Nutrition in children

1. Normal nutrient requirements(RDA)
and
Nutrient value of common food
items.
PRESENTED BY: Kumar abhinav
Dr Purbasha Mishra
Moderator : Dr Pallavi Goyal

2. • Nutrition means Supply of nutrients for the release of
energy and growth of the body.
• Nutrients are the chemical substances required for the
production of energy, for the growth and for building of
body.
• Nutrition is procurement of these nutrients.

3. • The important nutrients required for the body are:-
a) Macro-nutrients: Some nutrients like carbohydrates,
proteins, fats and mineral like sodium are required in
large.
b) Micro-nutrients: Some nutrients like vitamins and
minerals like iron, zinc molybdenum etc are required
in very minute doses (even in micrograms).

4. • Dietary intake not only meets energy requirements
but also provides macronutrients and
micronutrients essential for sustaining the
functioning of multiple vital processes.
• Malnutrition and under-nutrition are the leading
worldwide cause of acquired immunodeficiency and
the major underlying factor for morbidity and
mortality globally for children <5 yr of age.

5. • The nutrient requirements of children are
influenced by
• (1) growth rate, (2) body composition, and (3)
composition of new growth.
• These factors vary with age and are especially
important during early postnatal life.
• Because of the high nutrient requirements for
growth and the body composition, the young
infant is especially vulnerable to undernutrition.
• Slowed physical growth rate is an early and
prominent sign of undernutrition in the young
infant.

6. • DRI (daily recommended intake ) is the general term
for a set of reference values used to plan and assess
nutrient intakes of healthy people. These reference
values, which vary by age and gender, include:
1) Recommended Dietary Allowance (RDA): an estimate
of the daily average nutrient intake to meet the
nutritional needs of >97% of the individuals in a
population, and it can be used as a guideline for
individuals to avoid deficiency in the population.
2) The estimated average requirement (EAR): is the
average daily nutrient intake level estimated to meet
the requirements for 50% of the population.

7. 3) Lower Reference Nutrient Intakes (LRNIs): is the
amount of a nutrient that is enough for only a small
number of people in a group who have low
requirements (2.5%) i.e. the majority need more.
4) Adequate Intake (AI): established when evidence is
insufficient to develop an RDA and is set at a level
assumed to ensure nutritional adequacy.
5) Tolerable Upper Intake Level (UL): maximum daily
intake unlikely to cause adverse health effects.

11. ENERGY
• The major determinants of energy expenditure are
in children:-
(1) basal metabolic rate,
(2) metabolic response to food (energy required for
digestion and absorption),
(3) physical activity, and
(4) growth.
Estimated energy requirement (EER): is the average
dietary energy intake predicted to maintain
energy balance in a healthy individual and
accounts for age, gender, weight, stature, and
physical activity level

12. •The EER was determined based on empirical research
in healthy persons at different physical activity levels,
including levels different from the recommended
levels . They do not necessarily apply to children with
acute or chronic diseases.
•Because adequate data on requirements for physical
activity in infants and children are unavailable and
because individual growth requirements vary,
recommendations have been based on calculations of
actual intakes by healthy subjects.

16. CARBOHYDRATES
• Energy equivalent 4 kcal/g.
Dietary carbohydrates include
a) Monosaccharides, (glucose, fructose),
b) Disaccharides (sucrose, lactose),
c) Oligosaccharides,
d) polysaccharides (starch), and sugar
alcohols.
• Although an UL for carbohydrates has not
been set, a maximal intake of <25% or <10% of
total energy intake from added sugars has
been proposed in various dietary guidelines.

17. •Higher intakes of added sugar (eg sucrose and high-fructose
corn syrup) can displace other macro- and micronutrients and
increase risk for nutrient deficiency.
•They increase the risk for obesity, diabetes, and dental
caries.
•They also increase LDL and triglyceride production in the
liver and serum uric acid levels which increases systolic blood
pressure and is associated with fatty liver disease and
metabolic syndrome.
•And are also associated with diarrhea, abdominal pain, and
failure to thrive in children when in excessive intake.

18. Dietary fibers
• Fiber consists of nondigestible carbohydrates mostly
derived from plant sources
• they escape digestion and reach the colon nearly 100%
intact.
• Classification:- previously classified as being water
soluble versus insoluble.
Soluble fibers (pectins, mucilages, oat bran) bind bile
acids and reduce lipid and cholesterol absorption.
Pectins also slow gastric emptying and the rate of
nutrient absorption.
 Insoluble fibers (cellulose, hemicellulose, and lignin-
non-carbohydrate) Increase stool bulk and water
content and decrease gut transit time.

19. •The DRI classification:-
dietary fiber (nondigestible carbohydrates and lignin that
are intrinsic and intact in plants)
 functional fiber (with known physiologic benefits in
humans), and
total fiber (dietary plus functional).
•by-products of colonic fermentation are:-
1) carbon dioxide, methane (in addition to other gases),
2) Oligofructases (also known as prebiotics-substrates that
nourish beneficial commensurate gastrointestinal
microbiota), and
3) short-chain fatty acids (SCFAs)(acetate, butyrate, and
propionate).

20. •An UL has not been established for fibers, which are not
thought to be harmful to human health. A general rule of
thumb used for fiber intake in children (>2 years) is:
age (in years) + 5 = grams of fiber intake per day.

23. PROTEINS
• Amino acids and ammonium compounds are usable as
sources of nitrogen in humans. Amino acids are
provided through the digestion of dietary protein. They
have structural and functional role in our body.
• As there are no major stores of body protein, a regular
dietary supply of protein is essential.
• Energy equivalent of proteins 4 kcal/g.
• An UL for protein has not been set. Intake of proteins or
specific amino acids needs to be limited in some health
conditions, such as renal disease and metabolic
diseases, such as phenylketonuria and maple syrup
urine disease, in which specific amino acids can be
toxic.

24. • Based on our requirement, amino acids are classified into
Essential amino acids; and
Non-essential amino acids.
Examples of essential amino acids :- are histidine, isoleucine,
leucine, lysine, methionine, phenylalanine, threonine,
tryptophan, and valine;
Examples of Non-essential amino-acids :- are Alanine,
Arginine, Aspartic acid etc.
•Histidine, cysteine, tyrosine and arginine is essential amino
acid in newborns because of enzyme immaturity only for
infants but not adults.

25. • The proteins from animal are called as Biologically
complete proteins.
• Proteins from vegetable are called as Biologically
incomplete proteins.
Function of proteins
• Proteins are used in -
–various metabolic pathways as enzymes.
–Chemical coordination as hormones.
–body building.
–repair and maintenance of tissues.
–maintenance of osmotic pressure.
–the production of energy

26. • FATS
• Fat is the most calorically dense macronutrient, providing
approximately 9 kcal/g.
• Triglycerides are the most common form of dietary fat and
are composed of 1 glycerol molecule and 3 fatty acids.

27. • Acceptable Macronutrient Distribution
Ranges(AMDR)- for fats is 30-40% of total energy
intake for children 1-3 yr and 25-35% for children 4-
18 yr of age.
• They also provide essential fatty acids, play
structural and functional roles; and precursors for
cell membranes, hormones, and bile acids.
• Fats are for energy storage.
• It facilitates absorption of fat-soluble vitamins A, D,
E, and K.
• Decreasing simple sugars and increasing complex
carbohydrate intake reduce serum triglyceride
levels which a risk factor for cardiovascular disease
and part of the metabolic syndrome.

28. • RDA of fats
• Saturated and monounsaturated fats can be
synthesized endogenously so there is no AI or RDA set
for these dietary components.
• Trans fats have no known beneficial effects in humans;
therefore, no corresponding AI or RDA has been set.
• cholesterol, saturated, or trans fats have a positive
linear association between intake and risk for
cardiovascular disease so a threshold level has not
been set at which risk is increased.
• Long-chain PUFAs such as DHA and ARA play a variety
of structural and functional roles; they influence
membrane fluidity and function as well as gene
expression, and modulate the inflammatory response.

30. Essential fatty acids
•Humans cannot synthesize the PUFAs precursor omega ω3
(α-linolenic acid; ALA) and ω6 (linoleic acid; LA), and are
dependent on diet for these.
•Essential fatty acids are enzymatically elongated and
desaturated into longer-chain fatty acids;
ω3 PUFAs :-ALA can be converted to eicosapentaenoic (EPA)
and docosahexaenoic (DHA). DHA is found in breast milk and
is important for brain development and visual maturity.
ω6 PUFAs:- LA is converted to arachidonic acid(ARA)
inflammatory response.

32. • Micronutrients
i. Major Minerals:- Sodium, potassium, calcium,
phosphorous, magnesium and chloride.
ii. Trace elements:- Iodine, Iron, Zinc, Copper,
Selenium, Manganese, Molybdenum, Chromium,
Cobalt (as a component of vitamin B12),and
fluoride.
iii. Vitamins:- an organic molecule that is an essential
micronutrient needed by an organism in small
quantities for the proper functioning of
its metabolism. Essential nutrients cannot
be synthesized in an organism or only in
insufficient quantities.

33. Major Minerals
Calcium:
Dietary sources:- Dairy products, legumes, broccoli,
green leafy vegetables.
Deficiency: Can occur in premature infants without
adequate supplementation and in lactating
adolescents with limited calcium intake or in
patients with steatorrhea. Can lead to Osteopenia
or osteoporosis, tetany.

34. Phosphorus
Dietary sources:- meats, eggs, dairy products,
grains, legumes, and nuts; high in processed foods
and sodas.
Deficiency :- Rare, but can occur in premature infants
on unfortified milk and Also in patients with protein-
energy malnutrition. Can cause osteoporosis, rickets
and sometimes hypercalcemia, Muscle weakness,
bone pain, rhabdomyolysis, osteomalacia, and
respiratory insufficiency.

35. Magnesium
Dietary sources: vegetables, cereals, nuts.
Deficiency : Occurs as part of re-feeding syndrome
with protein-energy malnutrition or in Renal disease,
mal-absorption, or magnesium wasting medications.
May cause secondary hypo-calcaemia,
Neuromuscular excitability, muscle fasciculation,
neurologic abnormalities, and ECG changes.

36. Sodium
Dietary sources: processed foods, table salt.
Deficiency: Results from loss in diarrhea and
vomiting. Can lead to Anorexia, vomiting,
hypotension, and mental apathy. Severe malnutrition,
stress, and hypermetabolism may lead to excess
intracellular sodium, affecting cellular metabolism.

37. Chloride
• Dietary sources:- table salt or sea salt, sea-weed,
many vegetables.
• Deficiency:- Can occur in infants fed low chloride
containing diets, or in children with cystic fibrosis,
vomiting, diarrhea, chronic diuretic therapy, or
Bartter syndrome.
Can lead to failure to thrive and especially poor
head growth; anorexia, lethargy, muscle weakness,
vomiting, dehydration, hypovolemia.

38. Potassium
Dietary sources:- nuts, whole grains, meats, fish,
beans, fruits and vegetables, especially bananas,
orange juice.
Deficiency:- Occurs in protein-energy malnutrition
(eg:- refeeding syndrome), excessive potassium is
excreted in urine in any catabolic state, during
acidosis, from diarrhea, and from diuretic use.
Hyperkalemia may result from renal insufficiency.
Can cause:- Muscle weakness, mental confusion,
arrhythmias.

39. Trace elements
Zinc
Dietary sources: human milk, meats, shellfish,
legumes, nuts, and whole-grain cereals.
Clinical features:-
•Mild: impaired growth, poor appetite, impaired
immunity.
•Moderate to severe: mood changes, irritability,
lethargy, impaired immune function, increased
susceptibility to infection; acro-orificial skin rash,
diarrhea, alopecia.
Response to zinc supplement is gold standard for
diagnosis of deficiency.

40. Zinc deficiency

41. • IRON
• Critical component of enzymes, cytochromes,
myoglobin, and hemoglobin.
• Iron deficiency is the most common nutritional
deficiency in United States.
• Severe iron deficiency causes anaemia, behavioral and
cognitive effects, but recent evidence suggests that
even iron deficiency without anaemia may cause
behavioral and cognitive difficulties. Some effects, such
as the development of abnormal sleep cycles, may
persist even if iron deficiency is corrected in infancy.
• Lead poisoning can cause iron-deficiency anaemia and
should be explored as cause for at-risk infants and
children.

42. • Iron present in animal protein is more bioavailable
than that found in vegetables and other foods
because it is already incorporated into heme
moieties in blood and muscle.
• Management of iron deficiency with or without
anaemia includes treatment doses of 3–6 mg/kg
body weight of elemental iron.
• An average of 0.8 mg of iron must be absorbed each
day during the first 15 yr of life.
• Since, <10% of dietary iron usually is absorbed, a
dietary intake of 8-10 mg of iron daily is necessary
to maintain iron levels.

43. Selenium
Dietary sources:- seafood, meats, garlic
(geochemical distribution affects levels in foods).
Clinical features:-Skeletal muscle pain and
tenderness, macrocytosis, loss of hair pigment.
Keshan disease, an often fatal cardiomyopathy in
infants and children.

44. Copper
Dietary sources: human milk, meats, shellfish,
legumes, nuts, and whole-grain cereals.
Clinical features:-Osteoporosis, enlargement of
costochondral cartilages, cupping and flaring of
long bone metaphyses, spontaneous rib
fractures.
• Neutropenia and hypochromic anemia resistant
to iron therapy. Defect of copper metabolism
(Menkes kinky hair syndrome) results in severe
CNS disease.

45. Iodine
Dietary source:- iodized salt.
Clinical feature:- Cretinism
a) Neurologic endemic cretinism (severe mental
retardation, deaf mutism, spastic diplegia, and
strabismus) occurs with severe deficiency.
b) Myxedematous endemic cretinism occurs in some
central African countries where signs of congenital
hypothyroidism are present.

47. Flouride
Source:-Flourinated water supply
Function: incorporated into the hydroxyapatite
matrix of dentin.
Clinical feature:-Low intake increases incidence of
dental caries.
• Excess fluoride intake results in fluorosis.

48. Skeletal flourosis
Dental flourosis

49. Vitamins
•Fat-Soluble Vitamins :- Deficiencies in these vitamins
develop slowly because the body accumulates stores of fat-
soluble vitamins; but prematurity and some child health
conditions can place infants and children at risk. Excessive can
cause toxicity.
•Water-Soluble Vitamins :- Risk of toxicity is not as that of
with fat-soluble vitamins because excesses are excreted in the
urine.
But deficiencies of these vitamins develop more easily than of
fat soluble vitamins because of limited stores, with the
exception of vitamin B12.
•Carnitine is synthesized in the liver and kidneys from lysine
and methionine. In certain circumstances synthesis is
inadequate, and carnitine can be considered a vitamin.

54. Casal Neck- Pellagra

55. Pellagra

56. Hyper-pigmentation of Palms, Tongue, Knuckles –
Cobalamine (Vit B12) deficiency

58. Vitamin D:- Breast milk is a poor source of vitamin D, its
insufficiency is common in infants and children.
•The American Academy of Pediatrics recommends vitamin-D
intake of 600 IU/day for infants and children.
Vitamin K:- is important for bone health, and also important
cofactor for coagulation factors (factors II, VII, IX, and
X; protein C; and protein S).
Deficiency assessed by:-
a) prothrombin time,
b) protein in the absence of vitamin K (PIVKA-II), and
c) the vitamin K–dependent coagulation factor levels.
Neonates are at risk for vitamin K deficiency, leading to an
increased risk for hemorrhagic disease of the newborn.
Vitamin K prophylaxis at birth is recommended for all
newborn infants.

60. GROUP PARTICULARS BODY
WEIGHT
KG
NET ENERGY
Kcal/d
PROTEIN
g/d
VISIBLE
FAT
g/d
CALCIUM
mg/d
Iron
mg/d

61. GROUP PARTICULARS RETINOL B-CAROTENE THIAMIN
mg/d
RIBOFLAVIN
mg/d
NIACIN
EQUIVALENT
mg/d
PYRIDOXIN
mg/d
ASCORBIC
ACID
DIETARY
FOLATE
VIT B12
mg/d
MAGNESIUM
mg/d
ZINC
mg/d

62. Amounts of foods to offer

63. THANK YOU