nutrition final chapter 19 infancy, childhood, and adolescence

Foremilk

(produced for the first 10 to 20 minutes of the feeding) is thin; protein and carbohydrate contents are high

Hindmilk

(produced later in the feeding) is thicker and creamier; fat content increases to 60% of kcal or more; provides kcal for growth and promotes satiety

percentiles to show how a child's growth compares to other children of the same age

50th percentile is "average." Children usually track along a percentile line throughout childhood; deviations of 2 or more percentile lines (up or down) over time may be cause for concern. Tracking below the 5th percentile or above the 95th percentile is cause for concern.

Micronutrients in human milk match the infant's nutritional needs except for vitamin D and fluoride.

AAP recommends supplementation with 400 IU (10 micrograms) of vitamin D per day until dietary intake from foods and beverages can supply this much. Consult dentist or pediatrician to see if fluoride supplementation is necessary. Breastfed infants of vegan mothers may need vitamin B-12 supplement.

ways to prevent choking

Always monitor children while eating Child should be seated while eating Limit distractions Don't talk while chewing Avoid foods that are choking hazards until the child has molars Round or oval shape (e.g., grapes, round slices of hot dogs) Larger than 1/2-inch diameter Soft or sticky texture (e.g., peanut butter) Difficult to chew into small bits (e.g., raw vegetables, large pieces of meats, nuts, popcorn) In general, delay introduction of potential choking hazards until second molars erupt (around 3 or 4 years of age) Get trained on Heimlich maneuver and/or first aid

Carbohydrates make up the remaining kcal, supply energy, add flavor

Avoid high fiber intakes: high-fiber foods take up space in the stomach, but provide few kcal; infants and young children (small stomach capacity) who fill up on high-fiber foods may not be able to eat enough to meet energy and nutrient needs. Limit added sugars: foods rich in added sugars supply kcal, but few nutrients. Dietary Guidelines recommend limiting added sugars to <10% per day. American Heart Association recommends limiting added sugars to <25% of kcal/d.

proper use of BMI to assess weight status among children and adolescents

BMI = kg/m2 (review Chapter 7) After age 2, plotting BMI-for-age is the best way to assess weight status of children. Although we calculate BMI the same way for children and adults, the WHO weight status classifications for adults (e.g., BMI ≥ 30 = obese) do NOT apply to children or adolescents. Instead, BMI is plotted on a BMI-for-age chart and interpreted based on percentile. Note that BMI is lowest around 6 to 7 years of age, then gradually increases to adult levels

breastfeeding to feeding behaviors and body weight later in life

Breastfed infants learn to respect internal cues for hunger and satiety (i.e., they eat when they're hungry and stop eating when they're full). This behavior, if carried through life, promotes maintenance of a healthy body weight and lower risk of obesity-related diseases.

strategies to begin healthy eating habits early in life

Caregivers must be good role models! Use MyPlate as a guide for building healthy meals. The portions are smaller, but the proportions are the same as for adults Division of responsibility: Caregivers are responsible for the what, when, and where of eating. Let the child be responsible for how much is eaten (or whether to eat at all). In most cases, the child's appetite will guide him to meet his energy (and nutrient) needs. Provide a variety of nutrient-dense foods choices at each meal and snack and let the child choose from among these.

strategies to reduce childhood overweight and obesity

Children have an advantage over adults: they are still growing and can use excess stored calories for growth For kids, focus on physical activity first Limit screen time Plan at least 60 minutes per day of vigorous physical activity Age-appropriate Social Caregivers should be involved Restrictive diets are not recommended. Rather, focus on moderate calorie intake. Limit sugar-sweetened beverages Choose low-fat or fat-free dairy products Moderate portion sizes Less reliance on fast food If weight loss is needed, it should be gradual. Monitor changes in height to make sure the eating plan is not too restrictive. In extreme cases (morbid obesity), prescription medications or bariatric surgery are options.

healthy choices from fast food restaurants

Choose grilled instead of fried Choose fruit or salad as the side instead of fries Limit portion sizes: choose kid's size, request one patty instead of double or triple, share the meal with a friend Skip the cheese, bacon, and mayonnaise Choose calorie-free beverages or low-fat or skim milk instead of sugar-sweetened beverages Choose veggie toppings instead of meat on pizza or salad bar

nutritional strategies to prevent or treat constipation

Constipation is a common complaint of preschoolers; if left untreated, can lead to fecal impaction or bowel perforation. Develop healthy bowel habits; pay attention to natural urges to defecate Adequate fiber: fruits, vegetables, whole grains, beans Adequate fluid Some fruit juices have a laxative effect: prune, grape, apple Consider dairy alternatives (e.g., soy milk). Dairy foods may promote constipation in some children.

nutrients of concern for preschoolers. Iron

Deficiency is common among preschoolers Stores of iron (transferred from mother at the end of gestation) have run out Intake of iron-rich foods is low Consequences of iron deficiency for this age group Decreased stamina Impaired cognitive ability Behavioral problems Impaired immune function Consume iron-rich foods to prevent iron deficiency. Lean meats (source of heme iron) Fortified breakfast cereals (source of nonheme iron) Consume non-heme iron with a source of vitamin C (e.g., orange juice) to enhance absorption If clinical deficiency is detected, iron supplementation is necessary

Fat provides ~55% of total kcal - WOW!

Dense source of kcal for growing infant Short- and medium-chain fatty acids are easily digested Good source of omega-3 and omega-6 fatty acids that are needed for proper development of the nervous system.

ways to prevent early childhood caries (cavities)

Do NOT put babies to bed with a bottle. Carbohydrate-rich fluid bathes the teeth for extended time; oral bacteria create acids that dissolve tooth enamel.Do not allow continuous access to bottles or sippy cups during the day. (Same reason as above) Limit foods and drinks with added sugars (especially gummy or sticky foods that adhere to teeth) Brush gums/teeth regularly with a soft toothbrush

energy needs of infants

Due to rapid growth and high basal metabolic rate, calorie needs per kilogram of body weight for infants are 2 to 4 x higher than those of adults. (You do not need to memorize the EER equations.) Infants require a concentrated source of kcal. Exclusive feeding of human milk or infant formula (both have a high % of kcal from fat) is ideal to meet infant's nutritional needs from birth until about 6 months of age.

nutritional composition of infant formula

Except for the immune-enhancing components of human milk, infant formula is nutritionally similar to human milk. Mothers who cannot or choose not to breastfeed can be assured that infant formula is a safe and nutritious alternative to human milk.

Water needs are met with human milk or formula

Except in cases of severe vomiting or diarrhea, infant fluid needs can be met by consuming enough human milk or formula to meet energy needs. There is RARELY a good reason to give an infant supplemental water. In fact, too much water can lead to water intoxication (i.e., overdilute the blood)! Signs of dehydration >6 hours with no wet diapers, concentrated (dark or strong-smelling) urine Unusual fatigue or fussiness Dry mouth and lips Absence of tears when crying Sunken fontanels (soft spots) on skull Cold and splotchy hands and feet

recommendations for caffeine intake for children

Excessive caffeine intake can be detrimental for children and adolescents. GI distress Sleep disturbances Anxiety Increased blood pressure Irregular heartbeat Energy drinks (which contain caffeine and other stimulants) are marketed to youth. For children, AAP recommends limiting caffeine intake to 100 milligrams per day (equivalent of 1 cup of coffee)

Rate of growth influences appetite

Fluctuations in appetite throughout childhood are normal and usually reflect the demands of growth

benefits of eating breakfast

Fortified breakfast cereal is typically the greatest source of iron, vitamin A, and folic acid for children ages 2 to 18. Emerging research suggests that eating breakfast is associated with better weight management. Don't limit selections to traditional breakfast fare; sandwiches, wraps, and leftovers offer nutritional benefits as well.

symptoms of food allergies and intolerances

GI distress (nausea, vomiting, diarrhea) Respiratory distress (sneezing, coughing, wheezing) Skin rash or hives (i.e., urticaria) Cardiovascular effects (low blood pressure, irregular heartbeat)

Effects of lead poisoning

GI distress, lack of appetite Irritability Fatigue (anemia) Intellectual and behavioral problems

factors that contribute to childhood overweight and obesity

Genetics Excess energy intake Sugar-sweetened beverages Unregulated access to snack foods Reliance on energy-dense fast foods Increasing portion sizes Targeted food advertising Inadequate energy expenditure Average screen time is 7 hours per day (compare to reasonable limit of 2 hours per day) Lack of planned and unplanned physical activity (recommendation is 60 minutes per day of vigorous physical activity) Lack of safe outdoor play areas

6 to 12 months

Gradually add foods, building to a variety of grains, fruits, vegetables, and meats by 12 months of age. In general, infants can handle more texture (e.g., dry cereal, strips of toast, biter biscuits, small pieces of soft fruit or cooked vegetables, small pieces of tender meats) as teeth erupt. It's messy, but infants will develop confidence and motor skills if they are allowed to self-feed. By 12 months, introduce cup with handle and wide base; aim to wean from bottles by 18 months of age. Give breast milk, formula, or small amount of water Avoid or limit fruit juice. Infants love it, but it can displace more nutrient-dense options, cause diarrhea, and increase risk for dental caries. Delay cow's milk until about 12 months of age

Protein provides 8% to 12% of total kcal.

Heat-treated cow's milk is the usual source of protein. Soy protein formulas are available for infants with milk allergies, but infants who are allergic to milk proteins are likely to be sensitive to soy protein as well. For allergy-prone infants, hydrolyzed protein formulas (in which the proteins are partially or completely broken down to amino acids) are usually the safest choice.

First feedings

Hold infant in same position as for breast/bottle feeding Start with 1 or 2 tsp of a new food Introduce one new food each week; monitor for signs of allergy or intolerance GI effects (diarrhea, vomiting) Skin rash Wheezing Present new foods on several consecutive days to foster acceptance Homemade baby food can be just as nutritious as jars of baby food purchased from the store Practice safe food handling Puree or mill foods to a texture that is suitable for the infant Freeze small portions in an ice-cube tray Salt and seasonings are not necessary Limit use of salt and added sugars Introduces infant to the traditional family foods

benefits of breastfeeding for the infant

Immune protection Mother/infant bonding Reduced risk of chronic diseases

Growth is a good indicator of nutritional status

In general, changes in weight reflect short-term changes in nutritional status Gains in height reflect long-term nutritional status

macronutrient needs of infants

Infants require a high-fat diet (~50% of total kcal) to meet the energy demands of growth despite a small stomach capacity. (Fat provides a lot of kcal in a little package.) ~15% of fat intake should come from essential fatty acids (used for brain and nervous system development). Relative protein needs (grams of protein per kilogram of body weight) are highest during infancy to support synthesis of new tissue. 0 - 6 months: 9.1 g/d (1.52 g/kg) 6- 12 months: 11 g/d (1.2 g/kg) Half of protein should come from essential amino acids. HOWEVER, excess protein places a burden on the infant's immature kidneys

Routes of lead poisoning

Inhaling lead dust (older homes with lead paint, industrial pollution) Drinking contaminated water (lead pipes) Consuming contaminated dietary supplements Eating foods stored in lead-containing vessels

nutrient concerns for school-age children

Intakes of fruits, vegetables, whole grains, and dairy products are inadequate Excessive intakes of sugar-sweetened beverages displaces nutrient-dense beverages and promotes gain of excess weight. Calcium intake continues to lag behind needs Sodium intake continues to exceed the UL One-third of school-age children are overweight or obese (defined as >85th percentile or >95th percentile for BMI-for-age, respectively). 40% of obese children become obese adolescents 80% of obese adolescents become obese adults

4 to 6 months

Iron-fortified cereal (generally recommended as the infant's first food) Pureed meats Cooked and strained vegetables (introduce vegetables before fruits because infants will naturally prefer the sweeter fruits) Cooked and strained fruits

Carbohydrates provide 35% to 40% of kcal

Lactose is the main disaccharide in human milk (lactose intolerance in infants is actually quite rare) Oligosaccharides promote growth of healthy gut bacteria

Carbohydrates provide 40% to 45% of total kcal

Lactose or sucrose is the main carbohydrate in infant formula. Lactose-free formulas are available (but lactose intolerance in infants is rare).

nutrients of concern for preschoolers Sodium

Like their adult role models, many preschoolers exceed the UL for sodium. The main risk associated with excessive sodium intake is hypertension. Developing healthy habits from a young age is easier than changing habits in adulthood! Strategies to limit salt intake Reduce reliance on processed foods (e.g., lunch meats, hot dogs, salty snacks) Encourage unprocessed fruits, vegetables, and whole grains Limit fast food consumption Rinse canned foods before cooking to remove ~50% of sodium Limit salt added during cooking and at the table

nutrition concerns for adolescents

Low calcium and vitamin D at a time when bone mass should be rapidly accrued. RDA for calcium increases to 1300 mg Low iron, especially among teenage girls (due to menstruation) Continued concern about obesity and chronic disease risk Excessive caffeine intake Emerging concern about alcohol abuse

Protein supplies <10% of total kcal

Low overall protein content to protect immature kidneys Easily digested Immune factors Hypoallergenic

Solid foods should be introduced gradually starting around 4 to 6 months of age.

Nutritional need Iron Calories (when the infant is taking >32 fl oz in a feeding or feeding >8 to 10 times per day, the infant is probably ready for complementary foods) Physiological ability GI tract Kidneys Physical ability Disappearance of extrusion reflex (pushing food out of the mouth with the tongue) Head and neck control Ability to sit with support Consider allergy prevention Human milk or infant formula will still remain the primary source of nutrition through the first year of life. Solid foods complement (rather than replace) human milk or infant formula

elationships between nutrition and autism spectrum disorder (ASD)

Nutritional status can both affect and be affected by ASD Nutrient deficiencies or food intolerances may trigger symptoms (active area of research) GI dysfunction and highly selective eating behaviors may precipitate nutrient deficiencies IMPORTANT: At this time, there is not enough evidence to recommend any dietary intervention for prevention or treatment of ASD. Gluten-free, casein-free (GFCF) diet is often used by families touched by ASD, but the American Academy of Pediatrics does NOT endorse the GFCF diet (or any other special diet) for prevention or treatment of ASD. Imposing dietary restrictions on a child who already has "food issues" may make nutrient intake worse

rapid growth of infants

Of all stages of the life cycle, growth rate is highest during infancy. At birth, the average infant is 7.5 pounds (about 3.5 kg) and 20 inches (about 50 cm) long. Infant weight usually doubles from birth to 6 months of age and triples from birth to 12 months of age. Infant height usually increases by 50% from birth to 12 months of age. Growth is not linear (growth spurts are followed by plateaus). Per kilogram of body weight, needs for most nutrients are highest during infancy.

To correct dehydration

Pedialyte (or similar electrolyte-containing fluid) Intravenous hydration

recommendations for prevention of food allergies

Previous recommendations involved delayed introduction of potentially allergenic food proteins. Some health professionals used to recommend maternal avoidance of potential food allergens during pregnancy and breastfeeding. However, the latest evidence does NOT support either practice. The best evidence to date supports exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with age-appropriate introduction of solid foods through 12 months of age. Exciting current research shows that early exposure to allergens may actually reduce risk for food allergies.

unaltered cow's milk is NOT suitable for infant feeding

Protein content is too high Mineral content is too high Fat content is too low

Growth rate dictates appetite

Rate of growth slows down after infancy, so relative energy needs (kcal per kilogram of body weight) decrease. Average weight gain = 4.5 - 6.6 pounds per year Average height gain = 3 to 4 inches per year Periods of decreased appetite are normal. Caregivers should be concerned if weight loss or signs of nutrient deficiencies are apparent.

Infant formulas come in three forms

Ready-to-feed Concentrated liquid Powder

proper infant feeding techniques

Respect internal cues for hunger and satiety. In most cases, the infant's appetite is the best gauge of the infant's energy needs. Pay attention to the infant's cues of hunger Fussiness Rooting (searching for the nipple) Pay attention to the infant's cues of fullness Turning the head away Losing interest in the bottle or breast Becoming playful Falling asleep Minimize swallowing of air; burp the infant every 10 minutes or every 1 to 2 ounces and at the end of the feeding.

Standardized, sex-specific growth charts

Stature (length)-for-age (stature is expressed as length until the child can stand) Weight-for-age BMI-for-age (preferred way to assess weight status of children from age 2 - 20) Head circumference-for-age (can be used to assess brain growth, especially for infants)

cardiovascular disease and type 2 diabetes can develop among youth.

The rapid rise in childhood overweight and obesity has been accompanied by an increase in children diagnosed with cardiovascular disease and type 2 diabetes. AAP recommends blood lipid screening and glucose screening for children who are overweight or obese. Among children, diet and physical activity are the first lines of treatment for these chronic disease. When it comes to fat intake, rather than restricting total fat, focus on choosing unsaturated plant sources of fat rather than saturated or trans fats.

lead poisoning Prevention

Use cold tap water, let tap water run before filling the cup Choose bottled water if contamination from lead pipes is a concern Avoid use of lead-containing dishes Consume regular meals with moderate fat intake Consume adequate iron and calcium (decreases absorption of lead)

Practice safe preparation

Use safe water source. Tap water and bottled water are both safe. Do NOT use "nursery water," which has fluoride added (could cause mottling of teeth). Use cold (rather than hot) water from the tap to limit potential lead exposure. Well water safety should be checked. Well water should be boiled before use until the infant is 3 months of age. Prepared formula may be stored in the refrigerator for 1 day, but unused formula (in the bottle used for feeding the infant) should be discarded after a feeding.Room temperature formula is usually okay to use. To warm formula, place a prepared bottle under hot running water or in a pan of hot water. Do NOT microwave bottles of infant formula; hot spots may burn the infant's mouth or esophagus.

Fat provides 45% to 50% of total kcal

Vegetable oils are the main source of fat in infant formulas. In most situations, an iron-fortified formula is recommended. Transition formulas are for older infants (6 months and older). These have lower fat content, improved taste, and lower cost.

recommendations for beverage choices

While fruit juice does provide some essential vitamins and minerals, whole fruits (with their fiber and phytochemicals) are less energy-dense sources of nutrients. Also, continuous exposure of teeth to carbohydrate-rich beverages can promote dental caries. NEW: American Academy of Pediatrics recently released revised guidelines for fruit juice consumption (after publication of our book) <1 year: no fruit juice is recommended 1 to 3 years: no more than 4 fl oz fruit juice per day 4 to 6 years: no more than 6 fl oz fruit juice per day 7 to 18 years: no more than 8 fl oz fruit juice per day Choose water or low-fat or fat-free, unflavored milk instead of sugar-sweetened beverages

Allergen

a type of antigen; a protein (e.g., milk protein) that stimulates an immune response

Food intolerance

adverse reaction to food that does NOT involve an immune response Most common culprits Food compounds that have druglike effects (e.g., red wine) Sulfites Food coloring agents Monosodium glutamate Food contaminants Digestive enzyme deficiencies

Food allergy

adverse reaction to food that involves an immune response

nutrients of concern for preschoolers Calcium

childhood is a critical period for bone growth and development; calcium deficiencies could have a lifelong impact on bone mineral density. Consume calcium-rich foods to prevent calcium deficiency. 2 servings per day of dairy products Up to age 2, choose whole milk products. Young children need the extra kcal to support growth After age 2, switch to low-fat or fat-free dairy products to limit intake of saturated fats. Develop heart-healthy habits from a young age. Fortified foods (e.g., cereal) and beverages (e.g., orange juice) Leafy green and legumes (although Ca from these sources is not as bioavailable)

nutrition recommendations for people with food allergies

complete avoidance of identified food allergens is usually the best strategy to prevent allergic response or anaphylaxis. The eight most common food allergies are required by law to be listed on food packages. Careful label reading is crucial. Immunotherapy (controlled exposure to allergens) may help some people develop a tolerance for certain food allergens. Children often outgrow food allergies by 3 years of age (although peanut allergies tend to persist). A registered dietitian nutritionist (RDN) can help people with food allergies to ensure nutritional adequacy despite food restrictions

Leaky gut

early exposure of immature GI tract to food proteins may sensitize the immune system

Failure to thrive

inadequate growth during infancy or childhood as a result of inadequate nutritional intake, inadequate nutrient absorption, or excessive energy expenditure Declining >2 percentile lines on growth chart Tracking below 5th percentile on growth chart May be due to medical condition, poverty, caregiver's lack of knowledge, or abuse/neglect

Fluoride

prevents dental caries Human milk and infant formula are poor sources of fluoride. If water supply is not fluoridated, consult dentist or pediatrician to determine if fluoride supplements are needed AFTER 6 months of age. CAUTION: excess fluoride could cause mottling of teeth.

Anaphylaxis

rapid and potentially fatal allergic response Low blood pressure Respiratory distress 8 most common food allergens Milk (most common among children) Shellfish (most common among adults) Fish Peanuts (actually a legume) Tree nuts Eggs Soy Wheat

vitamin K

required for blood clotting Infants are born with sterile gut; no bacterial synthesis of vitamin K Vitamin K administered via injection shortly after birth to prevent hemorrhage

vitamin D

required for bone health, immune function, normal cell development Human milk is low in vitamin D; total intake of infant formula may be too low to supply enough vitamin D for young infants American Academy of Pediatrics (AAP) recommends that all infants and children should receive 400 IU (10 micrograms) of vitamin D per day until their intake from formula, foods, or beverages provides this much. Supplements may be necessary to achieve this for exclusively breastfed infants until food or beverage intake supplies adequate vitamin D.

Iron

required for red blood cell health (part of hemoglobin), DNA synthesis, energy metabolism, cognitive development Term infants are born with a supply of iron to last ~6 months. Between 4 and 6 months of age, solid foods should be introduced to supply iron. First solid food is usually iron-fortified rice cereal. Human milk is low in iron, but the form of iron is highly bioavailable to infants. Most infant formula is fortified with iron (low-iron formulas are available, but they are NOT recommended). Iron supplements are usually not needed

Hygiene hypothesis

widespread use of antibiotics and antibacterial soaps, cleaners reduces the normal stimulation of the immune system; the immune system becomes sensitized to harmless proteins (e.g., food proteins) Low vitamin D status may impair normal immune function