SA

1. Medical nutrition therapy for lowbirthweight
infants

2. nutritional status
of children.
2. List three reasons for growth retardation in a child with
congenital heart
disease.
3. Identify the four major nutritional problems to be
considered for patients
with congenital heart disease.
4. Explain the appropriate diet therapy for congenital heart
disease, and
give supporting rationale.
5. Describe formulas and supplements used for infants
with congenital heart
disease.
6. Evaluate the introduction of solid foods and precautions
used when feeding.
7. Compare the feeding problems encountered in a child
with a defective
heart to those of normal children.
8. Describe methods of maintaining optimum nutritional
status in the hospitalized
child.
9. Teach parents and the child the principles of feeding
and eating when
congenital heart disease is present.

3. Nutrition can be provided to LBW infants in many ways, each of which has certain benefits and
limitations. The infant’s
size, age, and clinical condition dictate the nutrition requirements and the way they can be met. Because
of the
complexities involved in the neonatal intensive care setting, a team that includes a registered dietitian
nutritionist trained
in neonatal nutrition should make the decisions necessary to facilitate optimal nutrition (Ehrenkranz,
2014). Neonatal
nutritionists monitor compliance with standardized feeding guidelines; ensure that early, intense
nutritional support is
initiated; facilitate the smooth transition from parenteral to enteral nutrition; and monitor growth and
individualized
nutrition support to maintain steady infant growth. In regionalized perinatal care systems, the neonatal
nutritionist also
may consult with health care providers in community hospitals and public health settings.

4. Physiologic development
Gestational age and size
At birth, an infant who weighs less than 2500 g (5½ lb) is classified as having a low birthweight (LBW); an infant
weighing less than 1500 g (3⅓ lb) has a very low birthweight (VLBW); and an infant weighing less than 1000 g (2¼
lb)
has an extremely low birthweight (ELBW). LBW may be attributable to a shortened period of gestation,
prematurity, or
a restricted intrauterine growth rate, which makes the infant small for gestational age (SGA).
The term infant is born between the 37th and 42nd weeks of gestation. A premature (preterm) infant is born
before
37 weeks of gestation, whereas a postterm infant is born after 42 weeks of gestation.
Antenatally, an estimate of the infant’s gestational age is based on the date of the mother’s last menstrual period,
clinical parameters of uterine fundal height, the presence of quickening (the first movements of the fetus that can
be felt
by the mother), fetal heart tones, or ultrasound evaluations. After birth, gestational age is determined by clinical
assessment. Clinical parameters fall into two groups: (1) a series of neurologic signs, which depend primarily on
postures
and tone and (2) a series of external characteristics that reflect the physical maturity of the infant. The New Ballard
Score
examination is a frequently used clinical assessment tool (Ballard et al, 1991). An accurate assessment of
gestational age
is important for establishing nutritional goals for individual infants and differentiating the premature infant from
the term
SGA infant.

5. standard weight for that gestational age. An SGA infant whose intrauterine weight gain is poor, but whose linear and head
growth are between the 10th and 90th percentiles on the intrauterine growth grid, has experienced asymmetric
intrauterine growth restriction (IUGR). An SGA infant whose length and occipital frontal circumference are also below
the 10th percentile of the standards has symmetric IUGR. Symmetric IUGR, which usually reflects early and prolonged
intrauterine deficit, is apparently more detrimental to later growth and development. Some infants can be SGA because
they are genetically small, and these infants usually do well.
An infant whose size is appropriate for gestational age (AGA) has a birth weight between the 10th and 90th
percentiles on the intrauterine growth chart. The obstetrician diagnoses IUGR when the fetal growth rate decreases.
Serial ultrasound measurements document this reduction in fetal anthropometric measurements, which may be caused by
maternal, placental, or fetal abnormalities. The future growth and development of infants who have had IUGR is diverse,
depending on the specific cause of the IUGR and treatment. Some infants who suffered from IUGR are SGA, but many may
plot as AGA infants at birth. Decreased fetal growth does not always result in an infant who is SGA.
An infant whose birth weight is above the 90th percentile on the intrauterine growth chart is large for gestational age
(LGA). Box 41.1 summarizes the weight classifications. Fig. 41.1 shows the classification of neonates based on maturity
and intrauterine growth.

7. Nutrition requirements: Parenteral feeding
Many critically ill preterm infants have difficulty progressing to full enteral feedings in the first several days or
even weeks of life. The infant’s small stomach capacity, immature gastrointestinal tract, and illness make the
progression to full enteral feedings difficult (see Pathophysiology and Care Management Algorithm: Nutrition
Support of Premature Infants).
PN becomes essential for nutrition support, either as a supplement to enteral feedings or as the total source of
nutrition. offers a complete discussion of PN; only aspects related to feeding of the preterm infant are
presented here.

8. Fluid
Because fluid needs vary widely for preterm infants, fluid balance must be monitored. Inadequate intake can lead to
dehydration, electrolyte imbalances, and hypotension; excessive intake can lead to edema, congestive heart failure, and
possible opening of the ductus arteriosus. Additional neonatal clinical complications reported with high fluid intakes
include necrotizing enterocolitis (NEC), and bronchopulmonary dysplasia (BPD) (see Chapter 33).
The premature infant has a greater percentage of body water (especially extracellular water) than the term infant (see
Chapter 3). The amount of extracellular water should decrease in all infants during the first few days of life. This reduction
is accompanied by a normal loss of 10% to 15% of body weight and improved renal function. Failure of this transition in
fluid dynamics and lack of diuresis may complicate the course of preterm infants with respiratory disease.
Water requirements are estimated by the sum of the predicted losses from the lungs and skin, urine, and stool, and the
water needed for growth. A major route of water loss in preterm infants is evaporation through the skin and respiratory
tract. This insensible water loss is highest in the smallest and least mature infants because of their larger body surface
area relative to body weight, increased permeability of the skin epidermis to water, and greater skin blood flow relative to
metabolic rate. Insensible water loss is increased by radiant warmers and phototherapy lights and decreased by
humidified incubators, heat shields, and thermal blankets. Insensible water loss can vary from 50 to 100 mL/kg/day on the
first day of life and increase up to 150 mL/kg/day, depending on the infant’s size, gestational age, day of life, and
environment. The use of humidified incubators can decrease insensible water losses and thereby reduce fluid
requirements.

9. Excretion of urine, the other major route of water loss, varies from 1 to 3 mL/kg/hr (Doherty, 2017). This loss depends on
the fluid volume and solute load presented to the kidneys. The infant’s ability to concentrate urine increases with
maturity.
Stool water loss is generally 5 to 10 mL/kg/day, and 10 to 15 mL/kg/day is suggested as optimal for growth (Dell, 2015).
Because of the many variables affecting neonatal fluid losses, fluid needs must be determined on an individual basis.
Usually fluid is administered at a rate of 60 to 100 mL/kg/day the first day of life to meet insensible losses and urine
output. Fluid needs then are evaluated by assessing fluid intake and comparing it with the clinical parameters of urine
output volume and serum electrolyte, creatinine, and urea nitrogen levels. Assessments of weight, blood pressure,
peripheral perfusion, skin turgor, and mucous membrane moisture are performed daily. Daily fluid administration
generally increases by 10 to 20 mL/kg/day. By the end of the first week of life, preterm infants may receive fluids at a rate
of 140 to 160 mL/kg/day. Fluid restriction may be necessary in preterm infants with patent ductus arteriosus (an opening
between the pulmonary artery and the aorta), congestive heart failure, renal failure, or cerebral edema. However, more
fluids are needed by preterm infants who are placed under phototherapy lights or a radiant warmer or when the
environmental or body temperature is elevated.

10. Energy
The energy needs of preterm infants fed parenterally are less than those of enterally fed infants because absorption
loss does not occur when nutritional intake bypasses the intestinal tract. Enterally fed preterm infants usually require
110 to 130 kcal/kg/day to grow, whereas parenterally fed premature neonates can grow well if they receive 90 to 100
kcal/kg/day (AAP, 2019; Embleton and Simmer, 2014). Energy and protein should be provided as soon as possible to
prevent tissue
catabolism (AAP, 2019; Embleton and Simmer, 2014). Two to 3 g/kg/day of protein with a total energy intake of 60-80
kcal/kg/day should be started within a few hours of birth to maximize nitrogen balance and blood amino acid levels
(AAP, 2019; Embleton and Simmer, 2014).
Energy and protein intake should be increased as the infant’s condition stabilizes and growth becomes the goal (Table
41.3). Many VLBW infants are born AGA but at discharge from the hospital weigh less than the 10th percentile for
their postmenstrual age. This new SGA status is called extrauterine growth restriction (EUGR) or postnatal growth
failure. EUGR may occur as a result of poor energy and protein intakes and the decreased growth associated with
illness (Griffin et al, 2016).

11. Glucose
Glucose or dextrose is the principal energy source (3.4 kcal/g). However, glucose tolerance is limited in premature infants,
especially in VLBW infants, because of inadequate insulin production, insulin resistance, and continued hepatic glucose
release while intravenous glucose is infusing. Hyperglycemia is less likely when glucose is administered with amino acids
than when it is infused alone. Amino acids exert a stimulatory effect on insulin release. Prevention of hyperglycemia is
important because it can lead to diuresis and dehydration.
To prevent hyperglycemia in VLBW infants, glucose should be administered in small amounts. The glucose load is a
function of the concentration of the dextrose infusion and the rate at which it is administered (Table 41.4). The
administration of intravenous amino acids stimulates insulin production and the tolerance of intravenous glucose (Hay,
2018). The administration of exogenous insulin is avoided with premature infants (AAP, 2019). Insulin adheres to the
intravenous tubing, which results in blood glucose fluctuations as a result of nonsteady insulin concentrations. Additional
problems for the infant include hypoglycemia, decreased linear growth, the association of hypoglycemia with poor
neurodevelopment, and death (Alsweiler et al, 2012). In general, preterm infants should receive an initial glucose load of 5
to 7 mg/kg/min, with a gradual increase to 11 to 12 mg/kg/min. The glucose load can be advanced by 1 to 2
mg/kg/min/day. Hypoglycemia is not as common a problem as hyperglycemia, but it may occur if the glucose infusion is
decreased abruptly or interrupted.

12. Amino acids
Protein guidelines range from 3.0 to 4.0 g/kg/day (AAP, 2019). Protein in excess of these parenteral requirements should
not be administered because additional protein offers no apparent advantage, and increases the risk of metabolic
problems (Hay, 2018). In practice preterm infants are usually given 2 to 3 g/kg/day of protein for the first few days of life,
and then protein is provided as tolerated. Many nurseries stock starter PN, which is water, glucose, protein, and perhaps
calcium and is available 24 hours a day. Infants then can be provided with protein immediately on admission to the
nursery.
In the United States several pediatric PN solutions are available. The use of pediatric PN solutions results in plasma
amino acid profiles similar to those of fetal and cord blood or to those of healthy infants fed breastmilk (van Goudoever et
al, 2014). These solutions promote adequate weight gain and nitrogen retention. Standard amino acid solutions are not
designed to meet the particular needs of immature infants and may provoke imbalances in plasma amino acid levels. For
example, cysteine, tyrosine, and taurine levels in these solutions are low relative to the needs of the preterm infant, but
the methionine and glycine levels are relatively high. Because premature infants do not effectively synthesize cysteine
from methionine because of decreased concentrations of the hepatic enzyme cystathionase, a cysteine supplement has
been suggested. Cysteine is insoluble and unstable in solution; thus it is added as cysteine hydrochloride when the PN
solution is prepared.
In addition to plasma amino acid imbalances, other metabolic problems associated with amino acid infusions in preterm
infants include metabolic acidosis, hyperammonemia, and azotemia. These problems can be minimized by using the
crystalline amino acid products that are available and by keeping the protein load within the recommended guidelines
(Table 41.5).

13. Lipids
Intravenous fat emulsions are used for two reasons: (1) to meet essential fatty acid (EFA) requirements and (2) to provide
a concentrated source of energy. EFA needs can be met by providing 0.5 g/kg/day of lipids when giving the Intralipid®
emulsion. Biochemical evidence of EFA deficiency has been noted during the first week of life in VLBW infants fed
parenterally without fat. The clinical consequences of EFA deficiency may include coagulation abnormalities, abnormal
pulmonary surfactant, and adverse effects on lung metabolism.
Lipids can be initiated at 2 to 3 g/kg/day and should be provided over 24 hours (AAP, 2019). Lipids can be advanced by 1
to 2 g/kg/day until a rate of 3 g/kg/day is reached (Table 41.6). Plasma triglycerides should be monitored because elevated
triglyceride levels may develop in infants with a decreased ability to hydrolyze triglycerides. These infants usually have
lower gestational age, lower birthweight, SGA status, infection, surgical stress, or liver disease. Monitoring of serum
triglyceride levels is indicated, and a rate of less than 3 g/kg/day of fat may be required to keep serum triglyceride levels
under 200 to 250 mg/dL (AAP, 2019). Once the infant is medically stable and additional energy is needed for growth, lipid
loads can be increased slowly. Intralipids can be given to the infant with hyperbilirubinemia. At the present
recommendation of 3 g/kg/day, given over 24 hours, the displacement of bilirubin from albumin-binding sites does not
occur (AAP, 2014).

14. Electrolytes
After the first few days of life, sodium, potassium, and chloride are added to parenteral solutions to compensate for
the
loss of extracellular fluid. To prevent hyperkalemia and cardiac arrhythmia, potassium should be withheld until renal
flow
is demonstrated. In general, the preterm infant has the same electrolyte requirements as the term infant, but actual
requirements vary, depending on factors such as renal function, state of hydration, and the use of diuretics (Table
41.7).
Very immature infants may have a limited ability to conserve sodium and thus may require increased amounts of
sodium to
maintain a normal serum sodium concentration. Serum electrolyte levels should be monitored periodically.

15. Minerals
Calcium and phosphorus are important components of the PN solution. Premature infants who receive PN with low
calcium and phosphorus concentrations are at risk for developing osteopenia of prematurity. This poor bone
mineralization is most likely to develop in VLBW infants who receive PN for prolonged periods. Calcium and phosphorus
status should be monitored using serum calcium, phosphorus, and alkaline phosphatase activity levels (see Appendix 12).
Alkaline phosphatase activity levels in premature infants are greater than the levels seen with adults. It is common to see
levels up to 600 IU/L, which may reflect rapid bone growth (Abrams, 2017). When alkaline phosphatase activity levels of
800 IU/L or more persist, knee or wrist radiographs should be examined for rickets (Abrams, 2017). Elevation in alkaline
phosphatase activity also may be seen with liver disease. Serum phosphorous may be low with rickets (Abrams, 2017).
Preterm infants have higher calcium and phosphorus needs than term infants. However, it is difficult to add enough
calcium and phosphorus to parenteral solutions to meet these higher requirements without causing precipitation of the
minerals. Calcium and phosphorus should be provided simultaneously in PN solutions. Alternate-day infusions are not
recommended because abnormal serum mineral levels and decreased mineral retention develop.
Current recommendations for parenteral administration of additional calcium, phosphorus, and magnesium are
presented in Table 41.8. The intakes are expressed at a volume intake of 120 to 150 mL/kg/day, with 2.5 g/100 mL of
amino acids or protein. Lower fluid volumes or lower protein concentrations may cause the minerals to precipitate out of
solution. The addition of cysteine hydrochloride increases the acidity of the fluid, which inhibits precipitation of calcium
and phosphorus.

16. Trace elements
Zinc should be given to all preterm infants receiving PN. If enteral feedings cannot be started by 2 weeks of
age,
additional trace elements should be added. However, the amount of copper or manganese should be
reduced or omitted
for infants with obstructive jaundice, and the amounts of selenium and chromium should be reduced or
omitted in infants
with renal dysfunction. Copper can be concentrated in the liver with cholestasis, and it is recommended to
determine
copper status by plasma copper levels or plasma ceruloplasmin levels (AAP, 2019; Domellof, 2014). Parenteral
iron is not
routinely provided because infants often receive blood transfusions soon after birth, and enteral feedings,
which provide a
source of iron, often can be initiated. If necessary, the dosage for parenteral iron is approximately 10% of the
enteral
dosage; guidelines range from 0.2 to 0.25 mg/kg/day (Domellöf, 2014). Table 41.9 provides guidelines for
trace minerals.

17. Vitamins
Shortly after birth all newborn infants receive an intramuscular
(IM) injection of 0.3 to 1 mg of vitamin K to prevent
hemorrhagic disease of the newborn from vitamin K deficiency.
Stores of vitamin K are low in newborn infants, and there
is little intestinal bacterial production of vitamin K until
bacterial colonization takes place. Because initial dietary intake
of
vitamin K is limited, neonates are at nutritional risk if they do
not receive this IM supplement.
Only intravenous multivitamin preparations currently approved
and designed for use in infants should be given to
provide the appropriate vitamin intake and prevent toxicity
from additives used in adult multivitamin injections. The AAP
recommends 40% of the multivitamin for infusion (MVI)-
pediatric 5-mL vial per kilogram of weight (AAP, 2019). The
maximum dose of 5 mL is given to an infant with a weight of
2.5 kg

18. Transition from parenteral to enteral feeding
It is beneficial to begin enteral feedings for preterm infants as early as possible because the feedings stimulate
gastrointestinal enzymatic development and activity, promote bile flow, increase villous growth in the small intestine, and
promote mature gastrointestinal motility. These initial enteral feedings also can decrease the incidence of cholestatic
jaundice and the duration of physiologic jaundice and can improve subsequent feeding tolerance in preterm infants. At
times small, initial feedings are used only to prime the gut and are not intended to optimize enteral nutrient intake until
the infant demonstrates feeding tolerance or is clinically stable.
When making the transition from parenteral to enteral feeding, clinicians should maintain parenteral feeding until
enteral feeding is well established to maintain adequate net intake of fluid and nutrients. In VLBW infants it may take 7 to
14 days to provide full enteral feeding, and it may take longer for infants with feeding intolerances or illness. The smallest,
sickest infants usually receive increments of only 10 to 20 mL/kg/day. Larger, more stable preterm infants may tolerate
increments of 20 to 30 mL/kg/day (see Chapter 12 for a more detailed discussion of transitional feeding).

19. Nutrition requirements: Enteral feeding
Enteral alimentation is preferred for preterm infants because it is more physiologic than parenteral alimentation and is
nutritionally superior. Initiating a tiny amount of an appropriate breastmilk feeding whenever possible is beneficial
(Maffei and Schanler, 2017). However, determining when and how to provide enteral feedings is often difficult and
involves consideration of the degree of prematurity, history of perinatal insults, current medical condition, function of the
gastrointestinal tract, respiratory status, and several other individual concerns.
Preterm infants should be fed enough to promote growth similar to that of a fetus at the same gestational age, but not so
much that nutrient toxicity develops. Although the exact nutrient requirements are unknown for preterm infants, several
useful guidelines exist. In general the requirements of premature infants are higher than those of term infants because
the
preterm infant has smaller nutrient stores, decreased digestion and absorption capabilities, and a rapid growth rate.
Stress, illness, and certain therapies for illness may further influence nutrient requirements. It is

20. Energy
The energy requirements of premature infants vary with individual biologic and environmental factors. It is
estimated that
an intake of 50 kcal/kg/day is required to meet maintenance energy needs, compared with 110 to 130 kcal/kg/day
for
growth (Table 41.12). However, energy needs may be increased by stress, illness, and rapid growth. Likewise, energy
needs may be decreased if the infant is placed in a neutral thermal environment (the environmental temperature at
which an infant expends the least amount of energy to maintain body temperature). It is important to consider the
infant’s
rate of growth in relation to average energy intakes. Some premature infants may need greater than 130
kcal/kg/day to
sustain an appropriate rate of growth. Infants with BPD often require such increased amounts. To provide such a
large
number of calories to infants with a limited ability to tolerate large fluid volumes, it may be necessary to
concentrate the
feedings to a level of more than 24 kcal/oz

21. Protein
The amount and quality of protein must be considered when establishing protein requirements for the preterm infant.
Amino acids should be provided at a level that meets demands without inducing amino acid or protein toxicity.
A reference fetus model has been used to determine the amount of protein that has to be ingested to match the quantity
of protein deposited into newly formed fetal tissue (Ziegler, 2014). To achieve these fetal accretion rates, additional
protein must be supplied to compensate for intestinal losses and obligatory losses in the urine and skin. Based on this
method for determining protein needs, the advisable protein intake is 3.5 to 4.5 g/kg/day. This amount of protein is well
tolerated. For the ELBW infant, up to 4.5 g/kg/day of protein has been recommended for milk feedings (Agostoni et al,
2010; Koletzko et al, 2014).
The quality or type of protein is an important consideration because premature infants have different amino acid needs
than term infants because of immature hepatic enzyme pathways. The amino acid composition of whey protein, which
differs from that of casein, is more appropriate for premature infants. The essential amino acid cysteine is more highly
concentrated in whey protein, and premature infants do not synthesize cysteine well. In addition, the amino acids
phenylalanine and tyrosine are lower, and the preterm infant has difficulty oxidizing them. Furthermore, metabolic
acidosis decreases with consumption of whey-predominant formulas. Because of the advantages of whey protein for
premature infants, breastmilk or formulas containing predominately whey proteins should be chosen whenever possible.
Taurine is a sulfonic amino acid that may be important for preterm infants. Human milk is a rich source of taurine, and
taurine is added to most infant formulas. Term and preterm infants develop low plasma and urine concentrations of
taurine without a dietary supply. The premature infant may have difficulty with synthesizing taurine from cysteine.
Although no overt disease has been reported in infants fed low taurine formulas, low taurine may affect the development
of vision and hearing (Klein, 2002).
Energy must be provided at sufficient levels to allow protein to be used for growth and not merely for energy
expenditure. A range of 2.5 to 3.6 g of protein per 100 kcal is recommended. Inadequate protein intake is growth limiting,
whereas excessive intake causes elevated plasma amino acid levels, azotemia, and acidosis.

22. Lipids
The growing preterm infant needs an adequate intake of well-absorbed dietary fat to help meet the high energy needs of
growth, provide EFAs, and facilitate absorption of other important nutrients such as the fat-soluble vitamins and calcium.
However, neonates in general, and premature and SGA infants in particular, digest and absorb lipids inefficiently.
Fat should constitute 40% to 50% of total calories. Furthermore, a diet that is high in fat and low in protein may yield
more fat deposition than is desirable for the growing preterm infant. To meet EFA needs, linoleic acid should compose 3%
of the total calories, and alpha-linolenic acid should be added in small amounts (AAP, 2019). Additional longer-chain fatty
acids—ARA and DHA—are present in human milk and are added to infant formulas for term and premature infants to
meet
federal guidelines.
The premature infant has a greater need than the term infant for ARA and DHA supplementation. These fatty acids
accumulate in fatty tissue and the brain during the last 3 months of gestation; thus the premature infant has decreased
stores. Premature infants fed formulas supplemented with ARA and DHA frequently demonstrate greater gain in weight
and length and higher psychomotor development scores than premature infants not receiving the fatty acid
supplementation (Lapillonne and Moltu, 2016). The DHA and ARA content of human milk is variable, and the premature
infant may require supplements of ARA and DHA. However, research is needed to document supplementation use for the
premature infants provided human milk (AAP, 2019).

23. Preterm infants have low levels of pancreatic lipase and bile salts, and this decreases their ability to digest and absorb
fat. Lipases are needed for triglyceride breakdown, and bile salts solubilize fat for ease of digestion and absorption.
Because medium-chain triglycerides (MCTs) do not require pancreatic lipase and bile acids for digestion and absorption,
they have been added to the fat mixture in premature infant formulas. Human milk and vegetable oils contain the EFA
linoleic acid, but MCT oil does not. Premature infant formulas must contain vegetable oil and MCT oil to provide the
essential long-chain fatty acids.
The composition of dietary fat also plays a role in the digestion and absorption of lipid. In general, infants absorb
vegetable oils more efficiently than saturated animal fats, although one exception is the saturated fat in human milk.
Infants digest and absorb human milk fat better than the saturated fat in cow’s milk or the vegetable oil in standard infant
formulas. Human milk contains two lipases that facilitate fat digestion and has a special fatty acid composition that aids
absorption.

24. Carbohydrates
Carbohydrates are an important source of energy, and the enzymes for endogenous production of glucose from
carbohydrate and protein are present in preterm infants. Approximately 40% of the total calories in human milk and
standard infant formulas are derived from carbohydrates. Too little carbohydrate may lead to hypoglycemia, whereas too
much may provoke osmotic diuresis or loose stools. The recommended range for carbohydrate intake is 40% to 50% of
total calories.
Lactose, a disaccharide composed of glucose and galactose, is the predominant carbohydrate in almost all mammalian
milks and may be important to the neonate for glucose homeostasis, perhaps because galactose can be used for either
glucose production or glycogen storage. Generally galactose is used for glycogen formation first, and then it becomes
available for glucose production as blood glucose levels decrease. Because infants born before 28 to 34 weeks of gestation
have low lactase activity, the premature infant’s ability to digest lactose may be marginal. In practice, malabsorption is not
a clinical problem because lactose is hydrolyzed in the intestine or fermented in the colon and absorbed. Sucrose is
another disaccharide that is found in commercial infant formula products. Because sucrase activity early in the third
trimester is at 70% of newborn levels, sucrose is well tolerated by most premature infants. Sucrase and lactase are
sensitive to changes in the intestinal milieu. Infants who have diarrhea, are undergoing antibiotic therapy, or are
undernourished may develop temporary intolerances to lactose and sucrose.
Glucose polymers are common carbohydrates in the preterm infant’s diet. These polymers, consisting mainly of chains of
five to nine glucose units linked together, are used to achieve the isoosmolality of certain specialized formulas.
Glucosidase enzymes for digesting glucose polymers are active in small preterm infants.

25. Minerals and vitamins
Premature infants require greater amounts of vitamins and minerals than term infants because they have poor body
stores, are physiologically immature, are frequently ill, and will grow rapidly. Formulas and human milk fortifiers that
are developed especially for preterm infants contain higher vitamin and mineral concentrations to meet the needs of
the
infant, obviating the need for additional supplementation in most cases (Table 41.13). One major exception is infants
receiving human milk with a fortifier that does not contain iron. An iron supplement of 2 mg/kg/day should be
sufficient to
meet their needs (AAP, 2019). The other exception is the use of donor human milk fortifier, which requires the addition
of a
multiple vitamin and an iron supplement.

26. Feeding methods
Decisions about breastfeeding, bottle feeding, or tube feeding depend on the gestational age and the clinical
condition of
the preterm infant. The goal is to feed the infant via the most physiologic method possible and supply nutrients for
growth
without creating clinical complications.
Oral care with colostrum
The mother’s colostrum can be used as oral care for her infant as soon as it is available. Drops of colostrum are
placed
inside the infant’s mouth to aid in the prevention of infection. Colostrum is a rich source of proteins, minerals, and
immunologic factors which may protect the infant from illness (Gephart and Weller, 2014; AAP, 2019; American
College of
Obstetricians and Gynecologists [ACOG], 2014). Oral care with colostrum can be initiated before feedings are started.

27. Gastric gavage
Gastric gavage by the oral route often is chosen for infants who are unable to suck because of immaturity or problems
with the central nervous system. Infants less than 32 to 34 weeks of gestational age, regardless of birthweight, have
poorly coordinated sucking, swallowing, and breathing abilities because of their developmental immaturity. Consequently
they have difficulty with nipple feeding.
With the oral gastric gavage method, a soft feeding tube is inserted through the infant’s mouth and into the stomach.
The major risks of this technique include aspiration and gastric distention. Because of weak or absent cough reflexes and
poorly developed respiratory muscles, the tiny infant may not be able to dislodge milk from the upper airway, which can
cause reflex bradycardia or airway obstruction. However, electronic monitoring of vital functions and proper positioning of
the infant during feeding minimize the risk of aspiration from regurgitation of stomach contents. Tiny, immature infants
whose small gastric capacity and slow intestinal motility can impede the tolerance of large-volume bolus feeds may need
bolus feedings provided with a pump for a 30- to 60-minute infusion to aid in feeding tolerance.
Occasionally, elimination of the distention and vagal bradycardia requires the use of an indwelling tube for continuous
gastric gavage feedings rather than intermittent administration of boluses. Continuous feedings may lead to loss of milk
fat, calcium, and phosphorus, which deposit in the feeding tubing so that the infant does not receive the total amount of
nutrition provided. Bolus feedings provided with the use of the pump infusion can decrease nutrient loss and promote
better weight gain (Rogers et al, 2010; Senterre, 2014).
Nasal gastric gavage is sometimes better tolerated than oral tube feeding. However, because neonates must breathe
through the nose, this technique may compromise the nasal airway in preterm infants and cause an associated
deterioration in respiratory function. This method is helpful for infants who are learning to nipple feed. An infant with a
nasal gastric tube can still form a tight seal on the bottle nipple, but it can be difficult if an oral feeding tube is in place
during feedings

28. Transpyloric feeding
Transpyloric tube feeding is indicated for infants who are at risk for aspirating milk into the
lungs or who have slow
gastric emptying. The goal of this method is to circumvent the often slow gastric emptying
of the immature infant by
passing the feeding tube through the stomach and pylorus and placing its tip within the
duodenum or jejunum. Infants
with severe gastrointestinal reflux do well with this method, which prevents aspiration of
feedings into the lungs. This
method also is used for infants whose respiratory function is compromised and who are at
risk for milk aspiration. The
possible disadvantages of transpyloric feedings include decreased fat absorption, diarrhea,
dumping syndrome, alterations
of the intestinal microflora, intestinal perforation, and bilious fluid in the stomach. In
addition, the placement of
transpyloric tubes also requires considerable expertise and radiographic confirmation of
the catheter tip location.
Although associated with many possible complications, transpyloric feedings are used
when gastric feeding is not
successful.

29. Nipple feeding
Nipple feeding may be attempted with infants whose gestational age is greater than 32
weeks and whose ability to feed
from a nipple is indicated by evidence of an established sucking reflex and sucking motion.
Before this time they are
unable to coordinate sucking, swallowing, and breathing. Because sucking requires effort
by the infant, any stress from
other causes such as hypothermia or hypoxemia diminishes the sucking ability. Therefore
nipple feeding should be
initiated only when the infant is under minimum stress and is sufficiently mature and
strong to sustain the sucking effort.
Initial oral feedings may be limited to one to three times per day to prevent undue fatigue
or too much energy
expenditure, either of which can slow the infant’s rate of weight gain. Before oral feedings
begin, a standardized oral
stimulation program can help infants successfully nipple feed more quickly

30. Breastfeeding
When the mother of a premature infant chooses to breastfeed, nursing at the breast should begin as soon as the infant is
ready. Before this time the mother must express her milk so that it can be tube-fed to her infant. These mothers need
emotional and educational support for successful lactation. Studies report that premature breastfed infants have better
sucking, swallowing, and breathing coordination and fewer breathing disruptions than bottle-fed infants (Abrams and
Hurst, 2018). Kangaroo care—allowing the mother to maintain skin-to-skin contact while holding her infant—facilitates
her lactation. In addition, this type of contact promotes continuation of breastfeeding and enhances the mother’s
confidence in caring for her high-risk infant. The latter benefit also may apply to fathers who engage in kangaroo care
with their infants (Kassity-Krich and Jones, 2014).
Feeding infants with cups instead of bottles to supplement breastfeeding has been suggested for preterm infants based
on the rationale that it may prevent infant “nipple confusion” (i.e., confusion between nursing at the breast and from a
bottle). Complications such as milk aspiration and low volume intakes have to be monitored. Cup feeding has been
associated with successful breastfeeding at discharge, but increased length of stay in the hospital for the premature infant
(AAP, ACOG, 2014).

31. Selection of enteral feeding
During the initial feeding period, premature infants often require additional time to adjust to EN and may experience
concurrent stress, weight loss, and diuresis. The primary goal of enteral feeding during this initial period is to establish
tolerance to the milk. Infants seem to need a period of adjustment to be able to assimilate a large volume and
concentration of nutrients. Thus parenteral fluids may be necessary until infants can tolerate adequate amounts of
feedings by mouth.
After the initial period of adjustment, the goal of enteral feeding changes from establishing milk tolerance to providing
complete nutrition support for growth and rapid organ development. All essential nutrients should be provided in
quantities that support sustained growth. The following feeding choices are appropriate: (1) human milk supplemented
with human milk fortifier and iron and vitamins as indicated by fortifier used, (2) iron-fortified premature infant formula
for infants who weigh less than 2 kg, or (3) iron-fortified standard infant formula for infants who weigh more than 2 kg.
Premature infants who are discharged from the hospital can be given a transitional formula. Additional vitamin D may be
indicated to provide 400 IU per day (Abrams, AAP, 2013). Breast-fed infants may be provided with two to three bottles of
transitional formula daily to meet needs. The breastfed premature infant also should receive 2 to 3 mg/kg/day of iron for
the first 6 to 12 months and a multiple vitamin for the first year of life (AAP, 2019). Premature infants discharged home on
standard formula should receive a multivitamin until the infant reaches 3 kg in weight and then only vitamin D may be
needed to provide 400 IU per day (AAP, 2019). Blood ferritin levels can be measured to access the infant’s iron status and
the need for iron supplements (AAP, 2019).

32. Human milk
Human milk is the ideal food for healthy term infants and premature infants. Although human milk requires nutrient
supplementation to meet the needs of premature infants, its benefits for the infant are numerous. During the first month
of lactation, the composition of milk from mothers of premature infants differs from that of mothers who have given birth
to term infants; the protein and sodium concentrations of breastmilk are higher in mothers with preterm infants (Klein,
2002). When premature infants are fed their own mother’s milk, they grow more rapidly than infants fed banked, mature
breastmilk (Brownell et al, 2018).
In addition to its nutrient concentration, human milk offers nutritional benefits because of its unique mix of amino acids
and long-chain fatty acids. The zinc and iron in human milk are more readily absorbed, and fat is more easily digested
because of the presence of lipases. Moreover, human milk contains factors that are not present in formulas. These
components include (1) macrophages and T and B lymphocytes; (2) antimicrobial factors such as secretory
immunoglobulin A, lactoferrin, and others; (3) hormones; (4) enzymes; and (5) growth factors. It has been reported that
human milk compared with premature infant formula fed to preterm infants reduces the incidence of NEC and sepsis,
improves neurodevelopment, facilitates a more rapid advancement of enteral feedings, and leads to an earlier discharge
(AAP, ACOG, 2014). The use of the mother’s own milk for her infant supplemented with liquid donor human milk fortifier
and donor human milk is linked to decreased incidence of NEC (Sullivan et al, 2010). The use of donor milk and liquid
donor human milk fortifier compared with premature infant formula decreases the incidence of NEC treated by surgery
and decreases the days of PN (Cristofalo et al, 2013).

33. However, one well-documented problem is associated with feeding human milk to preterm infants. Whether it is
preterm, term, or mature, human milk does not meet the calcium and phosphorus needs for normal bone mineralization in
premature infants. Therefore calcium and phosphorus supplements are recommended for rapidly growing preterm infants
who are fed predominantly human milk. Currently three human milk fortifiers are available: powder bovine milk base,
liquid bovine milk base, and liquid donor human milk base. The bovine products contain calcium and phosphorus, as well
as protein, carbohydrates, fat, vitamins, and minerals, and are designed to be added to expressed breastmilk fed to
premature infants (Table 41.14). Vitamin supplements are not needed. One bovine fortifier is iron fortified and the other
requires the addition of iron. The human-milk base product is made from donor human milk that has been pasteurized,
concentrated, and supplemented with calcium, phosphorous, zinc, and electrolytes. A multivitamin and an iron supplement
are needed with the use of the human-milk base fortifier. The human-milk base fortifier comes as additives to make the
milk 24, 26, 28, or 30 kcal/oz milk. The higher concentrations are used for infants who are volume restricted or not
growing on lower caloric-dense milk (Hair et al, 2013). The calories and protein are higher with the increased
concentrations, but the concentrations of calcium, phosphorous, and zinc remain the same with the donor human milk
fortifier. Often the infant needs more energy and protein, but not increased mineral intake. A donor human milk cream
supplement is available that is pasteurized human milk fat and can be added to human milk.

34. Premature infant formulas
Formula preparations have been developed to meet the unique nutritional and physiologic needs of growing preterm
infants. The quantity and quality of nutrients in these products promote growth at intrauterine rates. These formulas,
which have caloric densities of 20, 24, and 30 kcal/oz, are available only in a ready-to-feed form. These premature
formulas differ in many respects from standard cow’s milk–based formulas (see Table 41.14). The types of carbohydrate,
protein, and fat differ to facilitate digestion and absorption of nutrients. These formulas also have higher concentrations
of protein, minerals, and vitamins.
Transitional infant formulas
Formulas containing 22 kcal/oz have been designed as transition formulas for the premature infant. Their nutrient content
is less than that of the nutrient-dense premature infant formulas and more than that of the standard infant formula (see
Table 41.14). These formulas can be introduced when the infant reaches a weight of 2000 g, and they can be used
throughout the first year of life. Not all premature infants need these formulas to grow appropriately. It is not clear which
premature infants need this specialized formula because studies have not always demonstrated improved growth with the
use of transitional formula (Young et al, 2016). Gain of weight, length, and head circumference for age and weight for
length should be monitored on the World Health Organization growth curves (Lapillonne, 2014). Transitional formulas are
available in powder form and in ready-to-feed form.

35. Formula adjustments
Occasionally it may be necessary to increase the energy content of the formulas fed to small infants. This may be
appropriate when the infant is not growing quickly enough and already is consuming as much as possible during feedings.
Concentration
One approach to providing hypercaloric formula is to prepare the formula with less water, thus concentrating all its
nutrients, including energy. Concentrated infant formulas with energy contents of 24 kcal/oz are available to hospitals as
ready-to-feed nursettes. However, when using these concentrated formulas, clinicians must consider the infant’s fluid
intake and losses in relation to the renal solute load of the concentrated feeding to ensure that a positive water balance is
maintained. This method of increasing formula density often is preferred because the nutrient balance remains the same;
infants who need more energy also need additional nutrients. As mentioned, the transitional formulas are available in
ready-to-feed and powder form and can be concentrated from 24 to 30 kcal/oz. However, this formula is still inadequate
for infants who need additional calcium (e.g., infants with osteopenia).
A ready-to-feed 30 kcal/oz premature infant formula is available. It meets the nutritional needs for premature infants
who must be fluid restricted because of illness. This 30 kcal/oz formula can be diluted with premature infant formula (24
kcal/oz) to make 26, 27, or 28 kcal/oz milks (see Box 41.2). These milks are sterile and are the preferred source of
providing concentrated milks to premature infants in the NICU. Infant formula powder is not sterile and is not to be used
with high-risk infants when a nutritionally adequate liquid, sterile product is available (Steele and Collins, Pediatric
Nutrition Dietetic Practice Group, 2019).

36. Caloric supplements
Another approach to increasing the energy content of a formula involves the use of caloric supplements such as
vegetable
oil, MCT oil, or glucose polymers. These supplements increase the caloric density of the formula without markedly
altering
solute load or osmolality. However, they do alter the relative distribution of total calories derived from protein,
carbohydrate, and fat. Because even small amounts of oil or carbohydrate dilute the percentage of calories derived
from
protein, adding these supplements to human milk or standard (20 kcal/oz) formulas is not advised. Caloric
supplements
should be used only when a formula already meets all nutrient requirements other than energy or when the renal
solute
load is a concern.
When a high-energy formula is needed, glucose polymers can be added to a base that has a concentration of 24
kcal/oz
or greater (either full-strength premature formula or a concentrated standard formula), with a maximum of 50% of
total
calories from fat and a minimum of 10% of total calories from protein. Vegetable oil should be added to a feeding at
the
time or given as an oral medication. Vegetable oil added to a day’s supply of formula that is chilled will separate out
from
the milk and cling to the milk storage container and will not be in the feeding to the infant.

37. Nutrition assessment and growth
Dietary intake
Dietary intake must be evaluated to ensure that the nutrition provided meets the infant’s needs. Parenteral fluids
and milk
feedings are advanced as tolerated, and the nutrient intakes must be reviewed to ensure that they are within the
guidelines for premature infants and that the infant is thriving on the nutrition provided. Appropriate growth and
growth
charts are reviewed in the following paragraphs.
Laboratory indices
Laboratory assessments usually involve measuring the following parameters: (1) fluid and electrolyte balance, (2) PN
or
EN tolerance, (3) bone mineralization status, and (4) hematologic status (Table 41.15). Hemoglobin and hematocrit
are
monitored as medically indicated. The early decrease in hematocrit reflects the physiologic drop in hemoglobin after
birth
and blood drawings for laboratory assessments. Early low hemoglobin levels are treated with blood transfusions if
needed.
Dietary supplementation does not change this early physiologic drop in hemoglobin.

38. Growth rates and growth charts
All neonates typically lose some weight after birth. Preterm infants are born with more extracellular water than term
infants and thus tend to lose more weight than term infants. However, the postnatal weight loss should not be excessive.
Preterm infants who lose more than 15% of their birth weight may become dehydrated from the inadequate fluid intake or
experience tissue wasting from poor energy intake. An infant’s birth weight should be regained by the second or third
week of life. The smallest and sickest infants take the longest time to regain their birth weights.
Intrauterine growth curves have been developed using birth weight, birth length, and birth head circumference data of
infants born at several successive weeks of gestation. The intrauterine growth curves are the standard of growth
recommended for premature infants. During the first week of life premature infants fall away from their birth weight
percentile, which reflects the normal postnatal weight loss of newborn infants. After an infant’s condition stabilizes and
the infant begins consuming all needed nutrients, the infant may be able to grow at a rate that parallels these curves. An
intrauterine weight gain of 15 to 20 g/kg/day can be achieved (Fenton et al, 2018).
Although weight is an important anthropometric parameter, measurements of length and head circumference also can
be helpful. Premature infants should grow between 0.7 to 1 cm per week in body length and head circumference. A
growth
curve based on gender can be used to evaluate the adequacy of growth in all three areas (Figs. 41.3 and 41.4). This chart
has a built-in correction factor for prematurity; the infant’s growth can be followed from 22 to 50 weeks of gestation and it
represents cross-sectional data from Canada, Australia, Germany, Italy, Scotland, and the United States (Fenton and Kim,
2013). The intrauterine curves are smooth into the World Health Organization Charts.

41. Discharge care
Establishment of successful feeding is a pivotal factor determining whether a preterm infant can be
discharged from the
hospital nursery. Preterm infants must be able to (1) tolerate their feedings and usually obtain all of their
feedings from
the breast or bottle, (2) grow adequately on a modified-demand feeding schedule (usually every 3–4 hours
during the day
for bottle-fed infants or every 2–3 hours for breastfed infants), and (3) maintain their body temperature
without the help of
an incubator. Medically stable premature infants who have delayed feeding development can go home on
gavage feedings
for a short period. In addition, it is important that any ongoing chronic illnesses, including nutrition
problems, be
manageable at home.
Most important, the parents must be ready to care for their infant. In hospitals that allow parents to visit
their infants in
the nursery 24 hours a day, staff can help parents develop their caregiving skills and learn to care for their
infant at home.
Often, parents are permitted to “room in” with their infant (i.e., stay with the infant all day and night) before
discharge,
which helps build confidence in their ability to care for a high-risk infant

42. Neurodevelopmental outcome
It is possible to meet the metabolic and nutritional needs of premature infants sufficiently to sustain life and
promote
growth and development. In fact, more tiny premature infants are surviving than ever before because of adequate
nutrition support and the recent advances in neonatal intensive care technology. There is concern that the ELBW
infant is
often smaller at discharge than the infant of the same postmenstrual age who was not born prematurely. One
report
suggests that providing appropriate protein intake during week 1 of life to ELBW infants leads to improved growth
of
weight, length, and head circumference at 36 weeks’ gestation, and improved head circumference in male infants
at 18
months’ corrected age (Poindexter, 2014). Improved neurodevelopment and growth at 18 months has been
reported with
ELBW infants who gained more weight and had greater head circumference growth during their stay in the nursery
(Ehrenkranz, 2014). The developmental outcome scores for ELBW infants have been higher as the intakes of MOM
increase (Lechner and Vohr, 2017). Supplements of donor milk and premature infant formula result in similar
developmental outcomes (O’Connor et al, 2016). Research on the neurodevelopment of premature infants who
receive
fortified donor human milk is needed (Arslanoglu et al, 2013).

43. Family-centered care where the parents can stay and care for their infants increases the parents’ knowledge and
skills
to care for their infant and the potential for their infant’s growth and development (Klaus et al, 2013; Ballard, 2015).
A
multidisciplinary support is needed to meet the needs for the infant and parents. Complementary therapies have
been
suggested for improved growth and development of the premature infant. Individual studies have suggested
benefits for
infant massage and for music therapy (Klaus et al, 2013; Anderson and Patel, 2018). More research is needed to
document
long-term effect of these therapies.
The increased survival rate of ELBW infants has increased concerns about their short- and long-term
neurodevelopmental outcomes. Many questions have been raised about the quality of life awaiting infants who
receive
neonatal intensive care. As a rule, VLBW infants should be referred to a follow-up clinic to evaluate their
development and
growth and begin early interventions (Wilson-Costello and Payne, 2015). The survival of ELBW infants has increased,
with
an increase in the number of children who are developmentally normal who attend school and live independent
lives as
adults (Wilson-Costello and Payne, 2015). Many of these premature infants reach adulthood with no evidence of any
disability (Fig. 41.7).

44. 1. Describe the etiology of celiac disease.
2. Explain the role of gluten in the pathophysiology of celiac disease.
3. Identify the sources of gluten.
4. Plan a gluten-free diet.
5. Provide adequate substitutes in the diet that enable the individual with
celiac disease to meet his or her RDAs/DRIs.
6. Teach parents or caregivers the specifics of dietary control and methods of
dietary compliance.
7. Alert adults with celiac disease of the necessity of strict adherence to the
diet and methods of dietary compliance.

45. BACKGROUND INFORMATION
Part of the information in this chapter has been modified
from the fact sheet on celiac disease distributed by the
National Institute of Health (www.nih.gov).
Celiac disease results from a patient’s sensitivity to a
flour protein (gluten). Flour is made up of about 10%
protein. Celiac disease has many names: gluten (or
gluten-induced) enteropathy, nontropical sprue, and
celiac sprue. This disease tends to run in families.
A jejunal biopsy of a patient with celiac disease invariably
shows mucosal atrophy of the small intestine. The
cells, instead of being columnar, are squamous (flat).
These abnormal cells secrete only small amounts of digestive
enzymes. Villi are also lacking in the intestine.

46. Medical records indicate that before the cause of celiac
disease was identified, only children were suspected to
have this disease. At present, adults with symptoms and
positive identification from intestinal biopsy are classified
as having adult celiac disease, especially if they respond
to gluten-free diets.
Apart from using the references at the end of this
chapter to find more details on celiac disease, the private
organizations list below are an excellent source for
details on the disorder.

47. Dietary Management of Celiac Disease
SYMPTOMS
The symptoms exhibited by a patient with celiac disease
are diarrhea, steatorrhea, two to four bowel movementsdaily,
loss of appetite and weight, emaciation; and in children,
failure to thrive (such children typically have “pot
bellies”). Children’s growth is retarded because of the
incompetent
mucosa, which causes severe malabsorption.
When the fat is not absorbed, it is moved to the large intestine
and becomes emulsified by bile and calcium salts.
The odor of the stool is caused by large amounts of fatty
acids. The unabsorbed carbohydrates are fermented by
the bacteria in the large intestine, producing gas and occasional
abdominal cramps. Hyperosmolarity induces the
colon to secrete water and electrolytes into the lumen.
The patient may show many malnutrition symptoms, including
bone pain and tetany, anemia, rough skin, and
lowered prothrombin time. Most adult patients have iron
and folic acid deficiencies, with microcytic and macrocytic
anemias. Symptoms such as cheilosis and glossitis,

48. PRINCIPLES OF DIET THERAPY
The basic principle of diet therapy for celiac disease is to
exclude all foods containing gluten—chiefly buckwheat,
malt, oats, rye, barley, and wheat. The patient’s response
to such a regimen is dramatic. A child shows improvement
in one to two weeks, while an adult takes one to
three months for visible improvement. In either case,
symptoms gradually disappear. With the child patient,
there is weight gain and thriving, and diarrhea and steatorrhea
clear up. The mucosal changes will also return
to normal after a gluten-free diet. The degree of improvement
is directly related to the extent the patient adheres
to the diet. The therapy can be proven to be curing the
disease if symptoms reappear when the patient returns to
a regular diet.

49. For most people, following this diet will stop symptoms,
heal existing intestinal damage, and prevent
further damage. Improvements begin within days of
starting the diet. The small intestine is usually completely
healed in 3 to 6 months in children and younger adults
and within 2 years for older adults. Healed means a
person
now has villi that can absorb nutrients from food
into the bloodstream.
To stay well, people with celiac disease must avoid
gluten for the rest of their lives. Eating any gluten, no
matter how small an amount, can damage the small
intestine.
The damage will occur in anyone with the disease,
including people without noticeable symptoms.
Depending on a person’s age at diagnosis, some
problems
will not improve, such as delayed growth and tooth
discoloration.

50. Some people with celiac disease show no improvement
on the gluten-free diet. This condition is called
unresponsive
celiac disease. The most common reason for
poor response is that small amounts of gluten are still
present in the diet. Advice from a dietitian who is skilled
in educating patients about the gluten-free diet is essential
to achieve the best results.
Rarely, the intestinal injury will continue despite a
strictly gluten-free diet. People in this situation have
severely
damaged intestines that cannot heal. Because their
intestines are not absorbing enough nutrients, they may
need to receive nutrients directly into their bloodstream
through a vein, or intravenously. People with this condition
may need to be evaluated for complications of the
disease.

51. PATIENT EDUCATION
After celiac disease has been diagnosed, patients should
be educated about its cause and treatment. Patients
who understand this illness are much more likely to
follow a prescribed diet. They should first be taught
that adherence to a gluten-free or gluten-restricted
diet is essential. If the patients also have lactose
intolerance (as is sometimes the case), the necessity
of avoiding milk and milk products must also be
emphasized.
Patients should be forewarned of the great difficulty in
following a gluten-restricted diet. Buckwheat, malt, oats,
barley, rye, and wheat all contain gluten and are extensively
used in different food products. Patients must
therefore be taught to read all labels on prepared and
packaged foods to ascertain if they contain gluten.
Gluten-free wheat products are commercially available
for those on special diets. In addition, potato, rice, corn,
soybean flours, and tapioca may be substituted.

52. If a patient is already malnourished when treatment
begins, an aggressive nutritional rehabilitation regimen
should be instituted. This includes high amounts of
calories,
protein, vitamins, and minerals. It should also
provide fluids and electrolyte compensation (with special
attention to potassium, magnesium, and calcium).
Medium-chain triglycerides (MCTs) should also be
included. A gluten-restricted diet may be deficient in
thiamin (vitamin B1) and should include vitamin
supplements.
All patients should be taught to plan their menus in
accordance with some food guides to achieve their daily
RDAs. Health professionals should help the patient in
this planning.

53. MULTIPLE CHOICE
Circle the letter of the correct answer.
1. Gluten is found in:
a. wheat, rye, oats, barley.
b. rice, potato, corn, beans.
c. milk and meat.
d. all of the above.
2. Jane has been diagnosed as having celiac disease.
Which of the following snacks would be suitable
for her to have in nursery school?
a. malted milk shake
b. popcorn and apple slices
c. hot dog with catsup
d. graham crackers and peanut butter
3. Diet therapy for celiac disease is continued:
a. indefinitely.
b. until patient is middle-aged.
c. through prepubertal growth spurt.
d. for at least six weeks.

54. Mrs. Jones, age 30, was recently diagnosed as having
adult celiac
disease, and her physician ordered a gluten-free diet. She
recognizes
you as a health professional and states that she is quite
apprehensive
about her diet. Counsel her regarding the following:
4. Explain what gluten is and why it is restricted.
5. Because Mrs. Jones works outside the home, she
will be eating lunch away from home. Provide
lunch suggestions that conform to her diet.
6. Name at least six typical foods containing gluten
for Mrs. Jones.
7. List the cereal grains that can be used on Mrs.
Jones’s diet.
8. Name at least five hidden food sources of gluten.

55. Diet Therapy for
Constipation, Diarrhea,
and High-Risk Infants

56. BACKGROUND INFORMATION
Space limitation has excluded chapters covering diet
therapy for a number of other clinical disorders of infancy
and childhood. This chapter remedies the situation
by providing student activities to cover three
important clinical subjects not yet discussed: constipation,
diarrhea, and high-risk infants.
The student should use the references provided at the
end of this chapter to obtain more details to supplement
the activities provided.

57. Constipation
BACKGROUND INFORMATION
Patterns of bowel movements among children and infants
vary. If a child is active, passes a soft to slightly compact stool,
gains weight progressively, shows normal
development, and is free from any known clinical disorder,
the mother has no reason to worry.
A newborn may have a constipation problem that is
most likely the result of plugging by meconium.
Constipation in an older infant is usually due to a change
in the type of feeding. An anatomical defect may also be
a cause, but this is rare. There are several ways to recognize
the presence of constipation in a young infant:
1. A change in the stool (number, consistency, texture,
appearance)
2. Pain in the infant when defecating
3. Distended abdomen with or before every bowel
movement
4. Very black or bloody stools
The constipation of many newborns disappears shortly
after discharge from the hospital. If this does not occur,
the mother should consult her pediatrician.

58. INFANTS
Constipation in a baby may be caused by a change in diet.
Some babies develop constipation when breastfeeding is
replaced with formula (homemade or commercial).
Characteristic signs include the face turning red, straining,
and the legs turned upward while defecating, even
though the child may pass a soft stool. The doctor will
evaluate the child after being informed of the symptoms.
The doctor first looks for any obstruction that may require
special medical attention. If no obstruction is
found, the mother should be advised of the benign nature
of the constipation and told that the child’s bowel habits
will return to normal after it adapts to the new formula.
Actually, the stools of some infants change from soft to
hard even if they are not constipated.

59. Other babies develop constipation when they are
switched from liquid or strained food to solid food. The
signs of such constipation vary. In some infants, a day
with normal bowel movements is followed by one with
none. In others, the passing of hard stools is accompanied
by crying and intense straining. Many of these cases are
of unknown origin. A typical cause is excessive water absorption
(reabsorption) by the colon, resulting in dry
stools and constipation. The anal passage may be
stretched, causing pain and bleeding if there is an open
wound. The child passes red stools, which are easily observed
on toilet paper. The management of this form of
constipation consists of a reduction in milk intake and an
increased intake of juices, fruits, and fluids. Some clinicians
may prescribe enemas, laxatives, and suppositories,
such as a glycerin suppository. The dosage and frequency
of application of these drugs must be determined with
care.

60. Home remedies have no scientific evidence; however,
adding sugar to the gut will draw water in to increase
osmotic load and will create softer stools. No studies have
examined how much sugar would be needed.
Infants older than 6 months may benefit from drinking
prune juice or increasing appropriate high-fiber foods
such as whole grain breads and cereals, fruit, vegetables,
and cooked legumes.

61. YOUNG CHILDREN
Constipation in children under 4 or 5 years old is of two
types: psychological and anatomical. The latter refers to
a defect in the muscles regulating the defecation process.
In some children under 2 years old, any initial sign of
constipation can create a psychological barrier to defecation.
When children start passing hard stools, they experience
some pain, so they subsequently strain to retain
the stools in order to reduce the pain. The accumulated
feces become larger and harder, causing more pain in
subsequent defecations. Some parents report that their
children turn red in the face, strain, and arch their backs
during bowel movement. Although toilet trained, they
soil their pants frequently and are reluctant to go to the
bathroom. Some parents complain that these children
are lazy. In this case, the parental attitudes make the constipation
problem worse. This psychological barrier to
bowel movement can be difficult to overcome.

62. On the other hand, constipation in some children results
from fecal impaction, which may develop for a number
of reasons. For instance, children between the ages
of five and eight may develop constipation because they
consider visiting the bathroom a waste of time. How are
older children with a constipation problem managed?
The basic principles are similar to those for an adult. If
the parents consult a physician, the doctor may need to
study the problem and advise the parents about what actions
to take.
As a start, the parents may help the child initiate a
good bowel movement by using an enema. The dose,
which may be large at the beginning, may be used until
a defecation pattern of three to five times a day is established.
Mineral oil is not recommended for young children.
The child should be put on a conditioning schedule,
such as 10 to 20 minutes daily on the toilet. The child
should also be encouraged to have bowel movements as
frequently as possible. At the same time, milk intake may
be reduced to 60%–80% of normal, and the intake of
fruits, juices, and bran cereals increased. A diet high in
fiber and fluid should be designed for future use to aid in
regulation.

63. Diarrhea
FECAL CHARACTERISTICS AND CAUSES
OF DIARRHEA
The stools of infants change with age and development,
as indicated in Table 29-1. It is important for parents to
recognize a child’s normal feces. Children with diarrhea
have an abnormally frequent evacuation of watery (and
sometimes greasy and/or bloody) stools. Diarrhea is frequent
among infants and children and can be a very distressing
condition. In chronic cases, it may last for weeks
or months, while the child continues to grow normally.
Chronic diarrhea may be a symptom of a disease. In general,
diarrhea is classified as acute or chronic according
to its stool, profile, cause, or site of clinical defect. There
are a number of common causes of diarrhea in infants
and children:
1. It can be due to a specific clinical disorder.
2. Bacterial contamination of formulas or foods can
cause food poisoning.
3. Some youngsters develop diarrhea because of intestinal
reactions to certain foods such as sugars, fats
(too little or too much), milk, and eggs.

64. TREATMENT AND CAUTION
The initial management of diarrhea in children involves
two steps. The clinician’s first and major objective is to
restore fluid and electrolyte balance by oral or IV therapy,
since a child is highly susceptible to dehydration.
Subsequently, the clinician determines if the child can be
managed adequately by oral nourishment without parenteral
feeding, which requires hospitalization.
If a child’s diarrhea is accompanied by mild to moderate
dehydration with persistent vomiting, hospitalization
for parenteral fluid therapy is indicated. In general,
it is feasible to provide oral fluids and electrolytes for
children with mild diarrhea or children recovering from
severe diarrhea. If diarrhea is mild to moderate and the
patient shows normal clinical signs otherwise and is not
dehydrated, most physicians prescribe outpatient therapy
consisting of an oral hypotonic solution of glucose and
electrolytes.

65. In caring for an infant with diarrhea, the major concern
is supplying an adequate supply of fluid and electrolytes.
Some readily available regular and commercial
solutions are listed in Table 29-2. Because milk contains
too many electrolytes, especially sodium, most clinicians
do not recommend it at the beginning of treatment. All
other solutions listed in the table may be initially fed to
a child with diarrhea. To prevent gas from being trapped
and the accompanying discomfort, some soda drinks can
be decarbonated. Gelatin should be made in half strength

66. to avoid aggravating dehydration. Kool-Aid and unflavored
gelatin should not be used, since they contain few
electrolytes.
After about two days of fluid and electrolyte support as
described, the diarrhea should subside somewhat. At this
stage, the child should be given a diluted regular infant
formula, for example, one fourth, one third, or even one
half of normal strength. Additional calories are supplied
by adding corn syrup (1 tsp per 3 oz of formula) or using
a supplemental feeding of strained baby cereals and fruits.

67. Recent concern has been expressed about the common
practice of eliminating milk, eggs, and wheat to reduce
diarrhea in a young patient. Although some
pediatric patients benefit from this treatment, the attending
physician must be alert to (1) potential undernutrition
that may occur if the elimination diet is
prolonged, and (2) the possibility that the child has celiac
disease (see Chapter 26). An elimination diet may mask
this disorder.
The initial treatment for diarrhea in children over 1
year old consists of giving clear liquids such as diluted
broth, fruit juices, soft drinks, gelatin dessert, and
popsicles.
After the diarrhea has subsided, a low-residue diet
may be used. Subsequent management is the same as
that for an adult (see Chapter 17). Once the condition
has stabilized, a regular diet appropriate to the child’s
age can be implemented.

68. Nutritional Management of Idiopathic Nephrotic Syndrome in
Pediatric Age
Introduction
Nephrotic syndrome (NS) in children is characterized by
proteinuria (≥40 mg/m2/h
or ≥300 mg/dL or 3+ on a urine dipstick or urine protein–
creatinine ratio ≥2000 mg/g or
≥200 mg/mmol), hypoalbuminemia, edema, and
hyperlipidemia [1]. The most frequent
form in childhood is idiopathic NS, which usually develops after
the first year of life, with
an incidence of 2–7 per 100,000 and a prevalence of nearly 16
per 100,000 worldwide

69. Fluid Balance
Patients with NS experience fluid retention and edema, and this leads to an overall
water imbalance in the body [9]. Nevertheless, fluid restriction for edema is usually not
recommended, as it may cause hypotension and acute kidney injury (AKI), worsening
intravascular volume depletion and dehydration [1,12]. However, moderate fluid restriction
can be advised with caution in selected cases, such as in patients who develop significant
hyponatremia, massive anasarca, or oliguric renal failure [12–14]. The management of
edema in NS first requires the assessment of the euvolemic state of the patient. In the
case of normal intravascular volume, moderate edema should be treated only with a
low-salt diet, without fluid restriction. Severe edema requires fluid restriction with loop
diuretics in hospital settings. In case of reduced intravascular volume with normal blood
pressure, albumin should be administered intravenously, followed by furosemide once
euvolemia is restored. Hypovolemic shock should be treated following specific resuscitation
guidelines [6]. All foods that are liquid at room temperature, such as milk, juice, yogurt, ice
cream, soup etc., should be counted upon evaluation of fluid intake [9]. A few strategies can
be implemented to control fluid intake in children, such as using small glasses filled to look
like they contain a greater amount of fluid, avoiding salty foods that increase thirst, offering
frozen pieces of fruit or chewing gum to quench thirst, and avoiding warm environment.

70. Macronutrients Intake
Carbohydrates
Although corticosteroids are the cornerstone of treatment for NS, their prolonged and
repeated use may lead to significant adverse effects, such as hyperglycemia and
insulin
resistance [13]. Corticosteroids can also cause weight gain, and subsequently obesity,
due
to behavioral changes, including increased appetite [15,16]. Obesity affects patients’
quality
of life and could seriously impact emotional health and social relationships in the
future
as adults [16]. Because of this, the short- and long-term effects of steroid therapy on
body
weight must be discussed with patients and their families [15]. Children and their
parents
need to be instructed to follow a healthier diet [14], with a focus on a reduced intake
of
Med. Sci. 2023, 11, 47 3 of 8
simple sugars [11], while an adequate intake of high-complex carbohydrates should
be
ensured to maximize the utilization of proteins

71. Proteins
NS causes protein loss through the damaged glomerular filtration barrier in the
urine.
Early management of the NS recommended an increased protein intake to replace
losses and
avoid the development of protein malnutrition [13]. However, recent studies
demonstrate
that increased dietary protein intake does not improve serum albumin
concentrations [13].
The higher dietary protein intake results in increased urinary protein losses without a
net
gain of protein, due to the altered glomerular permselectivity. In addition, a high-
protein
diet leads to changes in glomerular hemodynamics that may accelerate the
progression of
renal disease [10]. On the contrary, protein restriction can positively impact kidney
function
in adult patients with decreased renal function, but a very low-protein diet should
be
avoided for the risk of malnutrition [1]. Intake of high-quality proteins is
recommended in
patients with proteinuria, as it is recommended for the general pediatric population
[6,14].
Vegetable sources of protein are preferred whenever possible

72. Lipids
Dyslipidemia is a frequent metabolic complication in patients with active NS. It is
caused by compensatory protein and lipoprotein synthesis in the liver in response to
urinary protein loss, reduced transport of cholesterol in the bloodstream due to hypoalbuminemia, and an
acquired deficiency of enzymes involved in the regulation of lipid
metabolism, which are lost in urine. Additionally, corticosteroid use may be associated
with an elevation in blood lipid levels.
Managing dyslipidemia in pediatric NS during the acute phase
requires dietary optimization. Children over 2 years old should follow the Cardiovascular
Health Integrated Lifestyle Diet (CHILD-1): fats should be restricted to <30% of total daily
calories, saturated fats to <10%, and cholesterol consumption to <300 mg/d [1,13,18], while
simultaneously increasing the consumption of healthier fats, such as monounsaturated,
polyunsaturated, and omega-3 fatty acids [13]. On the other hand, children who also
present with hyperlipidemia should follow the CHILD-2 diet plan, which further limits the
intake of saturated fats to <7% and cholesterol to <200 mg/d [13]. No fat intake restriction
is recommended for children under the age of 2, and they can be breastfed

73. Sodium
Sodium plays a key role in regulating blood pressure and fluid retention in patients
with NS. Nevertheless, there is a lack of standardized recommendations for sodium
intake
in children with newly diagnosed NS. In children with NS, current suggestions for
sodium
restriction vary from <2 mEq/kg/d to an approach based on a “no added salt diet”
[6,11].
The Pediatric Nephrology Clinical Pathway Development Team proposes a one-to-one
ratio of 1 mg of sodium for each calorie (kcal) in order to adequately restrict sodium
intake
to energy requirement [11]. During the initial nutrition consultation, emphasis should
be placed on strategies to lower sodium in the diet, preferring fresh foods to processed
ones [11], identifying and limiting high-sodium foods, and avoiding salt when preparing
food or eating [9].

74. Calcium and Vitamin D
Metabolic bone disease (MBD) is a frequent complication of NS in children. The
pathogenesis is multifactorial. Urinary loss of minerals and plasma proteins, including
calcium and vitamin D binding protein, results in hypocalcemia and low vitamin D levels, which may lead to
osteopenia and osteoporosis. Corticosteroids decrease intestinal
absorption and tubular reabsorption of calcium. Hypocalcemia is usually not long-lasting
and serum levels of calcium can normalize during remission, but prolonged corticosteroid
therapy, especially due to frequent relapses, may cause MBD. Corticosteroids also suppress
the development and function of osteoblasts, as they increase the lifetime of osteoclasts
and inhibit the release of parathyroid hormone, which results in a reduced overall bone
mineral density [13]. Serum vitamin D levels should be routinely monitored in children
with NS starting at the time of diagnosis [20]. Periodic assessments are also indicated for
serum phosphorus, ionized calcium, parathyroid hormone, and alkaline phosphatase [13].
Moreover, dual-energy X-ray absorptiometry (DXA) can be considered in patients with NS
to measure bone mineral density [14]. Patients and their caregivers should be counseled
to monitor calcium and vitamin D intake in order to have an age-appropriate calcium
intake [11]. When dietary modification is not successful, patient-specific calcium and
vitamin D supplementation should be prescribed. Daily supplementation with 500 mg
of elemental calcium (250 mg twice daily) is advised [11,13]. Addressed hypocalcemia,
vitamin D supplementation regimens reported in the literature range from 800–1000 IU
of cholecalciferol daily to 60,000 IU once a week [11,13]. In patients with advanced renal
insufficiency, 1,25-dihydroxycholecalciferol should be used for vitamin D replacement [10].
There is insufficient evidence on the pharmacologic treatment of MBD in children with NS.
The prevention and treatment of steroid-induced osteoporosis in pediatric age are currently

75. Iron, Copper, and Zinc Deficiency and Anemia
The urinary loss of transferrin, erythropoietin, transcobalamin, ceruloplasmin, iron,
and trace elements may lead to anemia. Patients with iron deficiency anemia should
receive replacement therapy, and, in the case of low erythropoietin levels, therapy with
erythropoietin should be considered. Transferrin levels will correct with the resolution
of proteinuria [13]. Laboratory evidence of anemia that does not respond to iron or erythropoietin therapy
suggests deficiencies in other micronutrients, like copper, zinc, and
vitamin B12. Copper and zinc deficiencies result in reduced activity of copper and zinc
superoxide dismutase, shortening the life span of red blood cells. Moreover, the addition of
zinc therapy to the standard therapy of NS seems to reduce the number and the frequency
of relapses, to help induce remission [13], and to reduce the proportion of infections associ-
Med. Sci. 2023, 11, 47 5 of 8
ated with relapses, with a metallic taste as a mild adverse event [21]. The mechanism of
zinc action is not fully clear, but it is probably linked to its immunoregulatory role: zinc
deficiency might lead to the down-regulation of Th1 cytokines, with an increased risk of
infections [21]. Table 1 provides a summary of dietary recommendations to follow during
the acute phase of NS in children, based on the literature examined.

76. Reference: Lella, G., Pecoraro, L., Benetti, E., Arnone, O.C., Piacentini, G., Brugnara, M. and Pietrobelli, A., 2023. Nutritional Management of Idiopathic Nephrotic
Syndrome in Pediatric Age. Medical Sciences, 11(3), p.47.

78. When someone has the fever, the rate of burning calories increases with the
increase in temperature. The body needs more calories to function properly in fever
than it requires in an ordinary situation.
Diet plan in fever is crucial for the immune system to function properly. Since more
calories are burnt by the body in fever, one must have nutrient dense food to give
energy to the immune system to function properly. Studies have found that a low-
calorie diet in fever worsens symptoms and lengthens the duration of sickness.
The list of foods items listed below is beneficial for reducing fever:
1.Fluid-rich foods: Drink water, hot tea, fresh fruit juice. Intake of fluid-rich foods is
recommended such as poultry broths, thin soups, coconut water.
2.Fresh fruits: Fruits like apples, oranges, watermelon, pineapple, kiwi are rich in
vitamin C. This contains antioxidants that reduce fever.
3.Avoid fruits with heavy sugar and fruits canned in syrup because sugar inhibits
the immune system. The banana provides vital nutrients and easy to digest.
4.Proper intake of proteins: Scrambled eggs, smoothie with low-fat milk, dal, chana
or Indian cottage cheese are rich in protein and beneficial.

81. Stabilization Centre (SC)
 SC provides treatment for children 6 to 59 months
who are severely acutely malnourished who do not
have an appetite and/or have medical complications
 Average length of stay in SC is 4-7 days
 24 hour care
 Skilled personnel who have received the
appropriate training
 SAM Infants (less than 6 months) or are unable to
breast feed also require specialized treatment in SC

82. Purpose of SC
 For children 6 to 59 months without appetite or with medical
complications:
 To stabilize any medical complications so that the child can start nutritional
rehabilitation
 For infants less than 6 months:
 For breast-fed infants: To feed the infant and stimulate breast-feeding until
the infant can be fed
 For non-breast-fed infants: To nutritionally rehabilitate the infant.

83. Admission criteria for SC
Category Criteria
Children
6-59 months
Any of the following:
Bilateral pittingoedema+++
or
Marasmic-Kwashiorkor ( = W/H < -3 S
D or MUAC <115mm with any
grade of oedema)
Or
MUAC <115mm or W/H < -3 S
D or bilateral oedema+ / ++
WITH any of the following complications
Anorexia, no appetite for RUTF
Vomits everything
Hypothermia≤35.5 °c
Fever ≥38.5 °c
S
evere pneumonia
S
evere dehydration
S
evere anaemia
Not alert (very weak, lethargic, unconscious, fits or convulsions)
Conditions requiringIV infusion or NG tube feeding
Infants < 6 months Infant is too weak or feeble to suckle effectively (independently of
his/her weight-for-length).
W/L (weight-for-length ) < - 3 S
D (in infants > 45 cm)
Visible severe wastingin infants < 45 cm
Presence of bilateral oedema
Other reasonsfor inpatient enrolment
Readmission Children previously discharged from in-patient care but meets inpatient
care enrolment criteriaagain
Return after default Children who return after default (away from in-patient care for 2
consecutive days) if they meet the admission criteria

84. Exit criteria for SC
Category Criteria
Discharge to OTP  There are no medical complications
 Appetite has returned (the child has taken at least 75% of
the prescribed RUTF ration for at least 2 consecutive
days)
 Oedema is resolving
Discharge when
there is no OTP
Oedema
 Oedema is absent for 2
consecutive days
 is weight gain for 2
consecutive days after
loss of oedema
 Child is taking at least
90% of the RUTF
 There are no medical
complications
No oedema
 Weight gain for 5
consecutive days
 Child is taking at least
90% of the RUTF
 There are no medical
complications
Died Child died while in in-patient care
Defaulter Child is absent from in-patient care for 2 consecutive days
Medical referral
out of programme
Where the medical condition of the child requires referral out of
in-patient care e.g. to referral hospital

85. Guidelines for the inpatient treatment of
severely malnourished children
A. General principles for routine care (the ‘10 Steps’)
B. Emergency treatment of shock and severe anemia
C. Treatment of associated conditions
D. Failure to respond to treatment
E. Discharge before recovery is complete

86. A. General principles for routine care
(the ‘10 Steps’) 10
 Step 1. Treat/prevent hypoglycemia
 Step 2. Treat/prevent hypothermia
 Step 3. Treat/prevent dehydration
 Step 4. Correct electrolyte imbalance
 Step 5. Treat/prevent infection
 Step 6. Correct micronutrient deficiencies
 Step 7. Start cautious feeding
 Step 8. Achieve catch-up growth
 Step 9. Provide sensory stimulation and emotional support
 Step 10. Prepare for follow-up after recovery

87. An initial stabilization phase
where the acute medical conditions are managed;
and a longer rehabilitation phase.

88. Step 1. Treat/prevent hypoglycemia
Hypoglycemia and hypothermia usually occur together and are
signs of infection.
• Check for hypoglycemia whenever hypothermia (axillary <35.0C) is
found
• Frequent feeding is important in preventing both conditions.

89. Treatment:
If the child is conscious and dextrostix shows <3mmol/l or
54mg/dl give:
• 50 ml bolus of 10% glucose or sugar water ( orally or by nasogastric
(NG) tube.
• Then feed starter F-75 every 30 min. for two hours
(giving one quarter of the two-hourly feed each time)
• antibiotics
• two-hourly feeds, day and night

90. Treatment:
If the child is unconscious, lethargic or convulsing give:
• IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose or sugar
water by Ng tube.
Then give starter F-75 every 30 min. for two hours
(giving one quarter of the two-hourly feed each time)
• antibiotics
• two-hourly feeds, day and night

91. Monitoring:
 Blood glucose:
-if this was low, repeat dextrostix taking blood from finger or
heel, after two hours. Once treated, most children
stabilize within 30 min.
-If blood glucose falls to <3 mmol/ l give a further 50ml bolus of 10%
glucose or sugar water, and continue feeding
every 30 min. until stable
-level of consciousness: if this deteriorates, repeat dextrostix

92. Prevention:
Feed two-hourly, start straightaway or if necessary,rehydrate
first. Always give feeds throughout the night
Note: If you are unable to test the blood glucose level, assume
all severely malnourished children are hypoglycemic
and treat accordingly.
Sugar Water: Add two teaspoonful of sugar in 100ml of clean
drinking water

93. Step 2. Treat/prevent hypothermia
Treatment:
 If the axillary temperature is <35 °C.
 feed straightaway (or start rehydration if needed)
 rewarm the child: either clothe the child (including head),
cover with a warmed blanket and place a heater or lamp nearby
(do not use a hot water bottle), or put the child on the
mother’s bare chest (skin to skin) and cover them
 give antibiotics

94. Step 2. Treat/prevent hypothermia
Monitor:
 body temperature: during rewarming take temperature
two hourly until it rises to >37.oC (take half-hourly if heater
is used)
 ensure the child is covered at all times, especially at night

95. Step 2. Treat/prevent hypothermia
Prevention:
 feed two-hourly, start straightaway
 always give feeds throughout the day and night
 keep covered and away from draughts
 keep the child dry, change wet nappies, clothes and bedding
 avoid exposure (e.g. bathing, prolonged medical examinations)
 let child sleep with mother at night for warmth

96. Step 3. Treat/prevent dehydration
Note: Low blood volume can coexist with edema. Do not use the IV route
for rehydration except in cases of shock and then do so with care,
infusing slowly to avoid flooding the circulation and overloading
the heart

97. Diagnosis
Clinical signs of some and severe dehydration
Signs Some Severe
Recent frequent watery diarrhoea Yes, > 3 times a day Yes, profuse
Recent sunken eyes Yes Yes
Recent rapid weight loss 1-5 % 5-10%
Thirst Drinks eagerly Drinks poorly
Absence of tears No Yes
Weak/absent radial pulse No Yes
Cold hands or feet No Yes
Mental state Restless and irritable Lethargic/coma
Urinary output Decreased Absent

98. DEHYDRATION / REHYDRATION
In Malnourished Children
 All the signs of dehydration in a normal child occur in a severely malnourished
child who is not dehydrated – only history of fluid loss and very recent change
in appearance can be used
 Giving a malnourished child who is not really dehydrated treatment of
dehydration is very dangerous
 Misdiagnosis of dehydration and giving inappropriate treatment is the commonest
cause of death in severe malnutrition
 The treatment of dehydration is different in the severely malnourished child
from the normally nourished child

99. DEHYDRATION / REHYDRATION
In Malnourished Children
 Infusion are almost never used and are particularly dangerous
 ReSoMal must not be freely available in the unit – but only taken when
prescribed
 The management is based mainly on accurately monitoring changes in weight
 Severely wasted patients cannot excrete excess sodium and retain it in their body.
This leads to volume overload and compromise cardiovascular system. The
resulting heart failure can be very acute (sudden death) or be misdiagnosed as
pneumonia

100. Diagnosis
 History of recent changes in appearance of eyes
 History of recent fluid loss
 Check the eyes lids to see if there is lid-retraction.
 Check if patient is unconscious or not
 Check if patient has recently lost weight (if in SC)

101. Dehydration , septic shock
and hypoglycaemia
 If there is a history of recent watery diarrhoea and recent change in the
appearance of the eyes usually with the retraction of eyelid then treat the child for
dehydration.
 If this history and signs are not present, the child appears to be dehydrated
without a history of excess fluid loss or child has oedema then consider treating
for septic shock.

102. Dehydration , septic shock
and hypoglycaemia
 Signs of shock present:
 No history of major fluid loss
 No history of recent eyes sinking
 Fast weak pulse, cold peripheries, pallor and drowsiness
 Eyelid drooping/normal or closed when asleep/unconscious
 Septic shock
 Eyelid retracted or slightly open when asleep/unconscious
 Septic shock + hypoglycaemia

103. Oral Treatment of Dehydration
 The main complications of diarrhoea are dehydration, hypovolaemic shock and
congestive heart failure due to over-hydration as a result of the treatment.
 Severely malnourished children are very sensitive to overloading the system with
fluids and electrolytes.
 Therefore no ReSoMal (REhydration SOlution for MALnourished) or ORS
is given to prevent dehydration.
 ReSoMal is only given when dehydration is diagnosed.

104. ReSoMal
ReSoMal = Rehydration Solution for Severe Malnourished patients
 Presentation
- Sachet containing 84 g of powder, to be diluted in 2 liters of clean, boiled and cooled
water for treatment of 3 children
- Sachet containing 420 g of powder, to be diluted in 10 liters of clean, boiled and cooled
water for treatment of 15 children
Composition for one liter
 Glucose 55 mmol Citrate 7 mmol
 Saccharose 73 mmol Magnesium 3 mmol
 Sodium 45 mmol Zinc 0.3 mmol
 Potassium 40 mmol Copper 0.045 mmol
 Chloride 70 mmol
 Osmolarity 294 meq /liter

105. Oral rehydration with ReSoMal for severe Malnourished
During the first 2 hrs During the next 10 hrs Total over 12 hrs
Weight
in kg
5 ml/kg
every 30 minutes
Total over 2 hrs
20 ml/kg
5 ml/kg
every hour
Total over 10 hrs
50 ml/kg
70 ml/kg
3 15 ml every 30 min 60 ml 15 ml every hour 150 ml 210 ml
4 20 ml every 30 min 80 ml 20 ml every hour 200 ml 280 ml
5 25 ml every 30 min 100 ml 25 ml every hour 250 ml 350 ml
6 30 ml every 30 min 120 ml 30 ml every hour 300 ml 420 ml
7 35 ml every 30 min 140 ml 35 ml every hour 350 ml 490 ml
8
40 ml every 30 min
160 ml
40 ml every hour
400 ml 560 ml
9
45 ml every 30 min
180 ml
45 ml every hour
450 ml 630 ml
10
50 ml every 30 min 200 ml 50 ml every hour
500 ml 700 ml

106. Alternative recipes in the absence of ReSoMal
 Solutions can be made by using one of the following types of
rehydration salts:
 · Standard WHO-ORS (sachet containing 3.5 g of sodium chloride, 1.5 g
of potassium chloride, 20 g of glucose, total weigh: 27.9 g per sachet)
 *
 CMV® mineral and vitamin complex: 1 measure = 6,5 grams.
Water Standard WHO-ORS Sugar CMV*
2 liters 1 sachet 50 g 1 measure
10 liters 5 sachets 250 g 5 measures

107. Step 4. Correct electrolyte imbalance
 All severely malnourished children have excess body sodium even though plasma
sodium may be low (giving high sodium loads will kill). Deficiencies of
potassium and magnesium are also present and may take at least two weeks to
correct. Edema is partly due to these imbalances. Do NOT treat edema with a
diuretic.

108. Step 5. Treat/prevent infection
 In severe malnutrition the usual signs of infection, such as fever, are often absent,
and infections are often hidden.
 Therefore give routinely on admission:
-broad-spectrum antibiotic (s) AND
 measles vaccine if child is > 6m and not immunized (delay if the child is in
shock)

109. Antibiotics for Severely Malnourished Children:

110. Step 6. Correct micronutrient deficiencies
 No need of supplementation while using Therapeutic feed but Vitamin A is
recommended to all malnourish children except patient with edema.
 Some authorities recommend Folic acid at admission.

111. Step 7. Start cautious feeding
 Monitor and note:
• amounts offered and left over
• vomiting
• frequency of watery stool
• daily body weight

112. Weighing chart for F75
To 100ml Add 20.5g
To 250ml Add 50g
To 500ml Add 100g
To 1000ml Add 205g
You can make up 2 feeding at 1 time BUT divide the mix into 2 jugs and store the
second feed separately in the fridge.
Ensure the open bag of powder is sealed again properly to stop contamination

113. Step 8. Achieve catch-up growth
 In the rehabilitation phase a vigorous approach to feeding is required to achieve
very high intakes and rapid weight gain of >10 g gain/kg/d.
The recommended milk-based F-100 contains 100 kcal and 2.9 g protein/100 ml

114. Monitor during the transition for signs of heart failure:
 respiratory rate
 pulse rate
 If respirations increase by 5 or more breaths/min and pulse by 25 or more beats/min
for two successive 4-hourly readings, reduce the volume per feed (give 4-hourly F-100
at 16 ml/kg/feed for 24 hours,
 then 19 ml/kg/feed for 24 hours, then 22 ml/kg/feed for 48 hours, then increase each
feed by 10 ml as above).
 After the transition give:
 frequent feeds (at least 4-hourly) of unlimited amounts of a catchup formula 150-220
kcal/kg/d

115. Monitor progress after the transition by assessing the rate of weight
gain:
• weigh child each morning before feeding. Plot weight
• each week calculate and record weight gain as g/kg/day
If weight gain is:
• poor (<5 g/kg/d), child requires full reassessment
• moderate (5-10 g/kg/d), check whether intake targets are being met,or
if infection has been overlooked
• good (>10 g/kg/d), continue to praise staff and mothers

116. Step 9. Provide sensory stimulation
and emotional support
In severe malnutrition there is delayed mental and behavioral
development.
Provide:
• tender loving care
• a cheerful, stimulating environment
• structured play therapy 15-30 min/d
• physical activity as soon as the child is well enough
• maternal involvement when possible (e.g. comforting, feeding,
bathing,play)

117. Step 10. Prepare for follow-up after recovery
 A child who is 85% weight-for-length (equivalent to -1SD) can be
considered to have recovered (TFC). The child is still likely to have a
low weight-for-age because of stunting. Good feeding practices and
sensory stimulation should be continued at home.
 Show parent how to:
• feed frequently with energy- and nutrient-dense foods
• give structured play therapy
 Advise parent to
-bring child back for regular follow-up checks
-ensure booster immunizations are given
-ensure vitamin A is given every six months

118. B. EMERGENCY TREATMENT OF SHOCK
 Hypoglycemia?
 Dehydration?
 Septic Shock?