics 2010 126;2427-e434
• Results– Sociodemographic background similar between 2
groups– IDA infants less likely to exhibit object
permanence, less novelty preference on the FTII, lower BRS scores, and decrease engagement/orientation, described as “shyer”
![Page 56: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/56.jpg)
Iron Deficiency
• Among children in developing world, iron is the most common single nutrient deficiency
• No national statistics for prevalence of ID or IDA < 12 months
![Page 57: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/57.jpg)
Iron Deficiency in Breastfeeding• At 4 to 5 months prevalence of low iron stores in
exclusively breastfed infants is 6 - 20%.• A higher rate (20%-30%) of iron deficiency has been
reported in breastfed infants who were not exclusively breastfed
• The effect of iron obtained from formula or beikost supplementation on the iron status of the breastfed infant remains largely unknown and needs further study.
![Page 58: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/58.jpg)
Iron Deficiency Prevalence at 9 Months
1.1 mg iron per L plussupplemental foods
28-38%
12-15 mg iron per L 0.6%
![Page 59: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/59.jpg)
Iron Fortification of Formula
• “The increased use of iron-fortified infant formulas from the early 1970s to the late 1980s has been a major public health policy success. During the early 1970s, formulas were fortified with 10 mg/L to 12 mg/L of iron in contrast with nonfortified formulas that contained less than 2 mg/L of iron. The rate of iron-deficiency anemia dropped dramatically during that time from more than 20% to less than 3%.”
![Page 60: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/60.jpg)
ID and IDA 12-35 Months NHANES 2002
Population ID (%) IDA (%)General US 9.2 2.1Above poverty 8.9 2.2Below poverty 8.6 2.3Enrolled in WIC
10.7 3.2
Mexican American
13.9 0.9
Other ethnicity 15.2 4.4
![Page 61: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/61.jpg)
Iron
• Iron absorption from soy formulas is less• Greater bioavailabilty of iron in breastmilk
![Page 62: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/62.jpg)
Percent Reported Absorbed
Study
Human Milk 48%
Hallberg et al
Human Milk – in 5 to 7 month olds who are also eating solid foods.
21% Abrams et al
Iron Fortified Cow’s milk based Formula
6.7% Hurrel et al
Infant Cereals 4 to 5%
Fomon et al
Iron Absorption In Infancy
![Page 63: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/63.jpg)
Foman on Iron - 1998
• Proposes that breastfed infants should have supplemental iron (7 mg elemental) starting at 2 weeks.
• Rational:– some exclusively breastfed infants will have low iron stores
or iron deficiency anemia– Iron content of breastmilk falls over time– animal models indicate that deficits due to Fe deficiency in
infants may not be recovered when deficiency is corrected.
![Page 64: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/64.jpg)
AAP recommendations for Dx and prevention of ID and IDA:2010Pediatrics 2010 126 #5
• Birth-6 months: 0.27 mg/d– Assuming average content Breastmilk 0.35 mg/L
and average intake 0.78 L/day– Noted variability of iron content of breastmilk,
high risk populations (IUGR, LGA associate with maternal IDM, maternal anemia, Preterm birth)
![Page 65: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/65.jpg)
AAP recommendations for Dx and prevention of ID and IDA:2010Pediatrics 2010 126 #5
• 7-12 months: 11 mg/d– Factorial approach: iron loss, iron needed for
increased blood volume, tissue mass, and stores– Noted that there isn’t a sudden increase in needs
from 6 to 7 months.
![Page 66: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/66.jpg)
AAP recommendations for Dx and prevention of ID and IDA:2010Pediatrics 2010 126 #5
• Diagnosis:– Iron status is a continuum with IDA at one end of
the spectrum– No single measurement is currently available to
characterize iron status– HgB limitations include specificity and sensitivity.
Identifies anemia but not necessarily ID or IDA
![Page 67: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/67.jpg)
AAP recommendations for Dx and prevention of ID and IDA:2010Pediatrics 2010 126 #5
• Term, healthy infants have sufficient Fe to 4 months. • Formula fed: Fe needs met by standard infant formula with 12
mg/dl and introduction of complementary foods after 4-6 months. Whole milk shouldn’t be used < 12 months
• Breastfed: Exclusively breastfed infants are a increasing risk of ID >4 months and should be supplemented with 1 mg/kg/d oral Fe until appropriate complimentary food are introduced
![Page 68: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/68.jpg)
AAP recommendations for Dx and prevention of ID and IDA:2010Pediatrics 2010 126 #5
• 6-12 months– 11 mg/d– Use complimentary foods with higher iron
content. Liquid supplement may be needed to augment complimentary foods
![Page 69: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/69.jpg)
AAP recommendations for Dx and prevention of ID and IDA:2010Pediatrics 2010 126 #5
• Univeral screening should be done at 12 months with Hgb and risk determination
• Additional screening can be preformed at any time if there is a risk of ID/IDA including inadequate intake
![Page 70: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/70.jpg)
Iron: DRIAge Iron mg/d
Birth-6 months 0.27
7-12 months 11
1-3 years 7
4-8 years 10
![Page 71: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/71.jpg)
Food sources of IronFood Measure Iron (mg)
Iron fortified formula 8 oz 2.9
Infant Cereal (rice) 1TB 1.7
Strained meats with vegetable 2 Tb 0.1
Strained beef 2 TB 0.2
meats 2 TB 1.2
egg 1 0.7
Peanut butter 1 TB 0.3
Bread white 1 slice 0.2
Enriched macaroni cooked ¼ cup 0.5
vegetables ¼ cup 0.2
fruits ¼ cup 0.1
cheerios ½ cup 1.2
Rice Chex ½ cup 1
![Page 72: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/72.jpg)
Other Causes of Anemia
• Jones et al Hidden Threats: Lead Poisoning From Unusual Sources Pediatrics 1999 104(1223-1225)
• Jones et al Trends in Blood Lead Levels and Blood Lead Testing Among US Children Aged 1-5 years Pediatrics 2009 123 (e376-e385)
![Page 73: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/73.jpg)
Iron-Lead Interactions
• IDA increases intestinal lead absorbtion• Epidemiologic association between IDA and
increased lead concentrations• Primary prevention of IDA may contribute to
prevention of lead poisoning• IDA also decreases the efficiency of chelation
therapy for lead poisoning.• Effect of iron supplementation on iron replete
children with lead poisoning is not know
![Page 74: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/74.jpg)
Zinc
• Function: metalloenzymes associated with CHO and energy metabolism, protein catabolism and synthesis, nucleic acid synthesis, and heme biosynthesis. Other zinc dependent enzymes include erythrocyte carbonic anhydrase, alkaline phosphatase, DNA and RNA polymerases. Through its role in superoxide dismutase enzyme systems, Zinc acts in stabilzing cell membranes and protecting them from lipid peroxidation. Zinc is also involved in protein and collagen synthesis
![Page 75: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/75.jpg)
Zinc• Concentration in colostrum is high, but
concentration rapidly declines over 1st year. • Reports of subclinical zinc deficiency in
growing preterm infant fed human milk– * continued post-discharge
![Page 76: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/76.jpg)
Zinc
• Globally, zinc deficiency is widespread in infants and young children in developing countries, being a major cause of morbidity and mortality, and of impaired growth.– Diarrhea, pneumonia associated morbidities– Due to zinc dependent host defense mechanisms
(T and B cell functions)
![Page 77: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/77.jpg)
Zinc, Folate, Vitamin EAge Zinc mg/d Folate mcg/d Vitamin E mg/d
Birth-6 months 2 65 4
7-12 months 3 80 5
1-3 years 3 150 6
4-8 years 5 200 7
![Page 78: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/78.jpg)
B-12
• B-12 concentration in breastmilk may be influenced by maternal diet.
• Milk from lactating mothers following a strict vegan diet may provide inadequate vitamin B-12 to their infants.
• B-12 deficiency has been reported in infants breast-fed by mothers with pernicious anemia.
![Page 79: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/79.jpg)
Vitamin B12• No reports of overt toxicity• Overt deficiency
documented among infants and children who are fed no animal foods & are not supplemented
• DRI: (mcg.d)– B-6 months: 0.4– 7-12 months: 0.5– 1-3 years: 0.9– 4-8 years: 1.2
• 15 mo old infant• Breastmilk only, 10 x/day• Appeared well-nourished• Refused solids• Demonstrated
developmental delay• < blood B12, folate, Fe
![Page 80: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/80.jpg)
Vitamin B12
• Mother, appeared well-nourished
• taking extra Vit A, 100ug B12, 3-4000mg Vit C/day
• Reluctant to D/C breastfeeding
• Worried re: intro of solids, allergies
• Infant– supplemented
• folic acid, iron– 1000 ugB12 IM– PolyViFlor
![Page 81: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/81.jpg)
Clinical presentation and metabolic consequences in 40 breastfed infants with nutritional Vitamin B-12 deficiency
• Eur J Paed Neurol Nov 2010 14(16) 488-95• 40 Breast fed infants with B-12 deficiency (17
severe, 23 mild• Maternal B-12 satus major contributing factor• Symptoms: FTT (48%), DD (38%),
microcephaly (23%), anemia (63%)
![Page 82: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/82.jpg)
Fluoride
• Fluoride and dental caries– At beginning of 20th century dental caries was
common with extraction only treatment available– Failure to meet minimum standards of 6 opposing
teeth was common cause of rejection from military service in WWI and WWII
![Page 83: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/83.jpg)
Fluoride
• 1901 Dr. Frederick S Mckay noted mottled teeth (fluorosis) in practice in Colo Springs Colo that were resistent to decay
• 1909 Dr. FC Robertson noted same mottling in his area of practice after a new well dug– Believed was due to something in the water
![Page 84: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/84.jpg)
Fluoride
• 1945 study was conducted in 4 city pairs (Michigan, NY, Illinois, Ontario)
• Followed 13-15 years• 50-60% reduction in dental caries
![Page 85: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/85.jpg)
Fluoride
• Proposed mode of action– Promotes remineralization of areas of cariogenic
lesions– Increases resistance to acid demineralization– Interferes with formation and function of plaque
forming microorganisms– Improves tooth morphology
![Page 86: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/86.jpg)
Fluoride
• Concerns– Excess– Fluorosis– Cancer– other
![Page 87: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/87.jpg)
Fluoride
• Fluoride Recommendations were changed in 1994 due to concern about fluorosis.
• Breast milk has a very low fluoride content. • Fluoride content of commercial formulas has been
reduced to about 0.2 to 0.3 mg per liter to reflect concern about fluorosis.
• Formulas mixed with water will reflect the fluoride content of the water supply. Fluorosis is likely to develop with intakes of 0.1 mg/kg or more.
![Page 88: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/88.jpg)
Fluoride, cont.
• Fluoride adequacy should be assessed when infants are 6 months old.
• Dietary fluoride supplements are recommended for those infants who have low fluoride intakes.
![Page 89: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/89.jpg)
Fluoride Supplementation Schedule Age Fluoride Concentration in Local
Water Supply, ppm < 0.3 0.3-0.6 >0.6 6 mo. to 3 y 0.25 0.00 0.00 3-6 y 0.50 0.25 0.00 6 y to at least 16 y
1.00 0.50 0.00
American Dental Association, American Academy of Pediatrics, American Academy of Pediatric Dentistry, 1994.
![Page 90: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/90.jpg)
Fluoride
• To prevent fluorosis, tolerable upper limit (UL) has been set at 0.7 mg/d B-6 months, and 0.9 mg/d 7-12 months
• AAP– Not recommended < 6 months– 0.25 mg/d after 6 months if water contains < 0.3 ppm)– After tooth eruption: fluoridated water several
times/day (BF) or prepare formula with water with fluoridated water (<0.3 mg/L)
–
![Page 91: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/91.jpg)
Early Childhood Caries
• AKA Baby Bottle Tooth Decay
• Rampant infant caries that develop between one and three years of age
![Page 92: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/92.jpg)
Early Childhood Caries: Etiology
• Bacterial fermentation of cho in the mouth produces acids that demineralize tooth structure
• Infectious and transmissible disease that usually involves mutans streptococci
• MS is 50% of total flora in dental plaque of infants with caries, 1% in caries free infants
![Page 93: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/93.jpg)
Early Childhood Caries: Etiology
• Sleeping with a bottle enhances colonization and proliferation of MS
• Mothers are primary source of infection• Mothers with high MS usually need extensive
dental treatment
![Page 94: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/94.jpg)
Early Childhood Caries: Pathogenesis
• Rapid progression• Primary maxillary incisors develop white spot
lesions• Decalcified lesions advance to frank caries
within 6 - 12 months because enamel layer on new teeth is thin
• May progress to upper primary molars
![Page 95: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/95.jpg)
Early Childhood Caries: Prevalence
• US overall - 5%• 53% American Indian/Alaska Native children• 30% of Mexican American farmworkers
children in Washington State• Water fluoridation is protective• Associated with sleep problems & later
weaning
![Page 96: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/96.jpg)
Early Childhood Caries: Cost
• $1,000 - $3,000 for repair• Increased risk of developing new lesions in
primary and permanent teeth
![Page 97: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/97.jpg)
Early Childhood Caries: Prevention
• Anticipatory Guidance:– importance of primary teeth– early use of cup– bottles in bed– use of pacifiers and soft toys as sleep aides
![Page 98: Nutrient Needs: Part 2](https://reader036.vdocuments.us/reader036/viewer/2022062521/5681684c550346895dde4b72/html5/thumbnails/98.jpg)
Early Childhood Caries: Prevention
• Chemotheraputic agents: fluoride varnishes and supplements, chlorhexidene mouthwashes for mothers with high MS counts
• Community education: training health providers and the public for early detection