Feeding Of Infants And Children
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Feeding Of Infants And Children

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    Feeding Of Infants And Children Feeding Of Infants And Children Presentation Transcript

    • FEEDING OF INFANTS AND CHILDREN Myrna D.C. San Pedro MD, FPPS
    • SPECIFIC OBJECTIVES
      • To discuss the physiologic basis for feedings intrauterine, at birth & during the growing years
      • To enumerate the guiding principles of infant feeding
      • To discuss breastfeeding
        • Identify the anatomical structures of the female breast
        • Explain the physiology of lactation
        • Compare the different types of breast milk
        • Enumerate the factors affecting composition
        • Enumerate the advantages and disadvantages
        • Explain how to determine if breast milk supply adequate
        • Enumerate antenatal techniques and postnatal procedures to prepare mothers for proper breast-feeding
    • SPECIFIC OBJECTIVES
      • To discuss breastfeeding (continuation)
        • Compare the composition of human breast milk and cow’s milk
        • Explain wet nursing
      • To discuss artificial feeding
        • Compute the fluid and caloric requirement of a cow’s milk formula-feeding infant
        • Differentiate the various milk formulas
        • Define supplementary and complementary feedings
      • To discuss weaning and introduction of solids
        • Define weaning
        • State when to start solid feedings and why
        • Enumerate the recommended solid feedings
      • To define and demonstrate a “healthy” diet for children
    • RELATION OF MATERNAL & FETAL NUTRITION
      • Maternal diet ultimate source of fetal nutrients as evidenced by distinctly lower average birth weight among babies in low-income than from high-income groups
      • With poor maternal diet, less fat & protein storage in fetus, less vitamin A & iron storage in fetal liver & less Ca +2 deposition in fetal skeleton
      • Poor maternal diet also increases incidence of abortions, stillbirths & developmental abnormalities in fetus
      • Whatever physical, biochemical, physiologic & behavioral defects due to poor maternal diet intensified during neonatal period
    • AT BIRTH & NEONATAL PERIOD
      • After birth when infant can safely tolerate enteral nutrition judged by normal activity, alertness, suck & cry, feedings started
        • To maintain normal metabolism during transition from fetal to extrauterine life
        • To promote maternal-infant bonding
        • To decrease risks of hypoglycemia, hyperkalemia, hyperbilirubinemia & azotemia
      • Most infants can start breast-feeding immediately almost always within 1–4 hr
      • An infant's stomach’s emptying time varies from 1–4 hr or more during a single day
    • GENERAL GUIDELINES
      • By end of 1 st wk, most healthy infants will be taking 60–90 ml/feeding and want 6–9 feedings/24 hr
      • By end of 1 st month, >90% of infants will have established a suitable & reasonably regular schedule
      • Most will wake for a middle-of-the-night feeding until 3–6 wk of age though some will never desire this feeding while others continue it beyond 3–6 wk of age
      • Between 4–8 mo of age, many infants will lose interest in the late evening feeding
      • By 9–12 mo of age, most will be satisfied with 3 meals/day plus snacks
      • Not all infants conform to these general guidelines
    • REASONS FOR AN INFANT’S CRY OTHER THAN HUNGER
      • May not be receiving enough milk
      • May have discomfort such as uncomfortable clothing, colic or “gas”, wet diapers or feeling hot or cold
      • To gain sufficient or additional attention
      • Simply need to be held
      • Sick infants (uninterested in food and continue to cry even when held)
    • BREAST-FEEDING
      • Breast milk: the most ideal, safe & complete food
      • Breast milk protein of good biological value
      • Lactation may continue to 18-24 months (WHO)
    • BREAST STRUCTURE
      • Each breast has 15 to 20 lobes of milk-producing glandular tissue
      • Each lobe is made up of many smaller lobules
      • Special channels called ducts run from these lobes
      • Spaces around the lobules and ducts are filled with fatty & connective tissue stroma that determines the size
      • Nipple skin contains many nerves, oil & sweat secreting glands
      • The actual milk-producing structures nearly the same in all
    • WHAT HAS CHANGED?
      • University of Western Australia’s Human Lactation Research Group, with Medela, investigated the lactating breast using sophisticated ultrasound & research results overturned 160 years of received wisdom concerning the female breast
    • PHYSIOLOGY OF LACTATION
      • Nipple stimulation from baby’s breast sucking
      • Message sent to spinal cord, then brain
      • Increased prolactin levels released by anterior pituitary for milk production
      • Increased oxytocin levels released by posterior pituitary for milk ejection reflex
      • About 5% fat, 1.1% protein & 7% lactose that is fairly consistent, fatty acids generally reflect maternal diet, total N 2 of 1.2% includes significant portion of non-protein N 2
      • Sp. gr. 1.026-1.036 average being 1.031
      • PH 6.8-7.4 average of 7
      • **In poorly nourished women, composition constant but total yields lower
      About 600 ml in 1 st mo to 800 ml in the 6 th mo after which falls to 25-400 ml on the 2 nd yr By end of 1 st month of lactation MATURE
      • Fall in protein, decreasing cells/mm 3 & concentration of immunoglobulins but total volume increases
      • Gradual increase in fat & lactose
      • Na + , K + & Cl - concentrations decrease but Ca +2 & PO 4- constant
      Increases to <600 ml From 4 th -10 th day to 1 st month TRANSITIONAL
      • Yellow fluid
      • More protein (95% globulins & more IgA)
      • Less fat & sugar
      • More vitamins esp. vitamin A
      • More salt (Na + & K + )
      • Sp. gr. 1.040-1.060
      • Alkaline pH of 7.7
      10-40 ml/day 1 st 2-4 days COLOSTRUM CHARACTERISTICS QUANTITY TIMING TYPE
    • FACTORS INFLUENCING COMPOSITION
      • Time of day - Fat content highest early in the day & lowest at night
      • Mother’s diet - Milk usually light blue but the more fat the more yellowish
      • Mother’s emotional state - milk ejection reflex often absent or erratic during periods of pain, fatigue, or emotional distress
      • Whether fore or hind milk - . “Fore” milk, 1 st milk expressed is clear, thin & bluish reflecting low fat & high water content but “Hind” milk or end milk is thick & creamy white reflecting higher fat content
      • Drugs - Atropine, opium, lead, iodides, barbiturates, sulfonamides, INH & some antibiotics may be found in milk after prolonged use or in maximum doses
      • Smoking
    • DETERMINING ADEQUACY
      • If infant is satisfied after each nursing period
      • Contented and sleeps 2-4 hours between feedings
      • Regularly and adequately gaining weight
      • The “let-down” or milk ejection reflex in the mother is an important sign
    • ADVANTAGES OF BREAST-FEEDING
      • Proper quality & quantity of nutrients
      • Rates of growth better in the 1 st 3-4 months
      • Anti-infective properties universally accepted
      • Prevents allergy due to high IgA preventing antigen absorption
      • Contraceptive property, high levels of prolactin inhibit synthesis of ovarian steroids causing delay of ovulation & pregnancy
      • Psychological advantages
        • Fosters mother-child relationship
        • Tactile contact makes babies more secure, emotionally stable
        • A sense of fulfillment, satisfaction & joy for the mother
      • Protective against
        • Necrotizing enterocolitis
        • Otitis media
        • Dental caries
      • Others:
        • Safe, contains no pathogens
        • Always at the right temperature
        • Convenient & always available
    • ANTI-INFECTIVE PROPERTIES
      • Breast milk esp. colostrum contains plenty of antibodies
      • E. coli antibodies present
      • High % of lactose stimulates Lactobacillus bifidus
      • Lactoferrin binds iron & inhibits growth of E. coli, staphylococci & Candida albicans
      • Lysozyme bacteriostatic against enterobacteriaceae & staphylococcus species
      • Anti-staphylococcus factor
      • Lactoperoxidase kills streptococci & enteric bacteria
      • Secretory IgA against intestinal bacteria
      • Macrophages 90% of leucocytes, involved in phagocytosis & synthesis of bacteriostatic proteins: lactoferrin, lysozyme & complements C3, C4
      • Lymphocytes comprise 10%, approximately 34% B-lymphocytes responsible for synthesis of IgA
      • T-lymphocytes 50% against E. coli, rubella, CMV & mumps viruses & transfer delayed hypersensitivity
    • CONTRAINDICATIONS
      • Absolute : chronic diseases like open TB, cardiac diseases, thyrotoxicosis, advanced nephritis, mental & seizure disorders
      • Relative : when mother is taking anticoagulants, antibiotics, steroids or potentially toxic substances like benzene products
      • Mechanical contraindications on the part of the mother : retracted or oversized nipples
      • Mechanical contraindications on the part of the baby: congenital anomalies like harelip & cleft palate but breast milk may be pumped & given
      • Allergy should be proven
    • REASONS FOR NOT OR STOPPING BREAST-FEEDING
      • Lack of motivation or preparation of mothers
      • Anxiety, fear & uncertainty in the mother
      • Aesthetic reasons
      • Status seeking & effective promotion of infant foods
      • Mothers work to increase & augment family income
      • Separate maternity & nursery wards
      • Milk formula easily sucked from the bottle nipple
      • Cultural milieu
      • Mothers who can’t despite all desires & attempts
      • Presence of contraindications
    • ANTENATAL TECHNIQUES
      • Wear fitted maternity bra from 5 th month
      • Daily bath enough for cleaning nipples, avoid soap, alcohol & drying agents
      • Rub nipples & areolae with little anhydrous lanolin to make more supple
      • Express colostrum from 7 th month by squeezing areola between index finger & thumb about 3x each side
      • Practice Hoffman’s maneuver (tactile stimulation by thumb & opposing forefinger in the horizontal & vertical planes) for flat or pseudo-inverted nipple
    • POSTNATAL PROCEDURES
      • Breast-feeding maybe started about 30 min after NSD & 3-4 hrs after C/S
      • The baby should be comfortable, in semi-sitting position with lips engaging considerable areola & breast not obstructing breathing
      • The mother should be seated comfortably & relaxed (recumbent position if preferred) with areola held between her index & middle fingers or between thumb & index finger to control milk flow
      • Baby obtains 95% of milk in the 1 st 5 min & frequent feeds as well as short feeds on alternate breasts ideal then burp after
      • Teach mother how to break suction of baby when time to stop by pressing on a portion of the breast near baby’s lips to let air into mouth to prevent painful tagging between mother & child minimizing sore nipples
    • Less digestible Softer, smaller
      • Curds
      High ratio of methionine to cystine, higher levels phenylalanine & tyrosine Low ratio of methionine to cystine, lower levels phenylalanine & tyrosine
      • Casein
      Mostly  -lactoglobulin, some  -lactalbumin & traces of lactoferrin  -lactalbumin (40%) lactoferrin (25%) lysozyme (0.08%), albumin (0.08%), IgA, IgG, IgM (0.15%)
      • Whey proteins
      20:80 60:40
      • Whey-to-casein ratio
      3.3% 1-1.5% Proteins Both have water content of 87-87.5% w/ sp. gr. 1.026-1.036 average being 1.031 Water content & Specific gravity Both have pH 6.8-7.4 w/ average of 7 pH COW’S MILK BREAST MILK CONTENT
    • 4.8% 7% Carbohydrates mainly lactose Steatorrhea may occur Contains bile-salt stimulated lipase plus specific fatty acids, hence, more efficient
      • Digestion & absorption
      4-5% of fat calories, hence, better source of this
      • Linoleic acid
      9% 1.3%
      • Volatile fatty acids butyric, capric, caproic & caprylic
      Twice as much of the more absorbable olein
      • Neutral fat or triglycerides palmitin, stearin & olein
      3.5% but varies w/ maternal diet Fats COW’S MILK BREAST MILK CONTENT
    • Lesser More vitamin C
      • Ascorbic acid
      More thiamine & riboflavin More niacin
      • B complex
      Both contains large amounts of vitamin A, minimal vitamin D & should be given vitamin K to prevent hemorrhagic disease of the newborn
      • Fat-soluble vitamins
      Vitamins Lower & lesser absorbed Although low, sufficient because better absorbed
      • Iron
      Neonatal hypocalcemia may occur 2:1
      • Ca +2 /P - ratio
      Hypertonicity & acidosis common Hypotonic dehydration
      • With diarrhea
      Need for extra water Ensures free water
      • And water
      0.7-0.75% 0.15-0.25% Mineral content COW’S MILK BREAST MILK CONTENT
    • WET NURSING
      • Definition: Breast milk fed to an infant obtained from a lactating woman other than the mother
      • Purpose: For infants, like LBWs, who don’t seem to do well with any other type of milk
      • A good lactating woman should be able to supply milk for 2-3 babies at same time including own
      • A wet nurse should be in good health, have good personal hygiene & enough milk for another infant in addition to her own who is thriving well
    • ARTIFICIAL FEEDING
      • Isocaloric: Infant formulas or breast milk substitutes contain about 20 kcal/oz like breast milk
      • Caloric requirements: The average caloric requirement of a FT infant is about 80-120 kcal/kg during the 1 st few months of life & 100 kcal/kg by 1 yr
      • Fluid requirements: During the 1 st 6 months of life, about 130-190 ml/kg/day; as a rule, the infant regulates his or her own fluid requirement provided adequate amounts mostly from orange juice & other foods or water offered
      • Number of feedings daily: For the 1 st month or 2, feedings throughout 24-hr period, about 8 feedings/day but as quantity increases, number of feedings decrease adjusting to family pattern & by 9-12 months most infants satisfied with 3 meals a day
    • MILK FORMULAS
      • Certified Milk. Milk drawn cooled to <7 0 C immediately & kept at this temperature till delivery
        • Eliminates bovine tuberculosis, typhoid & other salmonella, dysentery, streptococcus & staphylococcus
      • Pasteurized Milk. Heating milk at 63 0 C for 30 min or for 15 sec at 72 0 C followed by rapid cooling to 65 0 C.
        • Destroys all pathogenic bacteria but only 99% of saprophytes
        • Destroys 20% of vitamin C & 10% of thiamine
        • Standards range from 5,000-10,000/ml to 50,000 non-pathogenic bacteria/ml
        • Should be kept at 10 0 C & do not use after 48 hrs
        • Only fresh milk is pasteurized
    • MILK FORMULAS
      • Homogenized Milk. Processing of milk through a fine aperture at high pressure at pasteurization temperature so that fat globules are broken down into a fine emulsion
        • Prevents creaming & renders fat more easily assimilated
        • Method used to incorporate vitamin D in milk
      • Evaporated Milk. Cow’s milk vaporized at 55-60 0 C to about 50% of its volume, homogenized, sealed in cans & autoclaved at 116 0 C for some time to destroy spores
        • Process can damage quality of protein
        • If can unopened, can keep for months without refrigeration
        • Lactalbumin less allergenic
        • 30 ml or 1 fl oz = 40 kcal
    • MILK FORMULAS
      • Condensed Milk. Cow’s milk to which 45% cane sugar added
        • Carbohydrate content 60% when diluted 1:4
        • Percentage composition of proteins 1.6%, fat 1.6%, carbohydrate 11% & minerals 0.36%
        • Used only for short periods of time if high caloric formula needed since nutritionally “out of balance”
        • Less fat-soluble vitamins & vitamin C
        • Main advantages are keeping quality & cheap cost
      • Dried Milk . Prepared by spraying whole or pasteurized milk into a hot chamber at a very high speed so that water is volatized immediately or by freeze-drying
        • Fine curds produced because protein altered
        • Vitamin C not affected
    • MILK FORMULAS
      • Skimmed Dried Milk. Fat removed before milk is dried so that fat content only 0.05%
        • Half-skimmed dried milk has fat content of 1.5%
        • Useful for fat intolerance, diarrhea or some prematures
      • Fermented Milk. Acidity of sour milk responsible for changing of the casein curds
        • Buttermilk. Milk allowed to turn sour by nature & its fat removed by churning; since frequently contaminated, sterile skimmed milk is inoculated with some lactic-acid producing organisms ( Lactobacillus acidophilus, L. bulgaricus, or Streptococcus lacticus )
        • Fermented Whole milk. After inoculation, milk incubated at 27-30 o C for 6-12 hrs after which refrigerated for several days
        • Protein Milk. Introduced by Finkelstein for treatment of diarrheas
    • MILK FORMULAS
      • Acid Milk. Prepared by addition of dilute mineral or organic acids to the milk, such as lactic acid milk popularized by Marriott
        • Overcomes buffer value of cow’s milk
        • Bactericidal effect in stomach & duodenum
        • May cause acidosis in infants
      • Filled Milk. Fat content of whole milk is replaced by vegetable oil, coconut oil & corn oil & this increases the amount of saturated fatty acids
      • Recombined Milk. Separated non-aqueous ingredients mixed together with or without water, e.g. in condensed milk recombination, butterfat & non-fat milk solids are put together again
    • MILK FORMULAS
      • Reconstituted Milk. Remaking of any milk product to approximate the composition of fresh cow’s milk, hence, for powdered milk, all that is needed is water
      • Follow-on Milk Formulas. Food intended for use as a liquid part of the weaning diet for the infant from the 6 th month onwards & for children between 12-36 months of age
        • Questions raised about the high protein content
        • Risk of hypernatremic dehydration due to high potential renal solute load
        • However, beneficial in places where supplementary foods are low in protein
    • MILK FORMULAS
      • Special Milk Formulas. Where either the carbohydrate, protein, fat or all these components have been altered to address specific needs
        • Phenylalanine-free. Milk formula for phenylketonuria
        • Lactose-free Formulas. For lactose intolerance or galactosemia
        • Soy formulas/Protein Hydrolysates. For infants with cow’s milk allergy
        • Powdered Protein. For prematures or debilitated infants or those with diarrhea
    • NOT RECOMMENDED FOR INFANTS
      • Whole Cow’s Milk
        • Protein content much higher than in breast milk 21% versus 7-16%, thus, increasing solute load
        • Low in iron
        • Use may result in occult blood loss in stools
      • Skimmed Milk & Low Fat Milk
        • Very low fat content
        • Deficient in vitamin C & iron
      • Goat’s Milk
        • Just as antigenic as cow’s milk
        • High protein content may result in increased renal solute load
        • Deficient in folic acid & iron
        • Carbohydrate content 25% versus 35-65% in breast milk
    • SUPPLEMENTARY AND COMPLEMENTARY FEEDINGS
      • Supplementary Feedings
        • Feedings provided in place of breastfeeding
        • Any food given prior to 6 months , the recommended duration of exclusive feeding
        • May include expressed or banked breast milk
      • Complementary Feedings
        • Milk feedings given in addition to breastfeeding or replacement foods (non-milk feedings)
        • Foods given in addition to breastfeeding after 6 months needed for adequate nutrition
    • WEANING
      • Definition: The process of introducing any non-milk food into the infant’s diet, irrespective of whether or not breast- or bottle-feeding continues
      • Introduction of solids usually done at about 4-6 months of age because:
        • Milk supply may no longer meet the nutrient requirements for growth
        • Intestinal tract better able to handle foreign proteins
        • Kidneys better able to tolerate increased protein loads
        • The infant exhibits developmental readiness
    • DEVELOPMENTAL READINESS FOR WEANING
      • Able to sit with support or briefly
      • Better head control
      • Better oral motor coordination (loss of extrusion reflex)
      • Better able to communicate degree of satisfaction
    • WEANING FOODS
      • Initial weaning foods are usually cereals, pureed or mashed fruits & vegetables and semi-solids
      • Ground fresh beef, liver or strained canned meats may be given initially by 6 months of age
      • When infant shows “gumming” or develops chewing motions, usually at 6-8 months of age, chewable biscuits & succulent solids may be introduced
      • Egg white, chicken & similar highly antigenic foods should be introduced with caution during the second 6 months to observe for & minimize allergic manifestations
      • Lifelong dietary habits may become established at weaning periods, hence, excessive salt & sugar intake should be discouraged
    • WEANING FOODS
      • By 8 months, most infants can also eat &quot;finger foods&quot; (snacks that can be eaten by children alone)
      • By 12 months, most children can eat the same types of foods as consumed by the rest of the family
      • Avoid foods that may cause choking (i.e., items that have shape and/or consistency that may cause them to become lodged in the trachea like nuts, grapes, raw carrots)
      • Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda
      • Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods
    • WHAT IS A “HEALTHY” DIET?
      • The Dietary Guidelines for Americans, 2005, describe a healthy diet as one that
        • Emphasizes fruits, vegetables, whole grains and fat-free or low-fat milk and milk products
        • Includes lean meats, poultry, fish, beans, eggs and nuts
        • Is low in saturated fats, trans-fats, cholesterol, salt (sodium) and added sugars
    • WHAT IS A “HEALTHY” DIET?
      • The Food Guide Pyramid incorporates current dietary guidelines with strong focus on activity
      • “ MyPyramid” indicates that nutrient needs vary as a function of age, sex, weight, height and level of activity
      • The goal is to support normal rates of weight gain without excessive fat deposition
      • The recommendations in the Dietary Guidelines and in MyPyramid are for the general public >2 years of age
    •  
    • Very Active Moderately Active (30–60 min of vigorous activity/day) Inactive (<30 min of vigorous activity/day) Needed by a 6-yr-old Boy 5 5 4 Meat, beans (oz/day) 3 3 2 Milk (cups/day) 1.5 1.5 1.5 Fruits (cups/day) 2.5 2 1.5 Vegetables (cups/day) 6 5 5 Grains (oz/day) 1,800 1,600 1,400 Energy (kcal/day) Daily Intakes of Each Food Group
    • WHAT IS A “HEALTHY” DIET?
      • The National Cholesterol Education Program and the American Heart Association Step I Diet recommends:
        • Dietary fat to about 30% of total daily energy intake
        • Saturated fatty acids <10% of energy
        • Cholesterol < 100 mg/1,000 kcal
        • PUFA 7–8% of energy
        • Monounsaturated fatty acids 12–13%
      • To decrease atherosclerotic heart disease in adulthood and may be effective in preventing obesity
    • a Based on EER from IOM DRIs macronutrients report, 2002, calculated by gender, age and activity level for reference-sized individuals. &quot;Reference size,&quot; is based on median height and weight for ages up to 18 yr and median height and weight for that height to give a BMI of 21.5 for adult females and 22.5 for adult males. b Sedentary means a lifestyle that includes only light physical activity associated with typical day-to-day life. c Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5-3 miles/ day at 3-4 miles/hour, in addition to the light physical activity associated with typical day-to-day life d Active means a lifestyle that includes physical activity equivalent to walking >3 miles/day at 3-4 miles/hour, in addition to the light physical activity associated with typical day-to-day life. Estimated Amounts of Calories a 1,600-2,000 2,000-2,600 2,800-3,200 3,000 2,800-3,000 2,400-2,800 1,400-1,600 1,800-2,200 2,400-2,800 2,600-2,800 2,400-2,600 2,200-2,400 1,400 1,800 2,200 2,400 2,200 2,000 4-8 9-13 14-18 19-30 31-50 51+ 1,400-1,800 1,800-2,200 2,400 2,400 2,200 2,000-2,200 1,400-1,600 1,600-2,000 2,000 2,000-2,200 2,000 1,800 1,200 1,600 1,800 2,000 1,800 1,600 4-8 9-13 14-18 19-30 31-50 51+ Male Female 1,000-1,400 1,000-1,400 1,000 2-3 Child Active d Moderately Active c Sedentary b Age (years) Gender
    • As point of reference: 3 ounces lean beef (the size of a deck of cards) or poultry = 25 g protein; 3 ounces fish or 1 cup soybeans = 20 g protein; 1 cup milk or yogurt = 8 g protein; 1 egg or 1 ounce cheese=6 g protein; 1 cup legumes=15 g protein; cereals, grains, nuts and vegetables = 2 g protein per serving 0.85 (or 46 g/day of protein) 0.80 (or 46 g/day of protein) 14-18 yr (RDA) 19-30 yr (RDA) Females 0.85 (or 52 g/day of protein) 0.80 (or 56 g/day of protein) 14-18 yr (RDA) 19-30 yr (RDA) 1.2 16-19 yr Males 1.5 7-15 yr 0.95 (or 34 g/day of protein) 9-13 yr (RDA) 2 3-6 yr 0.95 (or 19 g/day of protein) 4-8 yr (RDA) 2.5 1-2 yr 1.05 (or 13 g/day of protein) 1-3 yr (RDA) 3 6-11 mo 1.2 (or 11 g/day of protein) 7-12 mo (RDA) 3.5 0-5 mo 1.52 0-6 mo (AI) 1978 FNRI Publications, Daily Requirements of Filipinos (g/kg BW/day) 2005 Dietary Reference Intakes, U. S. Food and Nutrition Board, National Academy of Sciences (g/kg BW/day) Daily Protein Requirement
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