Nutrition

CONTENTS
 Definition of nutrition
 Caloric requirements
 Breast feeding
 Vitamins
 Protein Calories Malnutrtion

NUTRITION
 Nutrition is the science that interprets the interaction
of nutrients and other substances
in food (e.g. phytonutrients, anthocyanins, tannins,
etc) in relation to maintenance, growth, reproduction,
health and disease of an organism. It includes food
intake,
absorption, assimilation, biosynthesis,catabolism and
excretion.

CALORIC REQIREMENT OF CHILREN
OF VARIOUS AGES
AGE CALORIES/KG/DAY
Infants 110
1- 3 years 100
4-6 years 90
7-9 years 80
10-12 years 70
13-15 years 60

FORMULA TO CALCULATE CALORIC
REQUIREMENT
 Upto 10 Kg -> 100 kcal / kg
 11 – 20 kg -> 1000kcal + 50 kcal/kg for each kg above 10
kg
 Above 20 kg -> 1500kcal + 20 kcal /kg for each kg
above 20 kg.

SOURCES OF CALORIC SUPPLY
1. Carbohydrates 50 – 55%
2. Fats 30-35%
3. Proteins 10-15%

UTILIZATION OF CALORIES IN BODY
 Basal metabolic rate 50%
 Physical activity 25%
 Growth 12%
 Fecal loss 8%
 Specific dynamic actions of blood 5%

PROTEIN REQUIREMENT
AGE PROTEIN(gm/kg/day)
Infants 2.5
1-3 years 2.0
4-6 years 1.5
7-12 years 1.0
13-15 years 0.5

STRUCTURE
 The breast is a mass of glandular, fatty and connective tissue. The
breast is made up of:
 lobules – glands that produce milk
 ducts – tubes that carry milk from the lobules to the nipple
 fatty and connective tissue – surrounds and protects the ducts and
lobules and gives shape to the breast
 areola – the pink or brown, circular area around the nipple that
contains small sweat glands, which release (secrete) moisture as a
lubricant during breast-feeding
 nipple – the area at the centre of the areola where the milk comes out
 Ligaments support the breast. They run from the skin through the
breast and attach to muscles on the chest.
 There are several major nerves in the breast area, including nerves in
the chest and arm. There are also sensory nerves in the skin of the
chest and axilla.

FUNCTION
 The breast’s main function is to produce, store and
release milk to feed a baby. Milk is produced in lobules
throughout the breast when they are stimulated by
hormones in a woman’s body after giving birth. The
ducts carry the milk to the nipple. Milk passes from
the nipple to the baby during breast-feeding.

DEFINITION OF BREASTFEEDING
Breastfeeding is the feeding of an infant or young child
with breast milk directly from female human breasts (i.e.,
via lactation) not from a baby bottle or other container.

The Prolactin Reflex
1. (Long arrow) Nerve impulses from sucking go to brain
2. (Short arrow) The pituitary gland releases prolactin into
the blood
3. (Breast) This causes the alveolar cells to secrete milk and
swells the alveoli
The Milk Ejection Reflex
1. (Long arrow) Nerve impulses from sucking go to the
brain
2. (Short arow) The pituitary gland releases oxytocin into
the bloodstream
3. (Breast) This causes muscles around the alveoli in the
breast to squeez milk to the nipple
The milk ejection reflex

HOW BREAST MILK IS PRODUCED
 The let-down reflex
 How body responds to baby’s suckling:
Infant suckling stimulates the nerve endings in the nipple
and areola, which signal the pituitary gland in the brain to
release two hormones, prolactin and oxytocin.
How Breast Responds to Baby’s Suckling:
 Prolactin causes alveoli to take nutrients (proteins,
sugars) from blood supply and turn them into breast milk.
 Oxytocin causes the cells around the alveoli to contract
and eject milk down the milk ducts. This passing of the
milk down the ducts is called the “let-down” (milk
ejection) reflex.

CON’T…
 Let-down is experienced in numerous ways
including:
 Infant begins to actively suck and swallow.
 Milk may drip from the opposite breast.
 Mother may feel a tingling or a full sensation (after the
first week of nursing) in breasts or uterine cramping.
 May feel thirsty.

10 Steps to Successful
Breastfeeding
1. Have a written breastfeeding policy that is routinely
communicated to all health care staff.
2. Train all health care staff in skills necessary to
implement this policy.
3. Inform all pregnant women about the benefits and
management of breastfeeding.
4. Help mothers initiate breastfeeding within half an
hour of birth.
5. Show mothers how to breastfeed, and how to
maintain lactation even if they should be separated
from their infants.

CONT…
6.Give newborn infants no food or drink other than
breast milk, unless medically indicated.
7.Practise rooming-in - that is, allow mothers and
infants to remain together - 24 hours a day.
8.Encourage breastfeeding on demand.
9.Give no artificial teats or pacifiers (also called
dummies or soothers) to breastfeeding infants.
10.Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge from
the hospital or clinic.

BREAST MILK CONTENTS
Proteins
 Human milk contains two types of proteins: whey and casein.
Approximately 60% is whey, while 40% is casein.
 Lactoferrin inhibits the growth of iron-dependent bacteria in
the gastrointestinal tract.
 Secretory IgA also works to protect the infant from viruses and
bacteria, specifically those that the baby, mom, and family are
exposed to. It also helps to protect against E. Coli and
possibly allergies. Other immunoglobulins, including IgG and
IgM, in breast milk also help protect against bacterial and viral
infections.

BREAST MILK CONTENTS
 Lysozyme is an enzyme that protects the infant against
E. Coli and Salmonella. It also promotes the growth of
healthy intestinal flora and has anti-inflammatory
functions.
 Bifidus factor supports the growth of lactobacillus that
protects the baby against harmful bacteria by creating
an acidic environment where it cannot survive.

CONT’
 Fats
• It is necessary for brain development,
absorption of fat-soluble vitamins, and is a
primary calorie source.

• Long chain fatty acids are needed for brain,
retina, and nervous system development. They
are deposited in the brain during the last
trimester of pregnancy and are also found in
breast milk.

CONT’
Vitamins
 The amount and types of vitamins in breast milk is directly
related to the mother’s vitamin intake. Fat-soluble vitamins,
including vitamins A, D, E, and K, are all vital to the infant’s
health. Water-soluble vitamins such as vitamin C, riboflavin,
niacin, and panthothenic acid are also essential.
Carbohydrates
 Lactose is the primary carbohydrate found in human milk..
Lactose helps to decrease the amount of unhealthy bacteria in
the stomach, which improves the absorption of calcium,
phosphorus, and magnesium. It helps to fight disease and
promotes the growth of healthy bacteria in the stomach.

BENEFITS OF BREASTFEEDING TO MOTHER
1. This promotes mother and child bonding.
2. It prevens uterine bleeding in the mother after
delivery.
3. This is a natural form of Family Planning.
4. This reduces the risks of breast and ovarian cancer in
the mother.
5. This saves time and precious expenses need not be
used for buying milk powder and health care.

BENEFITS BREASTFEEDING FOR BABY
1. This provides the best possible nutrion to the
young child.
2. It reduces the incidence of coughs and colds,ear
infections,bronchitis,pneumonia,meningitis and
diarrhoea through its protective factors.
3. It protects the child from colic,asthma,eczema, nose
and food allergies.
4. It is essential for the optimal physical,emotional and
mental development of the child.Breastfed child are
also smarter.

HOW LONG TO BREASTFEED
 Newborns can nurse for 5 to 10 minute per breast; every 2 to
3 hours. This comes to about 10 to 12 feedings per day. In the
beginning, there is only colostrum, and there’s not very much
of it, so be ready to feed often but for short durations.
 One month or more: as baby gets older, his stomach will get
larger. He will nurse less frequently but for a longer duration at
each feeding session. For example, he may nurse 20 to 40
minute per breast every 3 to 4 hours.
 By 6 months, Baby may breastfeed for 20 to 40 minutes per
breast; 3 to 5 times per day.

CONTRAINDICATION TO
BREASTFEEDING
 Active /untreated TB
 Mom takes radioactive compound(cancer for
chemo)
 Mom take illegal drug
 HIV infection

THE PROPER WAY TO BREASTFEED
 Stimulate the baby mouth to open by touching the
nipple.
 Let the baby open the mouth wider.
 Bring the baby near to the breast
 Latch the baby to the breast

PROPER LATCH-ON
1. Baby open the mouth wider.
2. The chin touching the breast
3. The chick looked flatulent.
4. The lip are flanged out.
5. The breast looked full and round
6. Can hear the sound suck and swallow
7. The nipple looked long and round after breastfeed.

DISLATCH BABY AFTER
BREASTFEEDING
 Used little finger press on the gum to open the baby
mouth to dislatch from the nipple

 The Football Hold
 Hold baby at your side face up and lengthwise,
supported by pillows. If nursing on your right side, use
your right arm to support baby at your side, and guide
her head to your breast.

 The Cradle
 Sit with baby lengthwise across your abdomen with
your elbow supporting his head and your hand
supporting his bottom. Your other hand supports the
breast.

 The Cross Cradle
 Lay baby on her side, well supported (consider a
nursing pillow) and touching you. If you're feeding on
your left breast, use your right arm to support baby's
body and your right hand to support her head. Your
fingers support the left breast.

 Cross cradle hold position

 The saddle position involves the baby sitting astride
the mothers leg, facing the mother. It is useful for
mothers who have a particularly forceful letdown
reflex as they can lean back a little (called a reclining
feed) so that gravity isn't increasing that letdown. - See
more at: http://www.breastfeeding-
babies.com/saddle-
position.html#sthash.kIRdNA8N.dpuf

SIGNS THAT THE BABY IS GETTING ENOUGH
BREAST MILK
1. He is contented for 1-2 hours after a feed
2. He passes clear dilute urine 5-6 times a day
3. He passes bright yellow watery stools 6-8 times a day
4. He regains birth weight after 2weeks

BREAST MILK SUPPLY CAN BE
INCREASED BY:
1. Frequent feeds day and night
2. Allowing unlimited breastfeeding to satisfy baby’s
suckling needs
3. Mother to eat and drink sufficient quantities to
satisfy baby’s suckling her hunger and thirst
4. Cultural foods like ginger and rice wine are
compatible with breastfeeding.

VITAMINS
 Organic molecules with a wide variety of functions
 •Cofactors for enzymatic reactions
 •Essential, supplied in the diet
 •Two distinct types: Fat soluble (A, D, E, K)
 •Water soluble (B – complex, C)

 MALNUTRITION
WHO defines Malnutrition as "the cellular imbalance
between the supply of nutrients and energy and the
body's demand for them to ensure growth,
maintenance, and specific functions.“
Malnutrition is the condition that develops when the body
does not get the right amount of the vitamins, minerals,
and other nutrients it needs to maintain healthy tissues
and organ function.
St.Ann's Degree College for Women
Definitions

 PROTEIN ENERGY MALNUTRITION
It is a group of body depletion disorders which
include kwashiorkor, marasmus and the
intermediate stages
 MARASMUS
Represents simple starvation . The body adapts
to a chronic state of insufficient caloric intake
 KWASHIORKOR
It is the body’s response to insufficient protein
intake but usually sufficient calories for energy

Protein-Energy Malnutrition
 PEM is also referred to as
protein-calorie malnutrition.
 It is considered as the primary
nutritional problem in India.
Also called the 1st National
Nutritional Disorder.
 The term protein-energy
malnutrition (PEM) applies to a
group of related disorders that
include marasmus,
kwashiorkor, and intermediate
states of marasmus-
kwashiorkor.
 PEM is due to “food gap”
between the intake and
requirement.

AETIOLOGY:
Different combinations of many aetiological
factors can lead to PEM in children. They are:
 Social and Economic Factors
 Biological factors
 Environmental factors
 Role of Free Radicals & Aflatoxin
 Age of the Host

 Amongst the Social, Economic, Biological and
Environmental Factors the common causes
are:
 Lack of breast feeding and giving diluted formula
 Improper complementary feeding
 Over crowding in family
 Ignorance
 Illiteracy
 Lack of health education
 Poverty
 Infection
 Familial disharmony

 Role of Free Radicals & Aflatoxin: Two new
theories have been postulated recently to explain the
pathogenesis of kwashiorkor. These include Free
Radical Damage & Aflatoxin Poisoning . These may
damage liver cells giving rise to kwashiorkor.
 Age Of Host :
 Frequent in Infants & young children whose rapid
growth increases nutritional requirement.
 PEM in pregnant and lactating women can affect the
growth, nutritional status & survival rates of their
fetuses, new born and infants.
 Elderly can also suffer from PEM due to alteration of
GI System

The clinical presentation depends upon the type ,
severity and duration of the dietary deficiencies.
The five forms of PEM are :
1. Kwashiorkor
2. Marasmic-kwashiorkor
3. Marasmus
4. Nutritional dwarfing
5. Underweight child

Classification of PEM
Water low classificaition
Uses height for age and weight for age as index
Height for Age Weight for Age
Below 80% b/w 80%- 119% Above 120%
Below 90% Chronic
Malnutrition
Stunted Obese and
Stunted
Above 90% Acute Malnutrtion Normal Obese

WHO Classification
It uses weight for height and height for age as index
MODERATE
MALNUTRITION
SEVERE
MALNUTRTION
SYMMETRICAL
EDEMA
No Yes
WEIGHT FOR HEIGHT
(MEASURE OF
WASTING)
SD score b/w -2 to -3
70-79% of expected
SD score <3
<70%of expected
HEIGHT FOR AGE
(MEASURE OF
STUNTING)
SD score b/w -2 to -3
85-89% of expected
SD score <3
<85% of expected

KWASHIORKOR
 The term kwashiorkor is taken from the Ga language of
Ghana and means "the sickness of the weaning”.
 Williams first used the term in 1933, and it refers to an
inadequate protein intake with reasonable caloric (energy)
intake.
 Kwashiorkor, also called wet protein-energy malnutrition, is a
form of PEM characterized primarily by protein deficiency.
 This condition usually appears at the age of about 12 months
when breastfeeding is discontinued, but it can develop at any
time during a child's formative years.
 It causes fluid retention (edema); dry, peeling skin; and
hair discoloration.

 Kwashiorkor was thought to be caused by
insufficient protein consumption but with
sufficient calorie intake, distinguishing it
from marasmus.
 More recently, micronutrient and
antioxidant deficiencies have come to be
recognized as contributory.
 Victims of kwashiorkor fail to
produce antibodies following vaccination again
st diseases, including diphtheria and typhoid.
 Generally, the disease can be treated by
adding food energy and protein to the diet;
however, it can have a long-term impact on a
child's physical and mental development,
and in severe cases may lead to death.

SYMPTOMS
 Changes in skin pigment.
 Decreased muscle mass
 Diarrhea
 Failure to gain weight and grow
 Fatigue
 Hair changes (change in color
or texture)
 Increased and more severe
infections due to damaged
immune system
 Irritability
 Large belly that sticks out
(protrudes)
 Lethargy or apathy
 Loss of muscle mass
 Rash (dermatitis)
 Shock (late stage)
 Swelling (edema)

MARASMUS
 The term marasmus is derived from the Greek
word marasmos, which means withering or wasting.
 Marasmus is a form of severe protein-energy
malnutrition characterized by energy deficiency and
emaciation.
 Primarily caused by energy deficiency, marasmus is
characterized by stunted growth and wasting of muscle and
tissue.
 Marasmus usually develops between the ages of six months
and one year in children who have been weaned from breast
milk or who suffer from weakening conditions like
chronic diarrhea.

SYMPTOMS
 Severe growth retardation
 Loss of subcutaneous fat
 Severe muscle wasting
 The child looks appallingly thin and
limbs appear as skin and bone
 Shriveled body
 Wrinkled skin
 Bony prominence
 Associated vitamin deficiencies
 Failure to thrive
 Irritability, fretfulness and apathy
 Frequent watery diarrhoea and acid
stools
 Mostly hungry but some are
anoretic
 Dehydration
 Temperature is subnormal
 Muscles are weak
 Oedema and fatty infiltration are
absent

CLINICAL
FEATURES
-MUSCLE
WASTING
-FAT WASTING
-EDEMA
-WEIGHT FOR
HEIGHT
-MENTAL CHANGES
MARASMUS
Obvious
Severe loss of
subcutaneous fat
None
Very low
Sometimes quite and
apathetic
KWASHIORKOR
Sometimes
hidden by edema and
fat
Fat often retained
but not firm
Present in lower legs,
and usually in face
and lower arms
May be masked by
edema
Irritable, moaning,
apathetic
DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

CLINICAL FEATURES
-APPETITE
-DIARRHOEA
-SKIN CHANGES
-HAIR CHANGES
-HEPATIC
ENLARGEMENT
MARASMUS
Usually good
Often
Usually none
Seldom
None
KWASHIORKOR
Poor
Often
Diffuse pigmentation,
sometimes ‘flaky
paint dermatitis’
Sparse, silky, easily
pulled out
Sometimes due to
accumulation of fat
DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

A severely malnourished
child with features of both
marasmus and Kwashiorkor.
 The features of
Kwashiorkor are severe
oedema of feet and legs
and also hands, lower
arms, abdomen and face.
Also there is pale skin and
hair, and the child is
unhappy.
 There are also signs of
marasmus, wasting of the
muscles of the upper arms,
shoulders and chest so that
you can see the ribs.
MARASMIC-KWASHIORKOR

 Some children adapt to prolonged insufficiency
of food-energy and protein by a marked
retardation of growth.
 Weight and height are both reduced and in the
same proportion, so they appear superficially
normal.
NUTRITIONAL DWARFING OR
STUNTING

 Children with sub-
clinical PEM can be
detected by their
weight for age or
weight for height,
which are significantly
below normal. They
may have reduced
plasma albumin. They
are at risk for
respiratory and gastric
infections
UNDERWEIGHT CHILD

Treatment strategy can be divided into three stages.
 Resolving life threatening conditions
 Restoring nutritional status
 Ensuring nutritional rehabilitation.
There are three stages of treatment.
1. Hospital Treatment
The following conditions should be corrected. Hypothermia, hypoglycemia,
infection, dehydration, electrolyte imbalance, anaemia and other vitamin and
mineral deficiencies.
2. Dietary Management
The diet should be from locally available staple foods - inexpensive, easily
digestible, evenly distributed throughout the day and increased number of
feedings to increase the quantity of food.
3. Rehabilitation
The concept of nutritional rehabilitation is based on practical nutritional
training for mothers in which they learn by feeding their children back to health
under supervision and using local foods.
TREATMENT

 Promotion of breast feeding
 Development of low cost weaning
 Nutrition education and promotion of
correct feeding practices
 Family planning and spacing of births
 Immunization
 Food fortification
 Early diagnosis and treatment
PREVENTION

Nutrition

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