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Flashcards in Nutrition & GI CPS Deck (112):

Why are oral rehydration solutions preferred over oral rehydration powders?

Powders are more convenient to store, less expensive and have longer shelf life BUT there is a possibility for error of mixing and can get bad concentration of lytes


A parent asks if they can give juice or water to their child who has acute gastroenteritis. What do you say?

Fluids containing nonphysiological concentrations of glucose and lytes (carbonated drinks, sweetened fruit juices) are not good because they have high carb content, low lytes content and high osmolality and can produce osmotic diarrhea-secondly, do not give plain water to children with acute gastro because water can lead to hyponatremia and hypoglycemia


How effective is ORT compared to IV fluid therapy for moderately dehydrated children?

ORT is as effective, if not BETTER, than IV fluid therapy (as shown by meta-analyses)-also less traumatic for child, cheaper, easier to administer and can be done at home


What are the contraindications to ORT? (5)

1. Protacted vomiting2. Severe dehydration with hypovolemic shock3. Impaired consciousness4. Paralytic ileus5. Monosaccharide malabsorption


How early should you refeed a child with acute gastroenteritis?

Should refeed with an age appropriate diet as soon as child is rehydrated! -early refeeding induces digestive enzymes, improves absorption of nutrients, enhances enterocyte regeneration, reduces diarrhea duration, maintains growth, etc.-do NOT need to dilute formula or give lactose free formula for nonbreastfed infants


What is the treatment of choice in children with mild or moderate dehydration secondary to acute gastroenteritis?



What is the Rome III criteria for infantile colic?

Must include ALL of the following in an infant


A mother of an infant with colic asks you: "Should I start a hypoallergenic diet to improve my baby's colic?" How do you respond?

The evidence is conflicting on whether a hypoallergenic diet reduces colic or not-maternal consumption of hypoallergenic diet may reduce colic in a small number of infants


A mother of an infant with colic asks you: "Should I feed my baby a hypoallergenic formula to improve colic?" How do you respond?

Extensively hydrolyzed protein formulas may reduce colic in a small number of bottle-fed infants


A mother of an infant with CMPA asks you: "Can I feed my baby this partially hydrolyzed formula? It's cheaper!" How do you respond?

NO - partially hydrolyzed formulas are not hypoallergenic


A mother of an infant with colic asks you: "Should I feed my baby soy formula to improve colic?" How do you respond?

Soy formulas may reduce the symptoms of colic in some bottle-fed infants BUT this is not routinely recommended since soy protein is a frequent allergen in infancy-AAP stated that routine use of soy formulas has no proven value in colic treatment


Is lactase useful in managing infantile colic?-what about probiotics?

NO. All evidence points to no since congenital lactase deficiency is very rare-insufficient evidence to recommend for or against the use of probiotics or prebiotics for colic


What is the overall recommendation on the effectiveness of dietary modifications in treatment of colic?-what about in babies with severe colic?

Dietary modifications may reduce colic in only a very small minority of infants: evidence is conflicting and most studies were unblinded, small sample sizes and had inadequate outcome measures***Overall, we should avoid making nutritional interventions in vast majority of infants with colic-in severe colic, if there is a possible history of CMPA, can try an empiric 2 wk therapeutic trial of a hypoallergenic diet (maternal elimination of cow's milk from diet OR extensively hydrolyzed formula). If no benefit, then dietary restrictions should be lifted


What are the benefits of breastfeeding?-for baby? (4)-for mama? (4)

Baby:1. Decreased risk of infections: decreased bacterial meningitis, bacteremia, diarrhea, URTI, otitis media, UTI = for each additional month of exclusive BFing, have hospital admission reduction by 30% for infections in first year of life2. Decreased risk of SIDS (shown to be a link only, difficult to control for confounding factors such as sleeping position and smoking)3. Enhanced performance on neurocognitive testing4. Maternal-baby bondingFor Mama:1. Decrease in incidence of breast and ovarian cancer2. Delay in return of ovulation3. Greater postpartum weight loss4. Economical for family and society


What are the 10 steps to successful breastfeeding as promoted in the Baby Friendly Initiative?

1. Have written breastfeeding policy that is communicated to all the health care workers2. Train all health care staff in skills necessary to implement breastfeeding policy3. Inform all pregnant women of benefits of breastfeeding4. Help moms initiate breastfeeding within half hour of birth5. Practice rooming in where mom and baby stay in same room at all times to encourageBFing6. Show moms how to BF and maintain lactation even when separated from their infants7. Only give newborns breastmilk (no formula)8. Encourage breastfeeding on demand9. Give no artificial teat or pacifier10. Foster establishment of breastfeeding support groups and refer moms to them at hospital discharge


What are the absolute contraindications to breastfeeding?-relative contraindication?

Absolute contraindications:1. HIV positive moms2. Galactosemia positive baby3. Moms receiving chemotherapy4. moms receiving radiation therapyRelative contraindication:1. Phenylketonuria: current practice is to breastfeed as a supplement to low phenylalanine formula, along with strict monitoring of phenylalanine levels


What is the Baby-Friendly Initiative?

Evidence-based global program that protects, promotes and supports breastfeeding globally = has 10 steps that hospitals must adhere to in order to get the certification of being a "Baby Friendly" facility-shown to increase the initiation, duration and exclusivity of breastfeeding


What are the benefits of donor human breast milk for the premature infant? (5)

1. Decreased NEC2. Decreased infections3. Decreased colonization by pathogenic organisms4. Decreased length of stay5. Improved neurodevelopmental outcome***Remember that it's hard to control for other factors that may lead to poor outcomes


What is the screening process for donors of human breast milk?

1. Interview2. Serological screening: Hep B, C, HIV, Human T cell leukemia virus3. Physician consent-cannot be taking any medications, must be non smokers and non drinkers


How does the proecess of pasteurization change donor human breast milk?

1. Inactivates all bacterial and viral contaminants-bacillus spores are known to survive routine pastuerization but this is a very rare contaminant of human breast milk (more common in cow's milk)2. Denatures 13% of protein content but carbs, fats, salts are unchanged3. All beneficial immune cells are inactivated BUT IgA stays intact!-IgG is reduced-IgM is completely removed


In what population of neonates should donor breast milk be considered? (2)

1. Premature babies (CPS doesn't say cut off for GA)2. Babies requiring GI surgery


How long should corrected age be used for in premature infants when plotting them on a growth curve?

Should use corrected age until 2-3 yo (24-36 months)


At what age should we start using BMI for assessing growth?

2 yo and older


What is the definition of the following on a WHO growth curve:-underweight-severe underweight-stunting-severe stunting-wasting-severe wasting-overweight (birth-2 yo, 2-5 yo, 5-19 yo)-obesity (birth - 2 yo, 2-5 yo, 5-19 yo)-severe obesity: (birth-2 yo, 2-5 yo, 5-19 yo)

1. Underweight: weight for age 97th%-2 yo-5 yo: BMI for age > 97th%-5-19 yo: BMI for age > 85th%8. Obesity:-birth - 2 yo: weight for length > 99.9th%-2 yo-5 yo: BMI > 99.9th%-5 yo-19 yo: BMI > 97th%9. Severe obesity:-birth - 2 yo: N/A-2 yo - 5 yo: N/A-5 yo - 19 yo: BMI > 99.9th%****Overall, weight for age is not recommended over 10 years of age


What are trans fats?-why are they bad?-what are the components of a triglyceride molecule?

Products of partial hydrogenation of unsaturated fat to extend shelf life-trans fats increase low density lipoprotein cholesterol and decrease high density lipoprotein cholesterol thus increasing risk of cardiovascular disease-triglyceride molecule: glycerol backbone with 3 fatty acids attached


What is the chemical composition of:-saturated fats-unsaturated fats

Saturated fats: no double bonds between carbon atoms. Each carbon atom has 4 other atoms attached to it-unsaturated fats: contain one or more double bonds between two atoms of carbon. Come in cis form and trans form = TRANS FAT ARE UNSATURATED FATS WITH TRANS DOUBLE BONDS INSTEAD OF CIS BONDS


Is there a safe level of dietary trans fats?-largest dietary source of trans fats?

NO! Trans fats increase the risk of cardiovascular disease and offer NO benefit at all to human health! BAD BAD BAD-they do occur in small amounts in certain foods like dairy, meat, breast milk (depending on mothers' dietary intake of trans fats) but trans fats in processed foods are by far the largest dietary source of trans fats


What is required for a food to be labelled "trans fat free"?

Food item must contain less than 0.2 g of trans fat per reference amount and per serving and must be low in saturated fat (


In the neurologically impaired population, what improvements have been associated with nutritional rehabilitation? (6)

1. Improved overall health2. Improved peripheral circulation3. Healing of decubitus ulcers4. Decreased spasticity5. Decreased irribility6. Improved GER


What are predictors of poor nutritional status in neurologicallly impaired children? (2)

1. Spastic quadriplegia2. Presence of oromotor dysfunction


What are the nutritional causes of malnutrition in neurologically impaired children? (4)

1. Increased losses:-GERD in CP = vomiting and regurgitation-reflux esophagitis may lead to food refusal due to GERD2. Decreased intake:-often rely on caregivers for feeding (caregivers overestimate the caloric intake of the child)-if able to feed independently, may lack hand mouth coordination and spill an excessive amount of food or have inadequate amount of time to eat as per school schedule-may not be able to communicate hunger or satiety to care giver3. Altered metabolism-children with increased muscle tone or with athetoid forms of CP may require an increased amount of calories-children with mild to moderate diplegic or hemiplegic CP who can ambulate often need more calories to do daily activities4. Oromotor dysfunction-up to 90% of pts with CP-poor suck/choking/coughing with feeds


What are important questions to ask on a nutritional history for a neurologically impaired child? (7)

1. Does the child self-feed or depend on caregiver for feeds?2. Type and amount of food eaten3. How long is a typical meal?4. If self feeds, how much food is spilled?5. Any signs of oromotor dysfunction? -drooling, choking, coughing, delayed swallowing6. How much stress is associated with meals?7. What is the quality of the interaction between the caregiver, the child and the family at mealtimes?


What questions are important on medical history in evaluating nutrition in a neurologically impaired child? (6)

1. GERD symptoms (emesis, regurgitation, pain, food refusal)2. Chronic respiratory problems/recurrent pneumonia/respiratory symptoms suggestive of chronic aspirations-progressive fatigue towards end of meal may be suggestive of desaturation3. Medications: anticonvulsants for ex can decrease appetite and impair growth4. Recurrent infections?5. Decubitus ulcers? = sign of malnutrition6. Constipation?


On a physical examination, you would like to assess growth of a child with CP but the child is unable to stand and has significant scoliosis. What are 4 ways to measure growth in this child?

1. Triceps skinfold thickness2. Mid-arm circumference3. Lower leg length4. Upper arm length= very helpful in assessing nutritional status and may even be more accurate than weight-for-height to detect malnutrition


What investigations may be appropriate in a neurologically impaired child who is FTT?

1. CBC = look for iron deficiency2. Electrolytes and extended lytes3. Albumin: may reflect nutritional status but is not super reliable4. R/O suspected oromotor dysfunction: -swallowing study with different food textures-UGI study to r/o anatomical abnormalities (ie. SMA syndrome)5. R/O GERD:-based on clinical history or 24 hr pH probe


In a neurologically impaired patient with known history of aspiration, what two conditions are important to rule out?

1. GERD = is the patient aspirating gastric contents?2. Oromotor dysfunction = is the patient unable to swallow properly and is thus aspirating saliva/food?


What factors lead to increased risk of osteopenia and osteoporosis in neurologically impaired children? (4)

1. Reduced ambulation and weight bearing activity2. Malnutrition3. Limited sun exposure4. Use of anticonvulsant medication = alters vitamin D metabolism


What are the 3 methods of calculating energy needs of neurologically impaired patients?

1. Krick method:-kcal/day = (basal metabolic rate x muscle tone factor x activity factor) + growth factor-growth factor = 5 kcal/g of desired weight gain2. Height based method (depends on whether they have motor dysfunction or not)3. REE based method: 1.1 x measured resting energy expenditure


What are complications of long term NG tube use for feeding in neurologically impaired children? (4)-how long should NG feeds be used for in terms of nutritional support?

1. Sinusitis2. Congestion3. Otitis4. Skin irritation-should not be used for > 3 months-if needing > 3 months, consider G tube (gastrostomy)


A neurologically impaired patient presents to you with FTT and recurrent aspiration pneumonia. It is unclear from investigations whether the aspiration is secondary to GERD or swallowing dysfunction. What is your next step in management?

1. Insert NG tube and attempt trial of NG feeds for one month to assess tolerance-if aspiration improves or resolves, then it was caused by swallowing dysfunction = for this patient, recommend G tube only-if aspiration stays the same, then it was caused by GERD = for this patient, recommend G tube AND fundoscopy


What is a common medical complication of gastrostomy for placement of G tube?-treatment?

Development of GERD-treatment: may require prokinetics, change in formula/rate/volume of feeds-if nothing works, may need fundoscopy


What enteral formulas should be used in the following:-patients 1 yo

-Patients 1 yo: pediatric 1 kcal/ml formula***Avoid adult formulas since the calorie-to-nutrient ratio is inadequate for children (may get Ca, PO4, vitamin deficiency)


What is the ideal weight-for-height percentile for the following:-neurologically impaired children 3 yo with normal activity level-neurologically impaired children who are wheelchair bound but able to accomplish transfers-neurologically impaired children who are bedridden

-NI children 3 yo but normal activity level: 50th percentile-NI children > 3 yo wheelchair bound but can do transfers: 25th percentile-NI children > 3 yo bedridden: 10th percentile


What are 2 indications for enteral tube feedings in neurologically impaired children?

1. Oromotor dysfunction leading to clinically significant aspiration2. Inadequate oral intake leading to FTT


What are clinical features of dental fluorosis?-cause?

Dental fluorosis:-caused by abnormal enamel development from too much fluoride exposure-usually occurs in children


What level of fluoride has been found to have low risks for fluorosis while high benefits for preventing dental caries?

0.7 ppm fluoride-any higher and you risk dental fluorosis, any lower and you risk dental caries


What is the process of the development of dental caries?

1. Plaque (sticky film of bacteria) forms on surface of tooth2. Bacteria in the plaque feed on sugar and food residue to produce acid3. Acid dissolves the tooth surface, causing demineralization


What are the 3 stages of enamel development?-which 2 stages does fluoride affect?

1. Secretory stage: protein matrix is laid down and mineral deposition begins2. Transition stage: protein is removed and replaced.3. Maturation stage: mineralization is complete-fluoride affects stages 2 and 3


What are the 3 ways in which topical fluoride prevents dental caries?

1. Inhibits plaque by killing bacteria2. Inhibits demineralization: fluoride is incorporated into crystals on the tooth surface, making the surface more resistant to acid3. Enhances remineralization of enamel


In what circumstances should supplemental fluoride be administered? (3)-age requirement?-what is the recommended supplemental fluoride concentration for children: 0-6 mo, 6 mo - 3 yo, 3 yo - 6 yo, > 6 yo

(***ONLY for children > 6 mo of age)Add fluoride supplements IF:1. concentration of fluoride in drinking water is 6 yo: 1 mg/d


What are probiotics and give 3 examples? What are prebiotics and give 2 examples?

-Probiotics: live microorganisms that can confer health effect on host when consumed in adequate amounts, eg. lactobacilli, bifidobacteria, saccharomyces-Prebiotics: non-live food components which can confer a health benefit on host by modulating intestinal microflora (think FOOD for probiotics), eg. fructo- and galacto-oligosaccharides


What are the effects of gut microflora (3)?

1. Compete with pathogenic bacteria2. Increase mucin secretion for gut barrier protection3. Metabolize malabsorbed carbs into fatty acids (preferential fuel for enterocytes)


How do probiotics modify the gut microflora?

1. Produce antimicrobial compounds and antitoxins2. Compete with pathogenic bacteria for nutrients and adhesion receptors3. Enhance gut barrier function4. Immunomodulation


What is the definition of antibiotic-associated diarrhea?-incidence?

Greater than 3 loose stools per day for greater than 2 days occuring up to two weeks after initiation of antibiotics-occurs in 30% of patients


What is the evidence for probiotics in preventing antibiotic-associated diarrhea?-Evidence for yogurt containing probiotics

Meta-analysis and RCTs showed significant reduction of AAD using various probiotics (lactobacillus and saccharomyces were most effective)-yogurt containing probiotics did not prevent AAD in another study


What is the evidence for probiotics in C. diff infections?

Currently no evidence in pediatric studies to either support or refuse using probiotics to prevent or treat C. diff infections in children or adults-one adult study showed probiotics might be effective in preventing relapse in patients with recurrent C. diff infections


What is the evidence for probiotics in treatment of acute infectious diarrhea in children?-which probiotic was found most effective for this purpose?-does beneficial effects depend on when probiotics are initiated?

-NOT useful for treating bacterial diarrhea-In acute viral diarrhea, 5 pediatric meta analyses showed reduced duration of diarrhea, especially in Rotavirus infections-Lactobacillus was most effective probiotic in this setting-efficacy is strain and dose dependant-time dependant effects: more beneficial if initiated


What is the evidence for probiotics in preventing infectious diarrhea?

Studies show modest effect for some probiotic strains in preventing acute diarrhea in children who are not breastfed and in long-term facilities or day care for children with recurrent infections


What is the evidence for probiotics in treating irritable bowel syndrome?

Some effect in improving some symptoms such as abdominal distention and gassiness in 4 pediatric trials


What is the evidence for probiotic use in the treatment of infantile colic?

Insufficient evidence to recommend for or against use of probiotics -two trials did show significant reduction of crying in colicky infants receiving lactobacilli but these were small trials


What is the evidence for probiotic use in preventing NEC?

Meta-analyses have shown that enteral probiotic supplementation significantly reduced the incidence of severe NEC and mortality-overall, may help to prevent NEC and may be considered in preterm infants who are > 1 kg who are at risk for NEC (add probiotic to breastmilk)-there is currently no data for infants


What is the evidence for probiotic use traveller's diarrhea?What is the evidence for probiotics in preventing infections?

-No pediatric studies of probiotics in this situation so can't make any conclusionsProbiotics MIGHT help to reduce childhood respiratory illnesses, antibiotic use and absences from child care due to illness but ++ confounding factors so more trials are needed before drawing definitive conclusions


What is the evidence for probiotics in preventing atopic and allergic diseases?

Recent studies show no evidence for beneficial effect so more research is needed


What are potential side effects of probiotics?

May cause systemic or local infections-lactobacillus and saccharomyces sepsis has been described in critically ill or immunocompromised patients and in patients with central lines


Probiotics MAY be beneficial in treating which 5 conditions?

1. Prevention of antibiotic associated diarrhea 2. Shortening duration of acute viral diarrhea3. Prevention of NEC in prem infants4. Decreasing symptoms of irritable bowel syndrome5. Decreasing symptoms of colic


During what age does a normal physiological decrease in appetite and weight gain occur?

Between 2-5 years old (toddlers)-food consumption moderates to match a slower rate of growth


For a "picky eater" toddler, what advice can be useful for parents?

1. Decrease in appetite is normal for toddlers to match slower rate of growth2. Parents decide what food to offer, child decides how much to eat3. Give small portions of each food at each meal (one tablespoon of each food per year of age) 4. Snacks only mid-way between meals and not right before.5. Avoid excessive amounts of juice and milk (will decrease food intake)6. Eating should be enjoyable (no threats, etc.)7. Limit table time to 20 minutes. Remove all food when mealtime is over and only offer again at next planned meal or snack (will probably eat then)8. Exercise and play stimulates appetite9. No distractions at mealtimes10. Family should eat together for social time and learning by imitation11. When a child is growing well, there is NO role for nutritional supplements. Special toddler formulas are no substitute for eating healthy foods


Compare the growth patterns of breastfed vs. formula fed infants.

Breastfed babies grow faster than formula fed babies in the first 6 months of life, whereas formula fed babies grow faster after 6 months.


If a child has constitutional growth delay, when will you start to see slowed linear growth?

In the first 3 years of life ONLY!-after 3 yo, growth resumes at a normal rate but parallel to or under the growth curve or along the lower growth percentiles during the prepubertal years-after the age of 3, there should be NO MORE CHANGE in growth percentile until puberty


What is the pattern of growth disturbance seen in the following:-adjustment toward genetic potential from prenatal growth-endocrinopathy-nutritional problems/chronic systemic illness

-adjustment toward genetic potential = this is normal = will see both height and weight similarly affected-endocrinopathy = will see height affected more than weight-nutritional problems or systemic disease = affects weight first, then height later


What is the calculation for mid-parental height:-boys-girls

Boys:-(dad's height + mom's height)/2 + 6.5 cmGirls:-(dad's height + mom's height)/2 - 6.5 cm****these numbers will then be +/- 8.5 cm to get an appropriate normal range for that patient


What is the most common cause of growth failure in toddlers?

Inadequate caloric intake in an otherwise normal child


Name examples of conditions that may cause the following:-poor growth due to inadequate caloric intake-poor growth despite adequate intake-poor growth despite higher caloric intake than normal

-poor growth due to inadequate intake: chronic or recurrent infection, immunodeficiency, IBD, celiac disease-poor growth despite adequate intake: endocrine disease, renal failure, genetic syndrome-poor growth despite higher than normal intake: malabsorption


What is the basic workup for toddler with growth failure?-step 1-step 2-step 3

Step 1:1. CBC2. ESR/CRP3. Lytes4. Gas5. Blood glucose6. Renal function tests7. Serum protein and albumin8. Serum iron, TIBC, saturation, ferritin9. Extended lytes10. Liver enzymes11. Serum immunoglobulins12. Tissue transglutaminase and IgA level13. TSH14. UrinalysisStep 2:1. Sweat chloride2. Vitamin levels3. Fecal elastase4. Bone ageStep 3:1. Refer to specialist


What is the calculation for caloric needs?

Caloric needs = cal/kg/dayCaloric needs = caloric needs for weight age (cal/kg/d) x ideal weight for height (kg)/Actual weight (kg)***for a FTT, need additional calories on top of caloric needs per day in order to ensure catch up growth


What is a pharmacological option for children with growth failure due to inadequate dietary intake?

Only use after a careful assessment by an expert in this area!!!-cyproheptadine = appetite stimulant = antihistamine-can cause drowsiness but can help the child feel hunger and happier to eat


What is the role of enteral nutrition/tube feedings in a child with FTT due to inadequate caloric intake but is normal/healthy otherwise?

Should only be used as a LAST RESORT!-tube feeds are traumatic and unpleasant and can worsen oral aversion


What are possible causes of food refusal in toddlers? (2)

1. early unpleasant experiences with feeding caused by GERD or allergy (painful to eat)2. Being forced to eat and conflict over mealtimes = stress and unpleasant


A mother of a baby with congenital hypothyroidism asks you if it's ok to feed her baby soy-based formula because they are vegetarians. What do you say?

Soy formulas have phytoestrogens. One clinical study showed that abnormal thyroid function can occur from the ingestion of soy-based formula in infants with congenital hypothyroidism. THUS, it's ok to feed your baby soy-based formula as long as we monitor his thyroxine levels.


What is the evidence on soy-based formula and negative effects on reproductive maturity, cancer development and general health?

Phytoestrogens have been shown to have negative effects on these things in animal models BUT in humans, there is no evidence that phytoestrogens does any of these things with any clinical significance.-the study did find that women fed soy based formulas asinfants did have a slightly greater chance of using asthma and allergy medications, slightly longer duration of menstrual bleeding, and more dysmenorrhea than control group-overall, no significant toxicities have been reported


Out of IgE-mediated CMPA and non-IgE mediated CMPA, which has a higher risk of coinciding soy allergy?-what are s/s of each type of CMPA?

Non-IgE more likely to have coinciding soy allergy***overall: if a baby has CMPA, DO NOT USE SOY FORMULA!-IgE mediated CMPA: presents with urticaria, angioedema, respiratory and GI features-Non-IgE mediated CMPA: presents with significant GI manifestations only (usually blood in stool)


What 3 populations must soy-based formulas not be used OR used with caution?

1. Premature babies: don't use soy formulas as not enough nutritionm2. Congenital hypothyroidism: use with caution as can worsen hypothyroidism3. CMPA: best not to use unless you can be CERTAIN that the patient does not have non-IgE mediated CMPA


What are the benefits of breastfeeding beyond six months? (5)

1. Protective effect against overweight and obesity in childhood2. Continues to provide immune protection 3. Decreased risk of maternal breast cancer with longer durations of breastfeeding4. Decreased risk of ovarian cancer5. Increased sensitivity and bonding with child


What are the first solid foods that should be introduced into the diet of an infant?-when can foods with lumpy textures be offered?-when can cow milk be introduced? How much is max per day?

Iron-rich meat, meat alternatives and iron-fortified cereal = offer a few times each day-then gradually increase the number of times a day that complementary foods are offered while continuing to breastfeed-offer lumpy textures only after 9 months-can introduce cow's milk NO EARLIER than 9-12 months of age-limit to no more than 750 ml per day (25 oz) for children under 1 years old


What is the minimum age at which a child can have honey?

Do NOT give honey to a child under 1 year of age due to infant botulism


How much cow's milk is the max that an infant over the age of 1 can get?

500 ml per day (16 oz)


If a family has chosen to use formula, when should formula feeding continue until?-are soy, rich or other plant based beverages appropriate alternatives to cow's milk in the first two years?

Formula feeding can continue up to 9-12 months of age-soy/rice/plant based beverages are NOT appropriate in the first two years


What type of cow's milk is appropriate for children in the first two years?

Homo milk only(skim milk is not appropriate as it does not have enough fats for brain growth)


What is the recommended energy requirements of:-age 4-10-age 11-14-age 15-18

-Ages 4-10 (same energy requirement for boys and girls): 1800-2000 kcal/day-Ages 11-14: 2500 boys and 2200 for girls-Ages >15: 3000 for boys, 2200 for girls


Total caloric intake should comprise of how much carbs, protein and fats?

-Carbs: 50% (45-65%)-Protein: 25% (10-30%)-Fat: 25% (25-35%)


Why are the following useful as a fuel source for athletes?-carbs-proteins-fats

-Carbs: glucose is needed for energy; obtained from glycogen in muscle, released immediately during activity-Proteins: build and repair muscle/hair/nails/skin; required for long periods of exercise due to liver gluconeogenesis to maintain blood glucose-Fats: absorb fat soluble vitamins, insulation and cushion for organs


What 3 micronutrients are most important for athletes?

1. Vitamin D2. Calcium3. Iron


What is the daily recommended calcium intake for: -4-8 yo->9 yo

-4-8 yo: 1000 mg/day-> 9 yo: 1300 mg/day


What is the daily recommended Vitamin D intake per day for 4-18 yo?

600 IU/day but varies based on geographical location


What is the daily recommended iron intake per day for :-9-13 yo->14 yo

-9-13 yo: 8 mg/day->14 yo: 11 mg/day for males and 15 mg/day for females


What is the recommendation for fluid intake prior, during and post sporting activities?

-Prior to activity: 400-600 ml of cold water 2-3 hrs before event-during: 150-300 ml fluid q15-20mins (water is good for events 1 hr or in hot, humid weather)-post-activity: drink enough to replace sweat losses


What is the recommendation for meals around sporting activities?

-Eat meals a minimum of 3 hr before event to allow for proper digestion-avoid high fat foods as it delays gastric emptying-eat snacks minimum or 1-2 hrs before event-for early morning events, snack or liquid meal 1-2 hrs before, followed by full breakfast after event


What is the recommendaton for recovery foods post athletic event?

Consume within 30 mins of exercise and again within 1-2 hrs of activity to allow muscles to rebuild and ensure proper recovery


What are the health benefits of breastfeeding for baby (4)?

1. Decreased infections: GI, acute otitis media, respiratory tract infections2. Decreased SIDS3. Protective against obesity later in life4. Enhanced cognitive development


What are the health benefits of breastfeeding for mama (2)?

1. More rapid weight loss after birth2. Delayed return of menses


What are the signs of physiological and developmental readiness for solid food introduction in babies (4)?

1. Better head control2. Ability to sit up and lean forward3. Ability to let the caregiver know when they're full (ie. turns head away)4. Ability to pick up food and try to put it in their food


Which mothers are most at risk of not meeting recommendations for exclusive breastfeeding until 6 mo (3)?

1. Not married2. Lower socioeconomic status3. Lower education level


What is the recommendation of vitamin D supplementation for infants?-how much and for how long?

400 IU PO OD from birth to 1 yo for exclusively and partially breastfed infants


When should iron-rich foods be introduced into an infant's diet?

6 mo of age when iron stores are depleted and breastmilk alone can no longer meet all of the iron requirements-meat, meat alternatives (eggs, tofu, legumes), and iron-fortified cereals are recommended-offer 2 or more times per day-breastfeeding is to still be the main source of nutrition as other foods are introduced


What is the normal time period of infantile colic?-what is the definition?

Starts before 3-4 weeks of age and resolves by 4 months usually-definition: episodes last 3 or more hours per day, occur at least 3 days per week for at least one week


Is there any evidence in changing infant diet for treating infantile colic?

No evidence to support this! Rarely, cow's milk allergy can be associated with colic and mom can try a 1-2 week cow milk free maternal diet which may help but this should only be done with assistance from a registered dietician.


Should breastfeeding be held during acute gastroenteritis?

NO! For mild-moderate dehydration, use ORT and continue breastfeeding throughout since it has been shown to reduce the severity and duration of diarrhea (from Rotavirus specifically in studies)


What are the 5 contraindications to breastfeeding (not including medications)?

1. Galactosemia2. HIV infected mom (even if on antiretroviral therapy)3. Untreated, infectious TB4. Herpes lesions on both breasts5. Maternal severe illness preventing her from caring for her infant


Can hepatitis B/C be spread through breastfeeding?

Hepatitis B: virus may be found in breastmilk but transmission through BFing has never been reported so BFing is safely recommended for these infantsHepatitis C: not transmitted through breastmilk but can be transmitted from cracked and bleeding nipples


What are the two types of breastfeeding weaning?

1. Infant-led2. Mother-led


What are the risks of abrupt weaning of breastfeeding (2)?

1. Traumatic for the infant2. Increased risk of blocked ducts, mastitis or breast abscesses


What should baby's first foods be when introduced at 6 months of age?

Iron-fortified foods (meat, fish, iron-fortified cereals)