Nutrition in Early Childhood

1
Nutrition in Early Childhood

• Dr. Sheela Sharma
• MBBS, MD (Obstetrics and Gynaecology)

2
ENERGY

• 5.1. ENERGY
• Children need energy for deposition of tissues.
• Energy is also required for physical activity of
  daily life.
• When individual is in a state of complete rest,
  energy is expended
• for basal metabolism. Carbohydrates, fats and
  proteins in
• the food are the chief energy yielding nutrients
  and are
• aptly labelled as macronutrients. Minerals and
  vitamins are
• non energy yielding nutrients but most essential
  for cell
• function. Because of their requirement in smaller
  quantities,
• these are known as micronutrients. The energy
  obtained
• from the food is usually expressed in terms of
• Thermo chemical kilocalories. These are often
  loosely
• referred to as kilocalories or simply Calories.

3
ENERGY

• One gram of carbohydrate or 1 gram of protein
  provides 4 kcal or 16.7 KJ while 1 gm of fat
  releases 9 kcal or 37.7 KJ.
• Infants require (up to 1 year of age) on an av
  103 kcal /kg/day.

4
Calorie requrement in Boys and Girls

• Age boys girls
• 1 to 2 years 1200 1140
• 2 to 3 years 1410 1310
• 3to4 year s 1560 1440
• 4to5years 1690 1540
• 5to6years 1810 1630
• 6 to 7 years 1900 1700
• lm8years 1990 1770
• 8 to 9 years 2070 1830
• 9 to 10 years 2150 1880
• 10 to 11 years 2140 1910
• 11 to 12 years 2240 1980
• 12m 13 years 2310 2050
• 13 to 14 years 2440 2120
• 14 to 15 years 2590 2160
• 15 to 16 years 2700 2140
• 16 to 17 years 2800 2130
• 17 to 18 years 2870 2140

5
Proteins

• Protein is the second most abundant substance in
  the body,
• next to water. These are made up of twenty
  different amino
• aclds. The proteins differ in their arrangement
  and quantity
• of amino acids. A few amino acids can be
  adequately
• synthesized in the body (non-essential amino
  acids), while
• others must be supplied in the diet (essential
  amino acids).
• Essential amino acids include leucine,
  isoleucine, lysine,
• methionine, phenylalanine. threonine, tryptophan
  and valr.
• Histidine and arginine are essential during
  infancy because
• the rate of their synthesis is inadequate for
  sustaining the
• growth.

6
Proteins (contd)

• Functions of protein. (i) Protein helps the child
  to
• mw as the constituent amino acids are necessary
  /B , . . . for the synthesosf tlssues m the
  body.( ii) Protein is essential for
• the formation of digestive juices. hormones,
  plasma
• proteins, enzymes, vitamins and hernoglobin etc.
  (iii)
• Proteins also act as powerful buffers to maintain
  acid base
• equilibrium in the body. (iv) It is also a source
  of energy
• for the body.
• Excess protein, not used for building tissues or
• providing energy, is convened by the liver in to
  fat and
• stored in body tissues.

7
Proteins (contd)

• Requirements Protein requirements of children
  given table (next slide). Indian estimates are
  higher as these are
• calculatedin terms of the proteins actually
  present in Indian
• diets. An average adult requires 1.0 g/kg body
  weight of
• protein daily. During later half of pregnancy, an
  additional
• protein intake of 15 g per day is required.
  During lactation,
• an additional daily intake of 25 g during the
  fist six months

8
Protein requirement table

• 2-3 months 2.25
• 3 4 months 1.82
• 4-5 months 1.47
• 5-5 months 1.34
• 6 9 months 1.30
• 9-12 months 1.25
• 1-2 years 1.15
• 2-3 years 1.25
• 3 4 years 1.13
• 4 yeas 1.09
• 5-5 years 1.06
• 6 9 yeaan 1.0
• 10-12 years 1.48
• 13-15 years 1.0

9
NPU

• These protein requirements are given in terms of
  mixed vegetable protein contained in Indian
  diets, the net protein utilization
• (NPU) of which is assumed to be 65. If the
  protein in the
• diet is obtained from animal sources like egg,
  meat, fish or
• milk, lower intake of protein will usually be
  sufficient.
• The NPU of a protein is the proportion of
  ingested nitrogen
• that is retained in the body under specified
  conditions. NPU
• is a combined measure of digestibility and the
  efficiency
• of utilization of the absorbed amino acids.

10
Protein Quality

• Protein Quality
• A complete protein contains all of the essential
  amino acids
• in relatively the same amount as humans require
  for
• maintenance of good health and optimal growth.
  Protein
• in the food is obtained either from the animal or
  vegetable
• sources. The proteins of animal origin generally
  have a
• higher content of essential amino acids. 'These
  are,
• therefore, classified as biologically complete
  protein.
• Proteins from vegetable sources are often
  biologically
• incomplete, as these usually lack one or more of
  the
• essential amino acids. However, proteins of
  !,egetable origin
• may be used together in a judicious combination
  so that
• limiting essential amino acidin one of these is
  compensated
• for by an excess of that amino acid in the
  complementing
• protein. Proteins of rice and potato are
  considered good
• vegetable proteins.

11
Protein Quality

• A high quality protein should be complete as well
  as
• digestible. This is measured best by the
  biological value of
• the protein. Biological value (BV) is calculated
  as thc
• fraction of absorbed nitrogen retained in the
  body for
• growth or maintenance. Egg protein is considered
  a
• referenceprotein in this context as it is
  complete and well
• digested. The biological value of egg protein is
  100. BV of
• milk, rice and fish are 75, 67 and 75
  respectively. The
• combination of vegetable proteins may provide all
  the
• essential amino acids as in the reference
  protein. For
• example protein from !egumes has an excess of
• which can compensate for the low lysine content
  of wheat
• protein.

12
LIPIDS

• Lipids are a concentrated source of energy and
  provide insulation to the body. These also act as
  carriers for fat soluble vitamins.
• A healthy European or American obtains 35 to 40
  percent of his caloric needs from fats. Diet of
  persons in the less affluent societies may
  provide less than 10 percent of calories from
  fat. Lipids include triglycerides

13
LIPIDS (contd)

• LIPIDS TRIGLYCERIDES (FATS AND OILS)
  PHOSPHOLIPIDS(LECITHIN) STEROLS(CHOLESTEROLS)
• TRIGLYCERIDES SATURATED FA (animal sources
  COCONUT solid at room temp) UNSATURATED FATTY
  ACIDS (vegetable nuts seed sources liquid at
  room temp)
• UNSATURATED FA Mono saturated FA (oleic acis)
  PUFA

14
PUFA

• PUFA OMEGA 6 FA (linoleic acid arachidonic
  acid) Omega 3 FA (linolenic acidEPADHA)
• PUFA can not be adequately synthesized in the
  body hence should be supplemented in the diet

15
FUNCTIONS OF PUFA

• Important component of cell membranes
• They lower the blood cholesterol and triglyceride
  concentration.

16
LIPIDS (CONTD)

• Deficiency of EFA in the diet may result in
  growth retardation, reproductive failure, skin
  disorders, increased susceptibility to
  infections, decreased myocardial contractility,
  renal hypetension and hemolysis.
• Selective deficiency of omega-6 fatty acids leads
  to skin changes
• while lack of omega-3 results in neurological and
  visual symptoms.

17
LIPIDS (CONTD)

• Lecithin is the most important phospho lipid. It
  is a major constituent of cell membranes.
  Lecithins are not essential in diet as they can
  be synthesized in the body by liver.
  Phospholipids also act as emulsifying agents.

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LIPIDS (CONTD)

• cho l e s t e r o l is a lipid essential for good
  health.
• Cholesterol deficiency does not usually occur as
  it can
• also be synthesized in the human body in the
  liver from
• carbohydrates, protein or fat. It is an important
  constituent
• of cell membrane. Cholesterol can be transformed
  into
• related compounds like hormones, bile and vitamin
  D.
• Cholesterol is found only in animal foods
  including eggs,
• liver, kidney, cheese and ghee. EPA are essential
  for
• transport and breakdown of cholesterol. Excess
  cholesterol
• is stored and may lead to atherosclerosis.

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LIPIDS (CONTD)

• Recommended intake. Total fat intake should
  provide
• no more than 30 percent of daily energy intake.
  Saturated
• fats should not exceed 10 percent of total fat
  intake. A
• minimum of 3 percent of energy should be derived
  from
• linoleic and 0.3 percent from linolenic acid.
  Cholesterol
• intake should be limited to a maximum of 300 mg
  per day.
• Excess fat contributes to obesity, NIDDM, cancer,
• hypertension and atherosclerosis it is better to
  avoid excess of total fats, saturated fats and
  cholesterol, in that order of priority.

20
LIPIDS (CONTD)

• LIPIDS in circulation are bound with proteins
  that serve
• as transport vehicles. The lipid-protein complex
  is called
• lipoprotein. Four main types of lipoproteins are
  formed
• differing in their size and density. These are
  known as
• chylomicrons (rich in triglycerides), high
  density
• Lipoproteins (H DL), low density lipoprotein
  (LDL) and very
• low density lipoprotein (VLDL). Lipoproteins with
  a higher
• percentage of lipids have a lower density i.e.,
  LDL and
• VLDL those with a higher percentage of proteins
  have a
• higher density (HDL). Composition of these
  lipoproteins
• is depicted in Table 5.3.

21
LIPIDS (CONTD)

• High levels of chylornicrons and LDL are
  associated
• with a higher risk of cardiovascular diseases.
  HDL is a
• protective lipoprotein and high levels tend to
  protect agalnst
• the hem diseases.
• Cells all over the body remove fat from the
  passing by
• chylomicrons. Few remnants, that loiter for long,
  are
• removed by the liver. Liver is also an active
  site of iipid
• synthesis. The synthesized lipids are transported
  as VLDL
• to various organs that need them. The body cells
  remove
• triglycerides from the VLDL and convert them to
  LDL.
• Liver cells also have special receptors that
  remove LDL
• fro circulation.

22
CARBOHYDRATES

• Carbohydrates provide energy, contribute to taste
  and
• texture of foods, preserve foods and are
  essential for
• digestion and assimilation of other foods. They
  also protect
• the proteins from being used for energy.
  Monosaccharides
• (glucose, fructose, galactose, ribose,
  deoxyribose) and
• disaccharides (sucrose, lactose and maltose) are
  known
• as simple carbohydrates while polysaccharides
  (starch,
• glycogen, fiber) are referred to as complex
  carbohydrates.
• Grains are the richest food source of starch. A
  starch
• typically consists of thousands of glucose
  molecules linked
• together. Other important source of starch are
  legumes
• (beans and peas) and tubers (potato, cassava
  etc.).
• Glycogen is a more complex storage form of
  glucose an6
• is not found in plants. Body converts all
  carbohydrates
• (except those coming from fiber) to glucose.
  Glucose is
• used as a fuel by brain and muscle tissue or
  convened tc
• glycogen and stored by liver and muscles. Excess
  carbohydrates are converted to fat.

23
CARBOHYDRATES

• Carbohydrates constitute 55-60 of total energy
  intake and preferably obtained from grains,
  legumes, vegetables and fruits. Such a diet is
  lower in fat and energy and higher in fiber,
  vitamin and minerals.
• These diets also contribute to lower rates of
  under nutrition, obesity, tooth decay,
  cardiovascular disease and diabetes.
• Excessive carbohydrate consumption in form of
• concentrated sweets is associated with dental
  caries.
• obesity, ischemic heart diseases and cataract
  (glucose
• cataract ln diabetes, galactose cataract in
  galactosemia).
• Lack of carbohydrates may produce ketosis, loss
  of
• energy, depression and breakdown of body proteins.

24
FIBRE

• High fiber diet is advocated for chronic
  constipation, diabetes, obesity and
  hypercholesterolemia.
• Low fiber diet is particularly useful in
  irritable bowel syndrome, chronic colitis and
  partial chronic G1 obstruction.

25
FIBRE

• Fiber components include polysaccharides such as
• cellulose, hemicellulose, pectins, gums,
  mucilages and non
• polysaccharide lignins. Fibers are considered
  important
• because of their water-holding capacity, bile
  acid binding
• capacity and for the growth of the normal
  microflora of
• the intestines. Water soluble fiber e.g., gums
  and pectins
• help in lowering blood cholesterol and limit
  glucose
• absorption. Fibers insoluble in water result in
  softening of
• stools and acceleration of intestinal transit
  time.

26
MICRONUTRIENT(S)

• INTRODUCTION
• micronutrients are nutrients needed in tiny
  amounts, may, be a few mg or micrograms per day
  and include various minerals and vitamins. They
  do not contribute to the energy intake but normal
  healthy living is not possible without them.

27
MICRONUTRIENT(S)

• Micronutrient Deficiency A Global Issue
• Micronutrient malnutrition continues to affect
  over 2000
• millon people worldwide. There are several
  reasons for
• such deficiencies. The population may be
  deficient because
• have poor access to 111icronutrient rich food due
  to \
• poverty, defective crop growing pattern, \i"
  deficient soil quality, inappropriate climate or
  geographical isolation.
• Traditional dietary fads may also hinder intake,
  absorption
• or utilization of micronutrient rich foods.

28
MICRONUTRIENT(S)

• Micronutrient deficiency is clinically evident
  only in the later stage of the disease and
  therefore may result in grave consequences. The
  end results of such deficiencies include learning
  disability, impaired work capacity, increased
  susceptibility to infections and greater risk of
  dying. For the nation it means increased
  investment on health services, inferior economic
  productivity and poor gains on educational
  ventures.

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MICRONUTRIENT(S)

• Vitamins
• Vitamins are essential for life and maintenance
  of normal health. These act as cofactor in many
  enzyme systems and are therefore cardinal for
  various bodily functions such as energy
  production, hemopoiesis, reproduction,
  neurological functions, hydroxylation and
  synthesis of fats,

30
VITAMINS

• Any aberrations in these critica l mechanisms
  cause profound changes in the nervous system and
  integrity of skin, mucous membrane, synthesis and
  repair of connective tissues and drug metabolism.

31
VITAMINS

• Vitamins are required in very minute quantities
  in the
• diet. The fetus and the infant get adequate
  vitamins from
• the mother during pregnancy and lactation.
  Dietary intake
• of vitamins may be low or marginal during infancy
  and
• early childhood. There is increased requirement
  of vitamins
• in preterm babies, during post-operative stress,
  infections
• and in some genetic metabolic disorders.
  Intestinal
• absorption of vitamins is impaired in chronic
  diarrhea,
• malabsorption, and bacterial overgrowth in
  intestines.
• Certain drugs may have an adverse effect on the
  enzyme
• systems, which require the vitamin. Thus, these
  may
• inactivate the vitamin and its effects.

32
VITAMINS

• \/itamins are classified into two broad groups
  viz., fatsoluble and the water-soluble vitamins.
• Fat-soluble vitamins include vitamin A, vitamin
  D, vitamin E, and vitamin K.
• Vitamin B complex and vitamin C are the
  water-soluble

33
MINERALS

• These are small inorganic elements and are
  indestructible unlike other major nutrients and
  vitamins Calcium, phosphorus, potassium, sodium,
  chloride. magnesium and sulfur are known as
  macrominerals and are usually required in amounts
  more than 100 mg per day. as they are present in
  relatively higher amounts in body tissues.

34
TRACE ELEMENTS

• The tern trace is applied to concentrations of
  element not
• excceding 250 micro g per g of matrix. The
  definitive feature
• of a nutritionally significant trace element is
  either its
• essential intervention in physiological processes
  or its
• potential toxicity when present at low
  concentrations in
• tissues, food or drinking water. A WHO expert
  consultation
• has divided nutritionally significant trace
  elements into three
• groups (i) essential elements such as Iron,
  Iodine, Zinc,
• Selenium, Copper, Molybdenum and Chromium (ii)
• elements which are probably essential, i e . ,
  Manganese,
• Silicon, Nickel, Boron and Vanadium and
  potentially toxic elements that have essential
  functions at low levels. F, Pb, Cd, Hg, As, Al,
  Li, Sb.

35
VITAMIN A DEFICIENCY

• Vitainin A deficiency (VAD) results in blinding
  several
• hundred thousand children a year. It is now
  recognized
• not only to harm the eyes but also to increase
  childhood
• and maternal mortality. Globally. 21 ol children
  have
• vitamin A deficiency and suffer increased rates
  of death from diarrhea, measles and malaria.
  About 800,000 deaths
• In chldren and women of reproductive age are
  attributable
• to vitamin A deficiency which, along with the
  direct effects
• on eye disease, account for 1.8 of global DALYs.
• (disability adjusted life yeas). This appears to
  be lower
• than previous estimates, possibly because of
  vitamin A
• supplementation or food fortification programs
  during the
• last decade.

36
VITAMIN A DEFICIENCY

• Vitamin A is a subgroup of retinoids exhibiting
  the biological activity of retinol. Naturally
  occuring retinoids include retinol (vitamin A
  alcohol), retinyl ester (vitamin A ester),
  retinal (vitamin A aldehyde) and retinoic acid
  (vitamin A acid). Retinoic acid is the most
  active form of the vitamin.

37
VITAMIN A DEFICIENCY

• Physiology. Vitamin A is essential for normal
• maintenance and function of body tissues, for
  vision,
• Cellular integrity, immune competence andgmwth.
  Vitamin
• A deficiency is therefore a systemic disease,
  most specific
• effects involving the eye. Vitamin A is also
  termed as an
• anti-infective vitamin. This is attributed to its
  role in
• maintaining integrity of epi thelial tissue for
  resisting invasion by pathogens and for
  functional immune response.

38
VITAMIN A SOURCES

• Sources. Rich sources of pre-formed vitamin A or
  retinol are cod liver oil, shark liver oil and
  liver Moderate sources are butter, ghee (butter
  oil). and egg yolk. Best source of carotene is
  red palm oil.
• Provitamin A carolenoids are present in good
  amounts in carrots, green leafy and yellow red
  vegetables and ripe mangoes.

39
VITAMIN A DEFICIENCY SUBCLINICAL

• Subclinical deficiency. Respiratory system,
  urinary tract, intestinal epithelium and immune
  system are affected before the deficiency
  manifests clinically.
• Subclinical vitamin A deficiency contributes to
  an increased severity of certain infections and
  an increased risk of dying from these.

40
VITAMIN A DEFICIENCY Early FEATURES

• EARLY features. Defective dark adaptation is the
  most characteristic early clinical feature.
  resulting in night blindness.

41
VITAMIN A DEFICIENCY XEROPHTHALMAI

• Prolonged deficiency of VIT A in dlet results in
  a syndrome of xerophthalmia, especially prevalent
  in 6-36 month olds. It is often combined with
  general malnutrition. There is pigmentation of
  the caruncle with loss of normal lustre and moist
  appearance of palpebral conjunctiva, which
  appears dry and wrinkled. Bitot spots appear as
  chalky grey spots on the temporal side of
  cornea-scleral junction. Cornea is softened and
  ulcerated (keratomalacia). Eventually it is
  infected and perforation of cornea occurs,
  resulting in opacification and blindness. On
  fundoscopy, pale yellow spots can be visualised
  near the course of retina1 vessels and also in
  the periphery.

42
VITAMIN A DEFICIENCY OTHER FEATURES

• OTHER FEATURES Skin becomes scay and toad like.
  Toad skin is now believed to be due to essential
  fatty acids deficiency. Squamous metaplasia of
  respiratory mucosa makes these children more
  prone to respiratory infections. Alterations in
  mucosa of renal pelvis urinary bladder predispose
  to formation of renal and , vesical calculi.
  Atrophy of the germinal epithelium may .
  interfere with the reproductive functions.
  Vitamin A deficiency may rarely lead to
  hydrocephalus.

43
VITAMIN A DEFICIENCY

• Factors influencing vitamin A status. lntake of
• lt 180 micro g of retinol per day places a person
  at risk of vitamin A deficiency. Diarrhea. worms
  an'd other intestinal orders impair vitamin A
  absorption, while measles, resi r a t o r y tract
  infections and other febrile illnesses, increase
  the metabolic demands. PEM interferes with
  absorption, storage and utilization of vitamin A.
  In protein deficiency, RBP is not synthesized in
  adequate amounts.

44
VITAMIN A DEFICIENCY

• Retinol is actively accumulated in the last
  trimester of pregnancy. Levels of retinal in the
  breast milk are almost equal to the concentration
  of vitamin A in the maternal serum. Preterm
  infants have lower retinal levels and are at high
  risk for developing vitamin A deficiency
  specially at a time when epithelia1 cell function
  is of greatest significance.

45
TREATING VAD

• Specific. Immediately on diagnosis, oral vitamin
  A is
• administered in a dose of 50,000, 1 lakh, and 2
  lakh
• international units in children aped lt 6 months,
  6-12
• months, and gt 1 year, respectively. The same dose
  is
• repeated next day and 4 weeks later. Parenteral,
  watersoluble vitamin A administration is
  recommended (in half gtdoses suggested above for
  6-12 months and Uth in
• lt6 months of age) in cases with impaired oral
  intake,
• persistent vomiting and severe malabsorption. Oil
  based
• injections should not be used to treat
  xerophthalmia.

46
PREVENTING VAD

• Infants who are not breasrfed should receive a
  50,000 IU supplem e n t of vitamin A by 2 months
  of age (or two doses of 25,000 IU each with I
  month interval in between) in areas of endemic
  vitamin A deficiency. Every infant should be
  administered one dose of I lac units of vitamin A
  along with measles vaccine at 9 months followed
  by four more doses of 2 lakh 1U each at 18, 24.
  30 and 36 months.

47
IRON DEFICIENCY ANAEMIA

• Iron deficiency affects about two billion people
  globally. Recent estimates find that Iron
  deficiency anemia (IDA) is responsible for a
  fifth of early neonatal mortality and a tenth of
  maternal mortality. It also affects growth and
  development, limits the leaming capacity, reduces
  cognitive development and reduces work capacity
  of the affected.

48
IRON SOURCES

• Av in liver, kidney, egg yolk, green vegetables,
  and fruits.

49
IDA TREATMENT

• The optimal dose of elemental iron is 3 -6 mg per
  kg of body weight given orally in three divided
  does. With this hemoglobin level should rise by
  about 0.4 g!dL per day. Iron absorption improves
  in presence of vitamin C, when given on empty
  stomach or in between the meals.
• The phytates in cereals and phosphates in the
  milk diminish iron absorption. Therefore, iron
  should not be given just after the milk-feeds or
  after food.

50
IDA TREATMENT

• With iron therapy, the activity of iron
  containing enzymes in the cells improves. The
  child becomes less irritable and his appetite
  improves within 24 hours. Initial bone marrow
  response is observed within 48 hours. Rise ret i
  c u l o c y t e count occurs by the second to
  third day.
• This is followed by elevation of hemoglobin
  level. It may take up to two months depending on
  the severity of anemia. Body iron stores are
  repleted after correction of the hemoglobin
  levels.

51
IDA Prevention and Control

• In childhood, 10 mg of elemental iron is
  required every
• day. Children fed purely on milk diet are prone
  to develop
• anemia. To prevent anemia, supplementary foods,
• especially rich in iron should be administered to
  the child
• from 4 months of age. Pulses, beans, peas, green
  leafy
• vegetables are fairly good sources of iron. Iron
  in the egg.
• however is not easily absorbed.
• Preterm and low birth weight infants with low
  iron
• stores should receive 10-1 5 mg of elemental iron
  daily.

52
IDA Prevention and Control

• Iron needs are increased during puberty because
  of pubertal growth spurt and excessive bleeding
  during menarche in the girls. Therein, iron
  supplements are necessary during adolescence for
  preventing anemia of puberty.
• Several studies have shown that fortified salt
  has been able to prevent anaemia.

53
IODINE DEFICIENCY DISORDERS (IDD)

• Iodine deficiency disorders (IDD) refers to the
  wide spectrum of effects of iodine deficiency on
  growth and development. It includes endemic
  goiter, endemic cretinism, impaired mental
  function in chilben and adults with goiter and
  increased stillbirths and perinatal and infant
  mortality. Evidence is now available that these
  conditions can be prevented by correction of
  iodine deficiency.

54
IODINE DEFICIENCY DISORDERS (IDD)

• Iodine Essential Trace Element Iodine is an
  essential component of thyroid hormones. Sea
  foods and vegetables grown on iodine rich soil
  are good sources of iodine. Soil in Himalayan
  regions has low iodine content due to leaching
  caused by deforestation. Low lying areas subject
  to flooding or high rainfall, such as Ganges
  valley in India and Bangladesh are also severely
  iodine deficient.

55
IODINE DEFICIENCY DISORDERS (IDD)

• Requirement. A daily iodine intake of 50 micro g
  (1-12 mo), 90 micro g ( 1-4 yr), 120 micro g
  (7-12 yr) and 150 micro g From 12 yr onwards is
  is recommended. The requirement should be doubled
  in case of presence of goiterogens in the diet.
  Cassava, maize, bamboo shoots, sweet potatoes and
  millets are important sources of IODINE.

56
IODINE DEFICIENCY DISORDERS (IDD)

• ENDEMIC CRETINISM occurs with an iodine intake
  is lt25 micro g /day in contrast to a normal
  intake of 80-150 micro g/day
• affecting up to 10 of populations living in
  severely iodine deficient areas is associated
  with endemic goiter and characteristic clinical
  features, which include deaf-mutism, squint,
  mental retardation, characteristic spastic or
  rigid neuromotor disorder (spastic diplegia) and
  dwarfism

57
IODINE DEFICIENCY DISORDERS (IDD)

• Two types of endemic cretinism are described
• The neurological cretinism characterized by
  deaf-mutism, squint, proximal spasticity and
  rigidity more in the lower extremities, disorders
  of stance and gait with preservation of
  vegetative functions, occasional signs of
  cerebellar or Oculomotor disturbance and severe
  mental deficiency.
• Myxedemarous cretinism is characterized by
  retarded psychomotor development, severe short
  stature, coarse facial features and myxedema
  without deaf-mutism

58
ZINC DEFICIENCY

• Zinc is present in all organs of the body ,
  tissues, fluids and secretions of the body. The
  element is necessary for the RNA, DNA and
  ribosome stabilization. Zinc is critical for the
  functioning of the bio membranes.
• Animal foods such as red meat and pork are rich
  in zinc. Cheese, whole wheat, nuts and legumes
  also provide zinc.

59
ZINC DEFICIENCY

• Preadolescent children must receive 10 mg of zinc
  per day.
• Deficiency States. Severe zinc deficiency leads
  to growth retardation, hypogonadism, anorexia.
  alopecia, acral dermatitis, acrodermatitis
  enteropathica, behavioral changes and increased
  susceptibility to infections secondary to
  defective cell mediated immunity. Mild zinc
  deficiency is associated with a reduced growth
  rate and impaired resistance to infections. Zinc
  deficiency in pregnant women has been linked with
  premature delivery.

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FOLIC ACID

• Folic acid is a B group vitamin, first isolated
  from spinach leaf in 1941. It occurs naturally as
  folates, which are
• temperature and storage sensitive and cooking
  causes significant fall in their concentration.
  Recommended daily allowance is 100 micro g.
• Sources rich in folates are liver. green leafy
  vegetables.

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FOLIC ACID

• Foiic acid deficiency is also associated with
  increased thrombotic events, which may be related
  to increased homocysteine levels. A recent
  meta-analysis
• showed that 500-5000 micro g/d of folic acid
  intake reduces
• Homocysteine levels by 25. Folic acid seems to
  be protective against development of
  atherosclerosis and other vascular disease by
  virtue of its homocysteine lowering effect.

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FOLIC ACID FOR PREVENTING NEURAL TUBE DEFECT (NTD)

• all women should receive folic acid before or
  immediately after conception to have the desired
  effret,
• The ultimate goal of achieving better folate
  status in women of reproductive age group may be
  achieved by increasing the folate rich food
  intake, supplementation or food fortification.
  Folic acid also prevents pre term delivery,
  placental abruptions, infarctions and helps in
  increasing birth weight.

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FOLIC ACID FOR PREVENTING NEURAL TUBE DEFECT (NTD)

• In 1992, the US Public Health Services
  recommended that all women capable of being
  pregnant should consume 400 micro g of folic acid
  through childbearing age to reduce the risk of
  having pregnancy affected with NTD. Society of
  Obstetrics and Gynecology of Canada Expert
  Advisory Group on Folic Acid in prevention of NTD
  recommended that all women of child bearing age
  should consume 400 micro g of folic acid to
  prevent the first occurance starting before
  conception and continued till the end of 12th
  week of gestation. A daily intake of 4000 micro g
  of folic acid was recommended in previously
  affected pregnancies starting from one month
  before to 3 months

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VITAMIN B COMPLEX B1

• Thiamine exists in tissues mostly in the form of
  thiamine pyrophosphate (TPP), also known as
  carboxylase. It is , required for the synthesis
  of acetylcholine deficiency results in impaired
  nerve conduction. It is a cofactor in
  carbohydrate and protein metabolism. In thiamine
  deficiency, utilization of pyruvic acid is
  decreased.
• Therefore pyruvic acid and lactic acid accumulate
  in the tissues and their blood levels are
  increased.

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VITAMIN B COMPLEX B1

• Sources. Dried yeast, whole grain cereals,
  pulses, oil and groundnuts are good sources.
  Meat, fish And green vegetables are relatively
  poor sources.

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OVER TO HANDOUTS

• VITAMIN B COMPLEX, C, D, E, and trace elements.

67
PROTEIN ENRGY MALNUTRITION (PEM)

• Undernutrition is widely recognized as a major
  health problem in the developing countries of the
  world. Severe PEM, often associated with
  infection contributes to high child mortality in
  underprivileged communities. Further, early
  malnutrition can have lasting effects on growth
  and functional status. The frequency of
  undenutrition cannot be easily estimated from the
  prevalence of commonly recognized clinical
  syndromes of malnutrition such a marasmus and
  kwashiorkor because these constitute only
  proverbial tip of the iceberg. Cases with mild to
  moderate undenutrition are likely to remain
  unrecognized because clinical criteria for their
  diagnosis are imprecise and difficult
• to interpret accurately.

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PROTEIN ENRGY MALNUTRITION (PEM)

• Assessment of nutritional status by anthropometry
  is the simplest and most useful tool for
  assessing the nutritional status of children.
  Anthropometric measurements like weight, height
  and mid-arm circumference should be compared to
  the anthropometric norms for the corresponding
  age in the well nourished and healthy children of
  the community.

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PROTEIN ENRGY MALNUTRITION (PEM)

• Protein-energy malnutrition (PEM) is the most
  widely prevalent form of malnutrition among
  children. Nutritional status of children is an
  indicator of nutritional profile of the entire
  community. PEM affects every fourth child
  world-wide. 150 million (26.7) are underweight
  while 182 million (32.5) are stunted.
  Geographically. more than 70 of PEM children
  live in Asia, 26 in Africa and 4 in Latin
  America and the Caribbean.

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PEM Etiliology

• Poverty
• Low Birth Weight
• Infections
• Population growth
• Feeding habits
• High Pressure Ad for Baby Foods
• Social Factors

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CLINICAL MANIFESTATIONS OF PEM

• Nutritional marasmus and kwashiorkor are two
  extreme forms of malnutrition. Such extreme forms
  account for a small proportion of cases of
  malnutrition. A much larger number of subjects
  suffer from mild to moderate nutritional deficit.
  

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PREVENTION OF PEM

• Prevention at family level
• Exclusive breast feeding for first 6 months.
• Nutrition supplements after the age of 6 months.
• Complementary foods should be a judicious mixture
  of cereals and legumes Food should be energy
  dense thick consistency and given hygienecally.
• As much milk, meat, eggs should be offered with
  the complementary food to enhance the net dietary
  protein value.

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PREVENTION OF PEM

• Vaccine preventable diseases should be prevented
  by immunizations.
• Proper birth spacings between two pregnancies.

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PREVENTION AT COMMUNITY LEVEL

• Early detection of malnutrition and intervention
• Growth monitoring
• Integrated health packages (immunization
  kemoprophylaxix periodic devermin)
• Nutrition education.
• Technological measures iodizing the common salt,
  prevention of night blindness through vit A
  supplementation and distribution of folic acid
  and tron tablets.

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OBESITY

• It is form of development driven malnutrition.
• CAUSES
• EXOGENEOUS or ENDOGENEOUS
• ENDOGENEOUS CAUSES less than 10 of the total

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EXOGENEOUS OBESITY

• Dietary factors large infrequent meals high
  calorie density junk foods
• Habits psychogenic causes more indoor games
  watching TV
• Decreased energy expenditure.
• Genetic factors 1 ob gene which affects the
  appetite set point and metabolic rate

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MANAGEMENT OF OBESITY

• Diet calorie intake in between snacks junk
  foods should be curtailed high fibre low
  calorie encouraged
• Greater physical activity
• Behaviour modification constant encouragement
  help of a psychologist
• Drugs and surgical methods are NOT encouraged.

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PREVENTION OF OBESITY UNIVERSAL APPROACH

• SOCIAL CULTURAL POLITICAL PHYSICAL AND STRUCTURAL
  ENVIRONMENT to focus on prevention of rise in
  BMI.
• Issue of obesity should be addressed during every
  well child examination.
• Parents are asked NOT to overfeed the child.
• Food should NOT be used for comfort or reward.
• Sugared food should be avoided completely.