NUTRITION FOR INFANTS,

CHILDREN AND
ADOLESCENTS
Andrew Tershakovek, MD
Associate Professor of Pediatrics
University of Pennsylvania School of Medicine
Director, Weight Management Program
Childrens Hospital of Philadelphia
Lisa Hark, PhD, RD
Director, Nutrition Education and Prevention Program
University of Pennsylvania School of Medicine

2000 University of Pennsylvania School of Medicine

Objectives
To recognize the changing nutritional needs of
developing children, from infancy to adolescence.
To understand that nutritional recommendations for
children vary by age, stage of development,
and gender.
To recognize that nutritional and dietary behaviors
learned in children can have a significant impact on
adult health concerns such as obesity, cardiovascular
disease, and osteoporosis.
2000 University of Pennsylvania School of Medicine

Why is Nutrition Important?

Energy of daily living
Maintenance of all body functions
Vital to growth and development
Therapeutic benefits

Healing

Prevention

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Growth in Infants
Rapid body growth and brain development
during the first year:

Weight increases 200%

Body length increases 55%

Head circumference increases 40%

Brain weight doubles

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Major Determinants of
Caloric Needs
Basal metabolic rate (BMR)
Activity level
Growth (2x BMR during first year)
Stress (infection, surgery, illness)
Misc. (thermic effect of food)

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Monitoring Growth
Use updated growth charts

www.cdc.cov

Monitor trends in growth not one value using

wt, ht, HC (< 2 yrs), BMI.
In general, normals fall within 5th-95th%ile.
Evaluate changes in %iles.
Malnutrition results in:

Decreased weight (acute), then height,

then head circumference (chronic).

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Feeding the Newborn

What are the options?

Breast feeding

The American Academy of Pediatrics

recommends exclusive breast feeding
for 6 months.

Formula feeding

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Breast Feeding Questions

Why should I breast feed my baby?
I thought formula was the identical alternative.
How often and for how long will my baby nurse?
How do I know if the baby is getting enough?
How many months can I breast feed the baby
and when can I add formula?

2000 University of Pennsylvania School of Medicine

Breast Feeding
Advantages to Infants
Immunologic benefits (>100 components)
Decreased incidence of ear infections, UTI,
gastroenteritis, respiratory illnesses, and bacteremia.
Convenient and ready to eat.
Reduced chance of overfeeding?
Fosters mother-infant bonding.

2000 University of Pennsylvania School of Medicine

Breast Feeding
Advantages to Mothers
May delay return of ovulation.
Loss of pregnancy-associated adipose
tissue and weight gain.
Suppresses post-partum bleeding.
Decreased breast cancer rate.

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Assessment of
Breast Feeding
Weight pattern - consistent weight gain.
Voiding - # wet diapers/day, soaked?
Stooling - generally more stools than formula.
Feed-on-demand ~ every 2-3 hours.
Duration of feedings - generally 10-20 min/side.
Need for high fat hind milk.
Activity and vigor of infant.
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Breast Fed Infants

My 8 week old breast fed baby has not had a bowel
movement in 6 days. He gets 1 or 2, 4 oz bottles of
iron fortified formula at night as well. He is happy and
active. His appetite is good. He is not vomiting. His
abdomen is soft and nontender. What should I do?

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What should I do? - cont.

Discontinue the iron formula, it may be constipating.
Give 1 tsp of mineral oil per day until he goes.
Give a suppository each day until he goes.
Add cereal to the bottle to help his bowels and to
sleep.
Dilute the formula to give more water.
Give 1 oz apple juice per day until he goes.
Do nothing, breast fed infants may not have a bowel
movement for up to 7 days.
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Supporting Breast Feeding

Ask patients if they plan to breast feed.
Give prenatal guidance, materials and support numbers.
Support hospital initiatives to encourage breast feeding, such as
lactation counselors.
Ask about breast feeding support available to mother.
Become familiar with how to manage common problems such as
mastitis and inverted nipples.
Understand issues related to pumping and helping moms return
to work or wean the infant.

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Infant Formula
3 Forms:

Ready to feed - most expensive, does not

require water.

Concentrate - requires mixing with water in

equal parts.

Powder - requires mixing with water.

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Composition of Standard
Infant Formula
Caloric density: standard formulas contain
20 calories/oz (0.67 calories/cc).
Protein content: ratio of whey to casein variesmost are 60:40 similar to human milk.
Fat: most provide ~50% of calories from fat from
saturated and polyunsaturated fatty acids.
Carbohydrate: lactose, beneficial effect on mineral
absorption (Ca, Zn, Mg), and on colonic flora.
Micronutrients: Higher vitamin and mineral content
than human milk to cover 97% of the population.
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Special Formulas
Soy: used for vegetarians, lactase deficiency,
galactosemia.
Lactose free: cows milk-based formula.
Protein hydrolysate: infants who can not digest
or are allergic to intact protein.
Free amino acids.
Pre-term infant: unique for premies,
predominant whey protein, cows milk based,
higher protein and calcium, 20-50% MCT.
Pre-term follow up
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Assessing Readiness
to Feed
At what age it is best to introduce solid foods?
How do I know if he is ready to eat?
What food should I give the baby first?
Should I put cereal in the bottle? It seems to
help the baby sleep at night.
My baby likes to go to sleep in the crib with a
bottle. Is that OK?

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Feeding Skills Development

4-6 mos - experience new tastes.

Give rice cereal with iron.

6-7 mos - sits with minimal support.

Add fruits and vegetables.

8-9 mos - improved pincer grasp.

Add protein foods and finger foods.

10-12 mos - pulls to stand, reaches for food.

Add soft table food, allow to self-feed.

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Feeding Skills Development

12-18 mos - increased independence.

Stop bottle, practice eating from a spoon.

18 mos -2 yrs - growth slows, less interest in eating.

Encourage self-feeding with utensils.

2-3 yrs - intake varies, exerts control.

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Pre-school (1 to 6 Years)
1-2 years: on average, grows 12 cm, gains 3.5 kg.
Rate of growth slows by 4 years.

6-8 cm/year

2-4 kg/year

Brain growth triples by 6 years.

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Common Complaints
My 2 year old is such a picky eater.
I am worried about his diet.
My 3 year old eats noodles for dinner
every night. Is that ok?
I think my 4 year old is anorexic. She
wont eat when we have meal time.

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Cows Milk
My son is 9 mos and formula is so expensive.
Can I start giving him whole milk now?
My daughter is 14 mos and we drink skim milk.
Can I give her skim milk so I only have to buy
one type of milk for the family?

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Developing Healthy Habits

Offer a variety of healthy foods and snacks.
Encourage fruit and vegetable intake.
No junk food snacking.
Limit intake of juices ( 4 oz per day).
Increase intake of water (no soda).
Encourage low fat dairy products (3-4 servings/ day).
Make fun physical activity a habit.
Limit TV to no more than 1 to 2 hours per day.
Track growth and development carefully.
Be a good role model.

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Nutritional Concerns in
Childhood and Adolescents
Malnutrition and poverty.
Growth spurt-onset of menses for girls-changes
in body size/image.
Food fads, vitamins, athletes.
Eating disorders: anorexia and bulimia nervosa.
Overweight and obesity.
Hyperlipidemia and heart disease.
Bone mineralization and osteoporosis.
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Poverty and Malnutrition

18 million (22.7%) of children under 18 in
the US live in poverty.
Income <$14,306/year for family of 2 adults
and 2 children.
Iron deficiency anemia most problematic.
Low vitamin C intake.
Exposure to lead.

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Poverty and Malnutrition

Poor nutrition and cognitive function:

Decreased brain growth and or CNS development.

Poor performance on measures of cognitive ability.

Malnourished children are unprepared to benefit from

age-appropriate educational experiences.

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Adolescent Growth Spurt

Physiological growth stage (Tanner staging) rather
than chronological age, is the best indicator for
establishing requirements or evaluating intake.
Females: 11-14 years:

Grow 8.4 - 9.0 cm/year.

Girls deposit more total body fat.

Males: 13-16 years:

Grow 9.5 - 10.3 cm/year.

Boys deposit more muscle mass.

Boys tend to gain more weight at a faster rate and skeletal

growth continues longer than girls.
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Eating Disorders in
Adolescents
An estimated 20% of teens engage in some type
of abnormal eating.
5% of high schools girls have been diagnosed
with an eating disorder.
Adolescents are frequent users of OTC diet pills.
Multiple factors contribute: thin ideal , family
pressure, exhibiting body control.

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Diagnostic Criteria for

Anorexia Nervosa (DSMIV)
Refusal to maintain body weight over a minimal
normal weight.
Intense fear of gaining weight or becoming fat,
even though underweight.
Denial of low body weight.
In females, absence of at least 3 consecutive
menstrual cycles.
Specific types: restricting or binge purging.
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Diagnostic Criteria for

Bulimia Nervosa (DSMIV)
Recurrent episodes of binge eating characterized by:

Eating a larger amount of food than most people would eat

in a specific period of time.

A sense of lack of control over eating at this time.

Recurrent inappropriate compensatory behavior to

prevent weight gain (vomiting, laxatives, exercise).
Binge eating and other behaviors occur, on average,
at least twice a week for three mos.
Self-evaluation is unduly influenced by body shape /
weight.
Specify type: Purging type or non-purging type.
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Eating Disorders
Physicians Role
Know the diagnostic criteria and ask questions.
Look for warning signs.
Convey your concerns to the patient without
focusing on weight.
Expect denial, anger, or defensive reaction.
Know your limits and refer to an experienced
eating disorder team.

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Obesity in Childhood
and Adolescents
>20% of children/adolescents are overweight.
Increased by 50-100% over last 20-30 years:

More sedentary lifestyle and behavior (TV/video games).

Prevalence increasing more rapidly among AfricanAmericans.

Obese children and adolescents become obese
adults.
Recent reports indicate 8-45% of newly diagnosed
pediatric pts with diabetes are diagnosed with type 2.
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Obesity:
Health Consequences
Cardiovascular disease risk
Type 2 diabetes (epidemic)
Hypertension
Orthopedic
Sleep apnea
Gall bladder disease/steatohepatitis
Psychosocial problems
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Pediatric Obesity
Etiology and Treatment
Etiology:

Genetic predisposition: 80% risk if both parents obese

Environment

Dietary intake

Physical activity / sedentary activity

Treatment:

Multidisciplinary and comprehensive

Formal behavior modification

Family-based
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Prevention of
Cardiovascular Disease
Atherosclerotic process begins in childhood.
Childhood cholesterol levels associated with
degree of early atherosclerotic changes.
Cholesterol levels track.
Behavior tracking?

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Prevention of CVD
Current Recommendations
NCEP guidelines apply to children over 2 yrs.
Diet: <30% fat, <10% sat. fat,
<300 mg cholesterol/day.
Check fasting lipid profile when there is a positive
family history of early CVD, or elevated cholesterol
(hyperlipidemia) in a 1st degree relative.
Combine dietary intervention with healthy lifestyle
for maximum benefits.
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Osteoporosis
Bone mineralization peaks in teenageyoung adult years.
Maximizing peak bone mineralization may
decrease the risk of adult osteoporosis.
Maximizing bone mineralization:

Diet

Calcium

Sodium, protein, phosphorus

Weight bearing exercise.

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Dental Health
Cariogenic Bacteria

Food

Adherence

Frequency of eating

Sugar

Fluoride

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Disease Prevention
Developing Healthy Eating Habits
Discourage dieting and obsession with weight.
Pack healthy lunch at least twice a week.
Limit fast food eating out.
Encourage a balanced diet.
5 servings of fruits/vegetables a day.
Encourage low fat dairy products (3-4 / day).
Prepare meals that kids and teens enjoy.
Encourage teens to learn to cook healthy food.
Teach kids and teens label reading.
Be a role model.

2000 University of Pennsylvania School of Medicine