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MBBS V - Senior Clerkship - Block C CCT > Paediatric seminar: Failure to thrive > Flashcards

Paediatric seminar: Failure to thrive Flashcards

1
Q

What is the medical viewpoint for calorie?

A

The small calorie approx the energy needed to increase temp of 1g of water by 1C
The large calorie (Cal) approx the energy needed to increase temp of 1kg of water by 1C (4.2kJ) food calorie

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2
Q

What is excessive Cal leading to obesity?

A

Excessive 3500 Cal ~ 1 pound weight

Positive balance of 200 Cal per day for 5 weeks = 200 x 35 = 7000 Cal, leading to a gain of 2 pounds

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3
Q

What are the essential nutrients in food and milk?

A
  • Protein
  • Fat
  • Carbohydrates
  • Minerals
  • Vitamins
  • Water
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4
Q

Is protein sufficient in breast milk?

A

Protein in human breast milk is adeqauate for normal term infants (2-2.5g/kg/day)
Essential amino acids (human milk: in whey component)

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5
Q

Compare whey vs casein proteins

A

Whey proteins: 60-80% of proteins in human breast milk, its ratio changes with stage of lactateion
Portion that remains soluble on acidification: alpha-lactalbumin, lactoferrin, binding proteins, immunoproteins, enzymes (lipase, lyzozyme)
Casein michelles: complexes of proteins and salts, 20-40% of proteins in human milk; 80% of bovine milk. Acidification –> precipitates (producing cheese)

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6
Q

Which milk is casein dominant vs whey dominant?

A

Cows milk is casein dominant
Humans breast milk is whey dominant
* Colostrum- whey:casein = 90:10
* Mature milk- whey:casein = 60:40

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7
Q

What is the energy and protein intake in breast milk vs formula?

A

Breast milk: protein concentration (g/100cal) with age
Formula: designed to meet highest possible needs i.e. youngest of infants
Excess nutrients and increase metabolic stress

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8
Q

What are the fats in diet?

A
  • Dietary fat consists of provision of 40-50% of total caloric intake with at least 3% of total calories as linoleic acid
  • MCT can boost calories
  • LC- PUFA (polyunsaturated fatty acid) is important for growth and development of retina and brain: n-3, n-6 essential fatty acid (LA, DHA, ARA)
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9
Q

What is the glucose utilization rate in term infant?
What is the physiology of energy storage in infants?

A

4-6mg/kg/min (6-10g/kg/day)

  • Glycogen stored from the start of 2nd trimester
  • Storage can be exhausted within 12 hours
  • Lactose –> glucose (usage) and galactose (storage)
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10
Q

What are the constituents during fasting?

A
  • Glucose – 4-6mg/kg/min
  • Fluid - ~ 100-120 ml/kg/day depends on the age and status of baby
  • Other supplements e.g. Ca
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11
Q

A newborn weighing 3kg required fasting for a day procedure: what kind of fluid and how much would you give to the baby?

A
  • Body weight 3kg
  • Glucose req = 4-6mg/kg/min =26 gram glucose per day
  • Fluid req 100ml/kg/day = 300ml/day
  • Selection of fluid: D10 (10 gram/100ml)
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12
Q

What are the nutritional comparisons of milk: energy, protein, whey: casein, fat, carb, ironm vit D, renal solute load

A
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13
Q

What are benefits to baby for breastfeeding?
What immunologic protection?

A
  • Nutritional value: best composition with high bioavailablity
  • Reduced obesity and overfeeding
  • Protect against infection & allergy
  • Less contamination, readily available
  • Enzymes, hormones and immune factors
  • matches with the sequence of postnatal development of the immune system
  • help adaptation of the gastrointestinal tract in the switch from fetal to postnatal life
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14
Q

What are the protective properties of breastfeeding?

A

3 overlapping groups of bioactive agents
* Direct acting antimicrobial agents
* Antiinflammatory agents
* Immunomodulating agents
Protections against infections and atopy

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15
Q

What are the increased health risks of not breastfeeding (baby)?

A
  • Diabetes 40%
  • Obesity 25%
  • Recurrent ear infection 60%
  • Hospitalization for asthma or pneumonia 250%
  • Death in first year 27%
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16
Q

What are the benefits to mother for breastfeeding?

A
  • Involution of uterus
  • Better physical shape
  • Reduce neoplasm
  • Improves psychological well being
  • Less postnatal depression
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17
Q

What are increased health risks of not breastfeeding (mother)

A
  • Maternal Breast cancer 39%
  • Maternal Type 2 diabetes 14%/yr
18
Q

What are benefits to family for breastfeeding?

A
  • Maternal-infant bonding (attachment)
    (less school withdrawal, behavioral problem and abuse of child)
  • Contraceptive effect (for birth control)
  • Most economic & effective way of feeding
19
Q

What are the benefits to society for breastfeeding?

A
  • Less medical consultations
  • Less hospitalizations
  • Less medical expense related to infections
20
Q

What is breastfeeding disadv?

A
  • Physical exhaustion of mother (frequent, on demand feed)
  • Emotional stress on mother
  • Sleeping quality (mother) impaired
  • Infections – virus e.g. HIV, CMV, HTLV
  • Transmission of undesirable drugs e.g.Chemo-, radiotherapy, psychiatric drugs
  • Inborn error of metabolism – special diet
21
Q

Can a mom be too thin to breastfeed?

A
  • Previous study on breast milk from malnourished mothers in Gambia showed that the nutritional value of their milk is same as that of women in UK
22
Q

What are the contraindications of breastfeeding?

A
  • Chemotherapeutic agents
  • Drugs of abuse - e.g. marijuana, heroin, PCP/Amphetamines, nicotine
  • Radioactive compounds- require interruption of nursing
  • Anxiolytics,antidepressants,andantipsychotic medications effects are not known but are of concern
  • Contraindicated-
    Lithium, Tetracycline, Cyclosporine, Ergotamines, Bromocroptine (suppresses lactation)
23
Q

What are maternal illnesses that contraindicate breastfeeding?

A
  • Toxemia: drugs used to treat toxemia are contraindicated for nursing mothers and milks discarded until the medicatiosn are stopped
  • TB: +ve skin test and -ve chest radiographs may continue nursing while taking INH. If mother has active TB there should be no contact between the mother and the infant until mother is successfully treated.
  • HIV: HIV +ve mother should not breastfeed because virus is transmitted through the milk to the infant. In areas where substitutes for breast milk are not available, nursing should be done by HIV+ve mothers (3rd world countries risk of diarrheal illnesses in attempts to prepare formula with unclean water supplies.
  • Mastitis and breast abscess: infection caused by staphylococcus; may come from plugged duct. Should use antibiotic, heat and acetaminophen. Should not stop nursing.
  • Candida infection of the breast: topical antifungals like nystsatin and lotrimin should be used and the breast should be wiped off before feeds; check the infant for thrush and treat with mycostatin accordingly. Breastfeeding may continue.
  • UTI: may use penicillins, cephalosporins, gentamicin and ampicillin. Tetracyclines and chloramphenicol are C/I.
  • Hep A: may nurse if she feels well. If she develops hep A 2 weeks prior to delivery or within 1 week of infants birth, infant should recieve Ig
  • Hep B: infant should recieve HBIG and HBV vaccine after birth and mother may nurse. Although hep B has been isolated from human milk, predominant mode of transmission is vertical at the time of delivery,
  • Hep C: nursing not contraindicated
  • Varicella: if both infant and mother have varicella at birth, they should both be isolated and nursing may continue.
  • Herpes: infant should avoid contact with herpes lesions and if there are no vesicles on the breast, the mother may breastfeed.
  • CMV: breastmilk may contain viruses, it also contains antibodies that are protective against CMV. Therefore, breastfeeding should not be stopped in CMV infeted mothers
  • Syphilis: only contraindication if there are syphilitic lesions on the breast. After mother is treated and sores are healed, nursing may resume
24
Q

What is the WHO recommendation for when to breastfeed?

A
  • Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to 2 years of age of beyond
25
Q

During the consultation, Man Hong’s growth parameters are measured as follows:
* Body weight: 5.5 kg
* Body length: 63 cm
* Head circumference: 41.5 cm
* Are the growth parameters normal?

A
  • Head circumference at birth is at 3-10th centile
  • Head circumference at 5-month-old is at 3-10th centile
26
Q
  • Man Ho is receiving normal formula milk 4.5-5 oz per feed, Q4H, 4 times per day
  • Is the feeding good enough for a 5- month-old baby boy?
A
  • Oneoz=30ml
  • Each 30 ml of normal formula milk carries 20 Calorie
    Volume of milk intake per day:
  • 5ozx4=20oz=600mlperday
    Calorie intake per day:
  • 600ml/30ml x 20 Calorie = 400 Calorie
27
Q
  • Current body weight of Man Ho is 5.5 kg
  • Calorie intake / body weight / day = 400 Cal / 5.5 kg = 73 cal/kg/day
  • Is 5.5kg an ideal body weight?
  • How to calculate the ideal intake?
A
  • Ideal body weight e.g. 6.5 kg (10th centile)
  • Calorie requirement: 100 Cal/kg/day
    = 100 Cal x 6.5 = 650 Cal/day
  • Volume of normal formula milk (20 Cal/oz)
    = 650 Cal/20Cal x 30 ml = 975 ml (~32 oz)
    Daily intake of NF milk 6 oz x 5 per day carries 900ml/30ml x 20 Cal = 600 Cal/day
28
Q

Define failure to thrive

A

Failure of expected growth and well being in children younger than 3 years
Downward crossing of 2 percentile lines in weight over 6 months

29
Q

What are the organic causes of failure to thrive?

A
  • Intake problem (amount, technique, process)
  • Digestion/absorption problem
  • Excessive loss
  • Extra energy demand
  • Energy utilization problem
30
Q

Causes of inadequate food intake causing FTT?

A
  • Insufficient or inappropriate food (not available, poor knowledge/technique, child neglect)
  • Feeding problem (poor technique, inappropriate schedule, neurological, behavioural)
  • Mechanical: cleft palate, GI abnormalities
  • Anorexia: reduced appetite due to chronic illness, anemia, psychological disorders
31
Q

What are organic causes of FTT?

A
  • Intake problem (amount, technique, process)
  • Digestion/absorption problem
  • Excessive loss
  • Extra energy demand
  • Energy utilization problem
32
Q

What are causes of reduced absorption or digestion of nutrients leading to FTT?

A
  • Pancreatic insufficiency e.g. cystic fibrosis
  • Small intestine: loss or damage to villous surface due to coeliac disease, inflammation or food allergy
33
Q

What are causes of excessive loss of nutrients leading to FTT?

A

Vomiting
* GI: GER, obstructions e.g. pyloric stenosis
* CNS: increased ICP, drugs
* Systemic illness: UTI, other infections, metabolic disorder
Diarrhoea
* Post enteritis enteropathy, disaccharidase deficiency, cows milk protein intolerance, inflammatory bowel disease, coeliac disease, colitis e.g. allergic
Renal losses (uncommon)
* Renal failure, renal tubular acidosis
* DM, DI

34
Q

What are causes of increased energy requirement leading to FTT?

A
  • Chronic illness: heart failure, respiratory disease etc
  • Chronic infection
  • Chronic inflammation: SLE, IBS
  • Endocrine: thyrotoxicosis
  • Immunodeficiency
35
Q

What are causes of inability to utilize ingested nutrients leading to FTT?

A
  • Chromosomal or genetic abnormality e.g. trisomy
  • Metabolic disorder e.g. amino acid disorder
  • Endocrine disorder
36
Q

What are non organic causes leading to FTT?

A

Family dsyfunction: maternal depression, marital discordance, parental alcoholism, substance abuse, single parent, inexperience in parenting, poor parent-child bonding
Feeding disorder:
* Inappropriate food
* Distraction
* Meal time chaos
* Poor technique

37
Q

What is the nutritional requirement for preterm babies?

A
  • In the human foetus, amino acid requirement is different from normal term baby:
    3.6-4.8g/kg/day: between 24-30 weeks
    2-3g/kg/day: 30-36 weeks
    1.5-2g/kg/day: at aterm

IV nutrition can be started soon after birth in preterm infants

38
Q

What is the principle of nutrition for preterm infants?

A
  • Minimal enteral feedingm preferably with human milk should be initiated early (at 5-25 mk/kg/day) for stimulating many aspects of gut function, faster weight gain, shorter time to full enteral feeding without an increased risk fo NEC
  • Slow bolus feeding over 30-120 mins preferably to continuous feeding
39
Q

What are human milk fortifiers?

A
40
Q
  • In case human breast milk is not available, is there any other alternative for feeding of a premature baby?
A

Premature infant formula

  • 4.2oz=100cal
  • 4.2x30ml=126ml=100cal
  • Each oz of PIF carries 100cal/126 x 30
    = ~ 24 cal per oz
    i.e. similar to human breast milk fortified with 2 packets fortifiers per 50 ml HBM

MBBS V - Senior Clerkship - Block C CCT (52 decks)

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