nutrisi anak ppt
TRANSCRIPT
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Pediatric Nutrition
Darwin Deen, MD, MSRPSM
July 27,2001
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Overview• Newborn
feeding• Formulas• Requirements• Infant Feeding• Beikost• Nutrient
sources
• Toddler Diet• School-aged
children• Special Topics:
– Obesity– Eating disorders– Food
Intolerance– Healthy Eating
• Resources
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Developmental Stages
• Infants: newborn, 1, 2, 4, 6, 9, 12 months
• Toddlers: 15, 18, 24, 36, and 48 months
• Children: 5, 6, 8, 10 y.o.• Adolescents: 11-21 yrs.
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Newborns• Breastfeeding for 6-12 months• Iron-supplemented formula as an
alternative.• Low iron formulas do not reduce
GI symptoms.• Soy-based formulas for
intolerance symptoms but not for allergy.
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Breast vs. FormulasBreast Cow
ForSoy For
Cal/L 680 680 1000
Pro,g 10.5 14-16 *17-20
Case% 30 0-80
Whey%
70 18-100
Fat, g 39 35-37 36-37
CHO, g
72 72-74 68-70
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Requirements
• Calories• Protein• Iron• Calcium• Zinc
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Requirements• Calories:
– Infants: 105 kcal/kg/d– Toddlers: 90-100 kcal/kg/d– Children: 80-90 kcal/kg/d– Adolescence: 2100-2200 cal/d
for females and 2700-2800 cal/d for males
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Infants• Introduce solids at 4-6 months
when neuromuscular development is adequate: head control, ability to sit up, extrusion reflex has disappeared, infant swallows solids.
• Early introduction of solids increases risk of food intolerance & overfeeding.
• Start with a cereal (rice or barley) & add new foods one at a time.
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Infants*• 1-4 months-breast or formula only• 4-6 months-cereals added• 6-7 months-vegetables added• 8-9 months-start finger foods
(banana) & chopped (junior foods)• 9 months- add meat and juices
from a cup• 10 months- egg yolk (cooked) &
bite-sized cooked food• 12 months- whole egg, cows milk,
table foods
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Infants• Alternative strategy:• Cereals at 6 months, fruits at 7,
veges at 8, meats at 9.• Start with 1-2 teaspoons increase
gradually to 9 teaspoons (1 jar).• At 9 months: 6-12 t cereal, ½ oz.
Meat, 9-18 T fruit & vege, breast PRN or 26-31 oz formula.
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Nutrients in Baby Foods
• Cereals are fortified with iron.• Juices are fortified with Vit C.• Fruits and vegetables supply
vitamins & minerals.• Meats supply protein and iron.• Deserts supply only sugar and
starches.• Avoid dinners, deserts, and
pudding.
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Macronutrients in Foods
% Calories
From
Protein Fat CHO
Human Milk 6 56 38
Formula 9 48 43
Cow’s --WholeMilk --Skim
2240
483
3057
Baby Food 8 12 80
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Food Sources of Nutrients
• Iron: red meats, legumes, green leafy veges, fortified cereals, dried fruit, peanut butter
• Calcium: dairy, greens, broccoli, legumes, tofu, almonds, sesame seeds
• Zinc: meats, seafood, eggs, milk• Vit A: dark yellow & green veges• Folate: dark green leafy veges and
fruit• Vit B6: whole grain cereals, seeds,
nuts, legumes, potatoes
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Home-made• Thoroughly wash fresh or thaw
frozen fruits or vegetables. Trim meats well.
• Use canned goods without added salt or sugar & rinse.
• Steam or boil until tender. Stew meats.
• Puree in blender or grinder. Add water to adjust consistency.
• Will keep refrigerated for 48 hrs or can be frozen in ice cube tray.
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Toddlers• Between 1 and 3 appetite
declines along with growth rates. Parents require reassurance.
• Suggestions: provide small portions of “finger foods” to consume frequently.
• Avoid appetite stimulants.
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Toddler DietFood Group Portion Size
Milk- 3 servings 4-6 oz.
Meat/Alternative- 2 servings
1-2 oz.
Grains- 4 servings
Bread ½-1 slicePasta & Cereal ¼-½ cup
Fruits/Vegetables- 4 servings
Veg 2-4 TFruit 2T or ½ piece
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School Age Children• Advise 2-3 glasses of low fat or
skim milk per day.• Encourage physical activity and
limit TV hours.• Don’t use food as a reward.• Encourage nutritious snacks.• Encourage healthy family
eating patterns.
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Adolescents• Body Image issues• Encourage physical activity• Discourage dieting• Watch intake of soda and junk• Reinforce healthy attitudes
toward food and nutrition• See Adolescent Nutrition
presentation
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Special Topics• Obesity• Eating Disorders• Vegetarianism• Food Intolerance/Allergy• Healthy Eating Habits• Drinks/Snacks
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Obesity• Weight for Height or BMI > 85%ile is
overweight and > 95%ile is obese.• Increasing prevalence in children
and adolescence.• Associated with parental obesity
and inactivity (hours of TV).• Prevention is easier than treatment.• Encourage activity and healthy
eating.
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Eating Disorders• Common onset in adolescence• Be alert for body image
disturbances• Screen for medical complications• Treat with nutritional and
psychiatric interventions• See Eating Disorders presentation
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Vegetarianism• Protein: combine protein
sources to maximize biological value.
• eggs, grains, seeds, nut butters, hummus, tofu, soy milk, tempeh, dairy products, legumes, bean soups & chili, vege burgers, vegetables.
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Vegetarianism• Non-dairy Calcium sources:
– Green leafy veges: bok choy, kale, broccoli, mustard, turnip, beet, and collard greens
– Tofu– Dry beans– Sesame seeds or tahini– Figs, almonds, molasses– Fortified orange juice or soy milk
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Food Intolerance/Allergy
• Allergy: immunologic reaction to food
• Intolerance: non-immunologic• Clinically respiratory,
gastrointestinal, dermatologic or systemic symptoms
• Challenge testing
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Food Allergy
• More common in families with atopy history.
• Allergy symptoms: respiratory distress, vomiting, diarrhea.
• Foods to avoid: cow’s milk, eggs, nuts, fish, wheat.
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Food Allergy Symptoms
• GI: abdominal pain, bloating, diarrhea, malabsorption, nausea, vomiting, constipation
• Respiratory: asthma, chronic cough, runny nose, wheezing
• Dermatologic: eczema, atopy, urticaria, angioedema, itching, rash
• Systemic: anaphylaxis, headache, behavioral changes
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Common allergens• Milk• Wheat• Soy• Nuts (ground
or tree)
• Shellfish• Beef• Watermelon• Corn• egg
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Food Intolerance
• Skin rashes• GI symptoms: vomiting,
diarrhea, constipation• Upper respiratory
symptoms: cough, runny nose
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Healthy Eating Habits• Provide 3 meals and 2 snacks daily.• Choose foods from each food group
and proportions according to the pyramid.
• Choose whole grains when possible.• Avoid fatty or sugary items except in
small portions after a meal.
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Healthy Snacks
• 100% juice not sugar water.• Avoid too much soda, candy,
cake, non-juice soft drinks.• Low fat Milk and cheese,
yogurt, fruit, vegetables, muffins.
• PB&J on whole wheat bread.
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Healthy Carbohydrates
• Whole grain breads• Whole grain cereals• Tortillas (esp. corn)• Rice cakes• Pita bread• Pop Corn• Pretzels
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Healthy Fruits• Whatever the child likes, including:
– Apples– Bananas– Pears– Berries– Oranges– Melon– Grapes– Canned fruits
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Healthy Vegetables• Cooked or raw:
– Carrots, green peppers, cucumbers, radishes, cauliflower, tomatoes (grape or cherry)
• Cooked:– Broccoli, green beans, peas, etc.
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Healthy Protein Sources
• Low fat milk• Turkey or chicken• Yogurt• Cottage or other low fat cheese• Nuts• Tuna• Eggs
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Fruit Juice• AAP recent position paper on
juices: Americans spend $5 billion per year on fruit juices. Most are little more than sugar water (11-16% CHO). 6 oz. Juice = 1 fruit serving. Use cup not a bottle to avoid tooth decay. No more than 4-6 oz per day for infants and 8-12 oz per day for older children. Do not use as re-hydration formula. (Pedialyte is 2-3% CHO & much higher in Na & K). http://www.pediatrics.org/
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Drinks/Snacks• Apples wedges with peanut butter• PB&J sandwiches (substitute apple
butter• Raw veges with yogurt-based dip• Cottage cheese with canned fruit • rice cakes with PB or low fat cheese• Grilled cheese sandwich or Tortilla
with melted cheese
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Composition of Beverages*
Fluid CHO PR
O
Fat Cal Na K mOs
m
Gatorade 14 0 0 56 11
0
25 280
Pedialyte 6 0 0 24 22
4
17
9
270
Cola 25 0 0 96 9 0 650Man Ped Nutr P.146
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Composition of Beverages*
Fluid CHO PRO
Fat Cal Na K mOsm
Orange Juice 27 1.7 .1 112 2 474
1600
Apple Juice 29 .2 .3 116 7 296
1300
Skim Milk 12 8.4 .4 86 126
406
275
Whole Milk 11 8.0 8.2 150 120
370
650
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Iron deficiency• Very common in children. Risks
include: poverty, minority groups, immigrants, premis and LBW, maternal diabetes.
• Associated with learning problems (even without anemia).
• Reduced risk by using only high iron formulas and by adding meat and fruit to the diet.
• No need for Vit C supplement unless you are adding iron supplement.
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Current Controversies
• Addition of long-chain fatty acids to infant formula
• Why delay solids?• Sugar and dental caries
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Web resources in Pediatric Nutrition:
• Virginia Cooperative Extension: ABCs of Feeding preschoolers– http://www.ext.vt.edu/pubs/preschoolnutr/348-
009/348-009.html
• USDA Food Guide Pyramid for Young Children
– http://www.usda.gov/cnpp/KidsPyra/index.htm • About.com information on healthy eating for children
– http://nutrition.about.com/library/blchildfoodguide.htm
• General Children’s Health Info• http://www.kidshealth.org/
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More Web Resources:• Nutrition In Pediatric HIV Infection
– http://www.hivpositive.com/f-Nutrition/f-3-PediatricNeut/n-Zafonte.html
• Harvard Medical School’s Consumer Health Information– http://www.intelihealth.com/IH/ihtIH/
EMIHC000/20722/20722.html?k=tnavx3324x20722• American Dietetic Association Pediatric Practice Group
– http://www.eatright.org/dpg/dpg22.html• International Food Information Council
– http://ific.org/• Children’s Hospital of Iowa
– http://www.vh.org/Patients/IHB/Peds/Diet/PedsDiet.html
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References• Kleinman RE. Pediatric Nutrition Handbook 4th
Ed.: American Academy of Pediatrics, 1998• Tamborlane WV: The Yale Guide to Children’s
Nutrition. New Haven 1997• Picciano MF et. Al: Nutritional Guidance is
needed during the dietary transition in early childhood. Pediatrics 2000;106:109-114.
• Bogen DL Baker SS: Screening for iron deficiency anemia by dietary history in a high-risk population. Pediatrics 2000;105:1254-59.
• Deckelbaum RJ: Fat intake in children: is there a need for revised recommendations? J Pediatr 2000;136:7-9
• Hall RF Carroll RE: Infant Feeding. Peds Rev 2000;21(6):191-9.
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References• Trusswell AS: ABC of Nutrition 3rd Ed. BMJ Books,
London, 1999• Kreiter SR, et.al.: Nutritional Rickets in African
American breastfed infants. J Pediatrics 2000;137:153-7.
• Klish WJ, Baker SS: Soy Protein-based infant formulas. Pediatrics 1999;104:119-23.
• Renfrew MJ, et. al.: Interventions for influencing sleep patterns in exclusively breastfed infants. Cochrane Database Syst Rev. 2000; 2: CD000113.
• Walker WA, Watkins JB: Nutrition in Pediatrics: Basic Science and Clinical Applications. 2nd Ed. BC Decker Inc 1997, Hamilton
• Hendricks KM, Duggan C, Walker, WA: Manual of Pediatric Nutrition 3rd Ed. BC Decker, 2000, Hamilton.