1. The document discusses diet in critically ill children and children with renal diseases. It provides guidelines on calorie, fluid, protein and other nutrient needs based on the child's condition, including during acute renal failure or nephritis. 2. Enteral nutrition is preferred when possible, otherwise nasogastric or parenteral feeding may be used. Diet types include liquid diets, polymeric diets, and elemental diets. 3. For acute nephritis or renal failure, fluid intake is restricted based on urine output. Calories, protein and sodium are adjusted based on the child's needs and renal function. Close monitoring of electrolytes is needed.

1. DR G.RAJKUMAR
ASSOCIATE PROFESSOR PAEDIATRICS
DHANALAKSHMI SRINIVASAN MEDICAL COLLEGE
& HOSPITAL PERAMBALUR TAMILNADU INDIA

2. DIET IN A CRITICALLY ILL CHILD
1. Goals
a) Calories: BMR is roughly 22 kcal/kg/ideal weight. In a
bedridden child, activity, growth and SDA reduces and only
2/3 of the RDA need be given.
Add 10-15% of the calculated calorie towards extra
requirement due to fever and illness.
For every 1 degree Celsius rise in temperature, give 10%
calories more.
Conversion of Fahrenheit to Celsius:F-32/1.8
Conversion of Celsius to Fahrenheit: (C x 1.8) + 32

3. b) Fluids: The requirement is roughly 1 ml for each calorie.
The fluid requirement is usually calculated based on the
Holliday and Segar formula, taking into account the actual
weight of the child
When syndrome of inappropriate ADH (SIADH) secretion
is probable, restrict to 2/3 requirement.
In oligo-anuria, give only insensible loss and last day’s
output.
c) Carbohydrate: 15-30 g/kg/day of glucose is needed.
d) Protein: The RDA for age or roughly 1.5-2 g/kg can be
given. In renal failure, restrict to 0.25-0.5 g/kg body weight.

4. e) Fat: In malabsorption states and hepatobiliary and
pancreatic diseases, medium chain triglycerides (MCT)
is preferred as coconut oil or cotton seed oil.
Up to 10-15% of total calories can be given as visible
oil/fat.
f) Vitamins and minerals: The demand for
multivitamins and minerals like iron, zinc etc., increases
during illness due to poor intake, excessive loss and to
serve as coenzyme in metabolic and degradation
pathways.
This may further increase due to drug intake.

5. 2. Routes of Administration
a) Oral: It is the preferred route in most cases.
Enteral nutrition is tolerated by most patients unless there are
GI contraindications to oral feeding, e.g., peritonitis,
ischaemic enteritis, GI bleed etc. Enteral nutrition is essential
to support life and to sustain GI function. Nutritive and
nonnutritive sucking are essential in newborns and infants for
maturation of gut, orofacial development and emotional
satisfaction.
b) Nasogastric (NG) feeding: This is ideal in the comatose
and in some preterm and kwashiorkor patients. Orogastric,
nasojejunal and gastrostomy feeds are also given in certain
situations.

6. c) Parenteral: Often parenteral/IV nutrition is given
through peripheral route.
In specific indications partial/total parenteral nutrition
(PPN/TPN) are given.

7. 3. Types of Food for Enteral Nutrition
a) Family pot feeding: Household items like milk, fruit juice, idli, rice,
curd etc., can be given in less sick children.

8. b) Liquid diet: Soups, kanji water, fruit juice, egg flip, milk,
butter milk, high energy milk, cereal milk, milk + SAT Mix
(cereal pulse) etc., can be selected.
Isodense (isotonic) liquids that supply 100 kcal/100 ml are
preferred to supply calories and to prevent nausea, vomiting,
diarrhoea etc. e.g.. High energy milk - Vi glass milk with 1
tsp sugar and Vi tsp oil;
High energy cereal milk - Vi glass milk with 1 tsp sugar and 1
Vt tsp cereal flour
High energy cereal-pulse milk - Yi glass milk with 2 tsp SAT
Mix; fruit juice - 1 orange with 2 tsp sugar made up to 100 ml.
Egg flip - one egg in 3/4 glass milk with 2 tsp sugar (200 cal in
200 ml).
Butter milk or lassee - Vi glass yogurt with 2 tsp sugar.

9. c) Polymeric & non-elemental diet: Also refer Table
5.6. Carbohydrate, protein,
fat etc., are processed and then given, e.g., Casec
(Calcium caseinate - Mead Johnson), Promod (Whey -
Ross), maltidextrin, MCT or coconut oil, com oil to
supply long chain triglycerides (LCT), Polycose
(glucose polymer- Ross), Ten-o-Lip, Ten-o-Lip LF
(lactose free), Ten-o-Tube (Recon Ltd).
d) Elemental diet: e.g., amino acids, mineral mixtures,
glucose, fructose.
e) Combination of the above also can be given.

10. 4. Method of Administration
The desired calories can be given as 6-8 feeds/day.
 NG feed can be given as bolus feed allowed to fall
by gravity or as a continuous drip.
Continuous drip will not induce peristalsis and will
prevent nausea, abdominal pain, diarrhoea etc.,
and allows maximum absorption
Bolus mimics normal feeding; but is less tolerated.

11. 5. Complications
Complications of enteral feeding are:
a) Hypoglycaemia
b) Dehydration
c) Overhydration
d) Hypernatraemia
e) Hypercalcaemia (excess milk)
f) Vitamin and mineral deficiencies
g) Aspiration
h) Azotaemia
i) GI upset etc.

12. DIET IN DIARRHOEAL DISEASES
• Oral rehydration therapy (ORT) has revolutionised the
management of diarrhoea and it also has reduced morbidity
and mortality.
• Diarrhoea can be defined as increase in frequency, fluidity
and volume or bulk of stool compared to the normal bowel
habit of that individual.
• Out of the various terminologies used, the preferred terms
are
• Acute diarrhoeal disease (ADD),
• Acute dysentery (invasive diarrhoea),
• Persistent diarrhoea (PD) of more than 14 days duration
• Chronic diarrhoea with features of malabsorption or failure
to thrive.

13. Pathogenesis
• Diarrhoeal diseases lead on to fluid and electrolyte
malnutrition (FEM) and protein- energy malnutrition
(PEM).
• Osmotic, secretory and invasive processes are the
three main pathogenic pathways.
• Osmotic and secretory diarrhoeas are watery
diarrhoeas with small bowel involvement.
• Villus cell damage leads to reduced digestion and
absorption leading to osmotic diarrhoea.

14. • Enterotoxins lead to secretory diarrhoea (e.g., cholera,
enterotoxigenic E. coli - ETEC).
• In rotavirus diarrhoea, absorption decreases and secretion
exceeds absorption.
• In chronic diarrhoea, crypt cell hyperplasia leads to
secretory diarrhoea and villus cell damage leads to
disaccharidase deficiency and osmotic diarrhoea.
• Villus cells are absorptive and crypt cells are secretory.
• Villus cell damage may stimulate crypt cell
hyperplasia and secretory disorder may crop up on an
osmotic diarrhoea.
• Invasive diarrhoea produces blood and mucus due to
cytotoxin-mediated inflammation in large bowel.

15. Management
• Assessment of dehydration and categorisation into
plan A, B and C
• ORT is the cornerstone in the management of ADD
• Ensure user-friendly ORS.
• ORS with increased sugar leads to osmotic diarrhoea.
• These are called oral dehydration solution/ODS.
• Continued breastfeeding and early feeding from the
family pot reduce the duration and severity of
diarrhoea and also prevent malnutrition.
• Convalescing children need an extra meal/day for two
weeks.

16. ORS
• Sodium 90,
• Potassium 20,
• Chloride 80,
• Citrate 10 or
• Bicarbonate 30 and
• Glucose 111 mmol/L.
CHOLERA STOOL
• Sodium 101,
• Potassium 27,
• Chloride 92;
• Bicarbonate 14 mmol/L

17. • Acute dysentery requires drug therapy for 5 days
(e.g., nalidixic acid, erythromycin, tetracycline,
furazolidone, or metronidazole).
• Infestations like whip worm (WW) also need
appropriate therapy (mebendazole).
• Mebandazole is given as retention enema in resistant
cases, 2 tablets per day in 100 ml N. saline for 3 days.

18. Approach to Persistent Diarrhoea
• Perianal excoriation suggests osmotic diarrhoea.
• Steatorrhoea suggests fat malabsorption.
• Blood and mucus are seen in dysentery, inflammatory bowel
disease (IBD), WW colitis, polyposis etc.
• Prolapse rectum is seen in WW colitis.
• Formed, watery and mucus stool with abdominal pain
relieved by defaecation associated with normal growth often
suggests irritable bowel/non-specific diarrhoea.
• Osmotic diarrhoea abruptly stops on fasting trial, but
secretory diarrhoea due to crypt cell hyperplasia tends to
respond slowly.
• In mucosal damage, crypt cell hyperplasia may occur and
this in turn leads to secretory diarrhoea.
• Anti secretory agents like rececadoril may be beneficial.

20. • Apart from ORT and management of the cause, hypo-osmolar ORS, fasting
• trial and dietary manipulation by trial and error are often needed. The
various
• steps are given in Fig. 5.3. In severe and prolonged diarrhoea, hypo-
osmolar
• super ORS (or rice based) should be tried. Hypo-osmolar ORS is very
useful in
• non-cholera stool (appendix 7). There are two types of hypo-osmolar ORS;
one
• with sodium 75 and glucose 75 mmol/L and the other with sodium 60 and
glucose
• 24 mmol/L. Super ORS is starch-based ORS, starch 40 g instead of glucose
20 g in
• one packet.

21. • Hypo-osmolar or rice-based ORS is better accepted and it decreases stool
• output by 25% and also improves nutrition of the child. Dietary
management is
• most important. Various stepwise diets are given in Table 5.18. Low milk,
then
• milk-free and then starch-free diet can be tried in succession. In osmotic
diarrhoea,
• disaccharide (lactose, sucrose) free diets are rewarding (e.g., Prosoyal).
• Commercial lactose-free preparations are given in Table 5.18. In cow’s
milk
• protein intolerance (CMPI), milk protein also should be avoided and soya
protein
• can be tried (e.g., Nusobee). In soya protein intolerance (SPI), this should
• be avoided and chicken-based diet may be tried. Another kitchen-based
preparation

22. • Amylase breaks down starch into maltidextrins and reduces the
viscosity
• and bulk of the porridge. It becomes hypoosmolar and calorie
dense and does not
• swell as much as whole grain on cooking. Germination also
enhances the vitamin
• content of the grain.
• Soya milk, casein hydrolysate, whey hydrolysate and comminuted
chicken
• may be tried. Ten-O-Lip LF and Ten-O-Tube LF (Recon Ltd.) are
polymeric
• lactose-free diet for oral and NG feeding (Table 5.6). In resistant
cases, oral elemental
• diet may be tried, e.g., glucose, fructose, amino acids etc.

24. DIET IN RENAL DISEASES
• A. Acute Glomerulonephritis (AGN)
• Oliguria, haematuria, oedema and
hypertension mark acute nephritis. The
complications
• that can occur are hypertensive
encephalopathy, congestive cardiac
• failure, electrolyte imbalance and acute renal
failure.

25. • 1. Nutrition
• a) Fluid: Restrict fluid to insensible loss plus last day’s output when oliguria
• is present. Oliguria is defined as urine output less than 1 ml/kg/hour
• or 25 ml/kg/day. Insensible loss of water is 400 ml/m2/day. Normal glomerular
• filtration rate (GFR) is 25 ml/nr/minute or 10.20 ml/m2/min.
• i) Mosteller's formula for calculation of surface area:
• Infant = 25 ml/kg Adult = lOml/kg
• 1-5 yr = 20 ml/kg
• iii) Formula to calculate GFR:
• i) Preterm = 0.35 x length + S creatinine
• ii) Infant = 0.45 x length + S creatinine
• iii) Child = 0.55 x length + S creatinine
• If there is oedema and oliguria, give frusemide 1-2 mg/kg. If there is
• vomiting, give IV fluid. Insensible loss is replaced as 10% dextrose and
• urine output, 50%- as N. saline and 50% as 10% dextrose,
• b) Calories: Give liberal calories, RDA for age plus 10% extra for infection/
• c) Protein: Give RDA for age if blood urea is normal. In renal failure, restrict
• to 0.5-1.25 g/kg body weight.
• d) Sodium: Restrict sodium during oliguria and gradually add 1-2 g/day
• during diuretic phase and slowly increase to 10 g/day.
• e) Potassium: Potassium is avoided and fruits should not be given during
• oliguria. If complications are not subsiding with medical management,
• start peritoneal dialysis. During peritoneal dialysis, fluid and diet restriction
• are not strictly essential.
• 2. Peritoneal dialysis (PD): Indications—symptomatic uraemia, circulatory
• overload, hyperkalaemia and hypertension not responding to medical treatment.
• During PD, input of 20-50 ml/fluid/kg/cycle x 20 cycles are initially
• planned. 1.5% solution (type I) is generally preferred. Type II or higher strength
• solutions are used in overhydrated patients. 4.5% solution can be made up
• by adding 5 ampoules of 25% glucose to 1 Lof type I fluid. Type II fluid is
• 8.7%. From 4th cycle onwards, add KCI in a dose of 2 ml/L of PD fluid.
• Monitor blood urea and serum electrolytes daily.
• 3. Diuretic phase: During diuretic phase, slowly release fluid restriction, protein
• restriction and salt restriction.

26. • 4. Model diet in acute nephritis (Table 5.20): Four-year-old child
with 15 kg
• weight, oedema, hypertension and oliguria (urine output 300 ml)
with normal
• B. urea.
• a) Calories: RDA 1300 kcal (1000+ 100 kcal for each completed year;
bedside
• calculation); 10% extra— 130 kcal. Total 1430 kcal
• b) Protein: 1.75 g/kg—27 g
• c) Fluid: Urine output—300 ml
• Insensible loss—15 x 20 = 300 ml
• Total—600 ml
• d) Sodium: Vi to 1 g/day

27. • e) What to give? The fluids that can be given are kanji water, butter
milk and
• dilute milk (50-100 ml of milk made up to 1 glass).
• The food items that can be given are salt-restricted items like rice,
• kanji, idli, dosai, rice flakes, sugar, jaggery, honey, glucose, oil/ghee,
• unsalted butter and vegetables. Avoid high proteins, salt and fruits.
SAT
• Mix (cereal-pulse) can be given (100 g = 380 kcal and 8 g protein, 1
tsp =
• 20 cal and 0.5 g protein).
• Other items that can be substituted are rice flakes, ragi, nestum,
custard
• powder, honey, jaggery etc. Avoid high protein, extra sodium and
• fruits.

28. • B. Diet in Acute Renal Failure (ARF)
• 1. Causes of ARF
• a) Prerenal—e.g., dehydration, shock, burns
• b) Renal—e.g.. AGN. systemic lupus erythematosus (SLE), acute tubular
• necrosis, dysplastic/contracted kidneys, haemolytic uraemic syndrome
• (HUS).
• c) Postrenal—e.g., obstructive uropathy.
• In prerenal, serum creatinine is normal and urinary sodium is low, whereas
• in renal, both are high. Blood urea is raised in all the three types.
• 2. Management
• a) Fluid challenge: 20 ml/kg NS or RL or more till central venous pressure
• (CVP) is normal.
• b) Diuretic challenge: 1-2 mg/kg frusemide if well hydrated or 2 ml/kg 20%
• mannitol if underhydrated. If oligo-anuria persists, treat as ARF
• c) Fluids in ARF: IVF if oral is not tolerated. Quantity—insensible loss +
• last day's output. Type of fluid—insensible loss as 10% dextrose and
• output, 50% as N.saline and 50% as 10% dextrose.
• d) Sodium: No extra sodium when there is oligo-anuria and hypertension.
• e) Sodium bicarbonate: Acidosis is corrected by 1-2 ml/kg 7.5% Soda
• bicarb. This may be given 12 hourly.
• f) Potassium: To tackle hyperkalaemia, correct acidosis by giving soda
• bicarb, administer calcium gluconate 0.5-1 ml/kg IV 12 hourly and give
• insulin glucose in severe hyperkalaemia. 10 ml/kg of 5% glucose with 0.1
• U/kg insulin may be given as a slow drip. Cation (K) exchange resins and
• dialysis may be needed in severe cases.
• g) Phosphate: To control hyperphosphataemia, prevent absorption by giving
• aluminium hydroxide and supplement calcium. Avoid calcium phosphate
• (e.g., Ostocalcium) and give calcium carbonate (e.g., Shelcal). Avoid
• protein-rich food which tends to have high phosphate.
• h) Protein: Restrict protein intake to 0.5-1.25 g/kg/day. Provide esurea and other nitrogen wastes,
• i) Others: Treat anaemia (packed cells and erythropoietin in chronic cases),
• hypertension (Nicardia), infection (antibiotics) and coagulopathy (FFP).
• Antibiotics other than penicillins need dosage modification.
• 3. Recovery phase: During recovery phase, slowly increase fluids, protein and
• sodium.

29. • C. Diet in Chronic Renal Failure (CRF)
• CRF is usually due to end-stage renal disease. Patients present with growth retardation,
• anaemia, uraemia, acidosis, hypertension, oedema, hyperphosphataemia,
• rickets etc. The treatment modalities include dietary management with or without
• dialysis and ultimately renal transplantation whenever possible.
• 1. Dietary management: The goals are:
• a) to reduce nitrogen intake
• b) to maintain nitrogen balance
• c) to cover essential amino acid requirement
• d) to supply enough calories
• i) Energy: Infant 100-120 kcal/kg/day
• Children 80-100 kcal/kg/day
• In stunted children, RDA for height age is given rather than for chronological
• age.
• ii) Protein: High protein will aggravate acidosis, hyperkalaemia and
• hyperphosphataemia, whereas low protein will reduce BUN, improve
• renal function and reduce GI and neurological symptoms like nausea,
• vomiting, muscle cramps, convulsion, neuropathy etc. Milk is rich in
• phosphate and meat is rich in potassium. Protein intake is based upon
• the extent of CRF, mild/moderate or severe (Table 5.22).
• iii)Fluids: Thirst controls fluid intake and fluids should be given without
• producing water retention. If fluid retention occurs, give diuretic and
• restrict sodium and consider dialysis if water retention and weight
• gain increase in spite of diuretics.
• iv)Sodium: Sodium excretion is almost constant in CRF. Excess intake
• will lead to hypertension and fluid retention. Restrict salt intake to
• 300-600 mg/day in infants and to 1-2 g/day in older children.
• v) Potassium: Restrict potassium intake and give soda bicarb, calcium
• gluconate and potassium exchange resin (1 g/kg/day), if there is
• hyperkalaemia. Hypokalaemia can occur at any time. Give small dose
• of potassium or fruit juice if serum K is low normal or low.

30. • 2. Acidosis: Give 0.5-2 ml/kg soda bicarb in divided doses. Always correct
• hypocalcaemia to prevent tetany before giving soda bicarb.
• 3. Hyperphosphataemia and renal rickets: Hyperphosphataemia and rickets
• may develop in three months period after onset of CRF. Hence X-ray wrist
• should be taken after three months. Restrict phosphate intake (high protein
• diet). Give aluminium hydroxide (1 ml/kg/day), calcium (1 g/day) and alpha D
• 0.25 mg/day or up to 0.05 mg/kg/day. Alpha D is available as 0.15 mg and 1
• mg capsules. Serum Ca, phosphorus and serum alk. P04ase should be monitored
• every 2-4 weeks and maintain serum phosphorus level at 4-6 mg%.
• Cow’s milk is rich in phosphate and hence phosphate-low formula may be
• used, e.g., Similac.
• 4. Anaemia: Decreased erythropoietin and reduced RBC life span lead to anaemia.
• Packed cell transfusion and administration of erythropoietin are beneficial.
• Erythropoietin is given in a dose of 25-100 units/kg IV/SC thrice weekly.
• Higher doses are needed initially.
• 5. Diet in peritoneal dialysis: Strict dietary restriction is not required during
• PD; except in severe oliguria, oedema or hypertension.
• 6. Classification of CRF: CRF is classified according to GFR or symptoms.
• Glomerular filtration rate (GFR) does not approximate adult values till the third
• year of life. GFR is standardized to the surface area (1.73 m2) of a 70-kg adult
• and is expressed as ml/min/1.73 m2.
• 7. Model diet in mild-moderate CRF (Table 5.23)
• 5-year child with 15 kg, normal BP. Height 98 cm. Height age 4 years. Urine
• output 400 ml (> 1 ml/kg/hour) S. K normal.
• a) Fluid: According to thirst or insensible loss + last day’s output 15 x 20 -
• 300 ml + 400 ml = 700 ml or up to two-third maintenance 800 ml
• b) Calories: RDA for height age 1300 kcal + 20% extra = 1560 kcal.
• c) Protein: 1.4 x 15 = 21 g.
• d) Sodium: Restrict to 500 mg/day (no added salt).
• e) Potassium: Fruit juice can be given if S. K+ is normal.

31. • DIET IN HEART DISEASE WITH CONGESTIVE CARDIAC FAILURE
• (CCF)
• Cyanotic congenital heart diseases (CCHD) may lead to marked growth
retardation
• than acyanotic CHDs. However, PDA, VSD and pulmonary hypertension are
• common conditions that lead to growth faltering. This is attributable to
CCF,
• hypoxia, acidosis, respiratory infection, poor coordination of sucking and
swallowing
• and tiredness during feeding. 10-30% extra calories may be needed due to
• infection and the hypermetabolic state. Weight gain is essential to control
infection
• and to plan surgery as well. Fluid and salt restriction are required in CCF.

32. 1. Goals
a) Fluid: In oedema, restrict to insensible loss + last
day’s output or twothird
maintenance.
b) Calories: RDA for age + 10-30% extra.
c) Protein: RDA for age or up to 10-15% of total
calories as protein of high
biological value.
d) Sodium: Restrict to V2-I g/day.

33. • DIET IN RESPIRATORY DISEASES
• Respiratory diseases contribute to highest morbidity and mortality among infants
• and children. These lead to hypermetabolic state and at the same time lead
• to anorexia, vomiting and semistarvation. Warm fluids help in expectoration and
• have soothing effect on the throat. Encourage small frequent feeds from the
• family pot. Solid sugars like sweets, chocolates etc., that stick to the teeth and
• tonsillar crypts may act as nidus for infection. Vitamin A supplementation is
• known to decrease respiratory and diarrhoeal diseases.
• Vitamin A deficiency leads to increased bacterial binding to the mucosa.
• Vitamin E supplementation may decrease reactive oxygen species (ROS) and
• oxygen free radical disease in preterm babies on ventilators.
• In asthma, exclusion diet may be needed. In hypoallergenic diet, citrus
• fruits, groundnuts, chocolates, cow’s milk, egg, meat, fish etc., are avoided stepby step. Exclusion
diet is tried only if they fail to respond to round-the-clock
• bronchodilators or if food allergy is evident.
• Goals
• Calories: 10-20% extra calories are needed in acute and chronic respiratory
• diseases. Convalescing children should get 1-2 extra meals/day for at least 2
• weeks to restore weight and to prevent malnutrition.

34. • DIET IN HEPATIC DISEASES
• The goal is to provide adequate calories and electrolytes and to prevent
• hypoglycaemia, hypoalbuminaemia, hypokalaemia etc. Liberal carbohydrates and
• fruits, adequate protein and fat according to tolerance are given in mild diseases.
• High fat decreases gastric emptying and may aggravate nausea. MCT is better
• tolerated when there is decreased bile flow. Phospholipid extracts from soyabeans
• (Essentiale) is found to help in liver regeneration and to improve appetite.
Lornithine-
• L-aspartate (Hepamerz) orally or IV is beneficial in liver disorders.
• Ursodeoxycholic acid (UDLIV) is effective in cholestatic jaundice.
• Silymarin in a dose of 10-20 mg/kg/day in 3 divided doses for 1 month is
• also beneficial. It contains flavanoligans namely silybinin, silycristin and
• silydianin. It is a strong antioxidant and prostaglandin synthetase inhibitor.

35. 1. Hepatic encephalopathy
The aim is to reduce ammonia level and to support the liver.
a) Avoid protein by mouth.
b) Sterilize the gut by oral ampicillin or neomycin.
c) Lactulose 1-2 ml/kg/day in divided doses or till there is diarrhoea (up to
30 ml/dose).
d) Lactisyn or lactobacilli may be given orally.
e) Ryle’s tube aspiration and bowel wash.
f) Calorie requirement is RDA for age plus 10-20% extra calories. As much
calories as possible should be given as 10% glucose enriched with 25%
dextrose. Up to 12% glucose can be given through the peripheral vein.
g) Blood transfusion and salt-free albumin.
h) Supplement vitamin K and fresh frozen plasma (FFP).
i) Give hepatic drip to supply fluid and calories (Table 5.26)
j) Glucagon 0.03 mg/kg/day up to 1 mg/dose for 3 days helps in liver regeneration
and to prevent hypoglycaemia.
i) Supplement branched chain amino acids valine, leucine, isoleucine which
help in liver regeneration (proteinsteril hepa)

36. • DIET IN MALABSORPTION AND OTHER Gl DISORDERS
• 1. Malabsorption
• Among carbohydrate malabsorption, disaccharidase deficiency is
the most
• common, e.g., lactose intolerance. This is diagnosed by watery
diarrhoea
• and perianal excoriation due to acidic stool, presence of more than
2% reducing substance in motion at 2 separate testings and a pH
less than 5.6. Continue
• breastfeeding, stop artificial feeding and give curd or yogurt. Soya
milk
• may be started if necessary in very young infants. In older children,
cereals,
• pulses etc., can be continued along with family pot feeding.

37. • DIET IN DIABETES MELLITUS
• In children insulin-dependent diabetes (type I) is common. Non-insulin-
dependent
• diabetes (type II) is extremely rare. Malnutrition related diabetes (secondary
• diabetes) is also reported from developing countries. In syndrome X, there is
• hyperinsulinism and insulin resistance and is more common in those with central
• obesity. In children, initial control of diabetes is difficult as they tend to have
• ‘brittle diabetes'. After some months, the insulin requirement may come down
• and it is called the ‘honeymoon phase’.
• Maintain adequate carbohydrate, fat and protein ratio: carbohydrate 50-
• 60%, protein 10-15% and fat 20-30%. Avoid fasting and feasting. High fibre, low
• fat diet with adequate carbohydrate and protein is ideal for diabetic children.

38. • 1. Meal Planning
• The goal is to ensure normal growth and to keep FBS <115 mg/dl, PPBS < 126-140
• mg/dl, S. cholesterol < 200 mg/dl, S. LDL cholesterol < 130 mg/dl, HDL > 50 mg/dl,
• S. triglyceride < 160 mg/dl and glycated Hb (6-8 g) within normal limits. There
• should not be wide fluctuations in blood sugar and so timing of meals and
composition
• of diet should be relatively fixed and at the same time without monotony.
• Fasting and feasting may be avoided as far as possible. Meal times must be
• regular and quantity should be consistent. Sodium should be restricted to 3-5 g/
• day if there is hypertension and cholesterol should be restricted to 300 mg/day.
• BMR is roughly 22 kcal/kg ideal weight. Bitter things like bitter gourd may
stimulate
• beta cells of the pancreas.

39. • a) Carbohydrate: Avoid rapidly absorbed mono- and disaccharides and refined
• sugars like glucose, sugar, honey, sweets, sweet drinks etc., and encourage
• complex carbohydrates. Tubers should be restricted. Whole wheat is considered
• better than rice by some as it contains ‘Acarbose' which allows slow
• carbohydrate absorption. Rice is generally consumed in larger quantities than
• wheat and hence wheat is recommended by some.
• b) Fibre: Fibre is unabsorbed plant polysaccharide. It delays carbohydrate absorption
• and decreases hyperglycaemia. The suggested intake is 20-35 g/
• day. It increases insulin receptors and decreases insulin requirement. Pectin,
• gum etc., present in fibre bind bile salts and increase their excretion. Since bile
• salts are derived from cholesterol, this will reduce serum cholesterol. Fibre
• relieves constipation. Whole wheat, coriander, carrot, brinjal, cauliflower, ladies
• finger, mango etc., contain 1-3% fibre; and ragi, pulses, ground nut,
• peas, guava etc., contain 3-5% fibre. In ripe mango, the fibre content reduces.
• c) Low fat: Low fat increases insulin binding and reduces LDL and VLDL cholesterol
• and thereby decreases the incidence of atherosclerosis in diabetes.
• The polyunsaturated/saturated (P/S) ratio 1.2:1 is usually recommended.
• The ratio of polyunsaturated to monounsaturated to saturated fat may be
• equal for practical purpose. It may be better to give vegetable fat that contains
• PUFA. Avoid animal fat, hydrogenated oil (Dalda) etc. Fish and chicken
• are preferred than beef and egg. Turmeric, Bengal gram, onion and garlic
• reduce cholesterol.
• d) Fruits: When the blood sugar is well controlled, half to one fruit can be
• allowed at the expense of a snack or after exercise. The fruit can be selected
• based upon the carbohydrate content of the fruit

40. • 3. Exchange system
• Exchange system is useful to ensure fixed energy intake and to avoid monotony.
• 1 exchange will supply 10 g carbohydrate (Table 5.31).
• 4. Glycaemic index of foods
• It is currently under study, i.e., the effect of the food on the blood glucose
• concentration. It is defined as the increase in RBS following ingestion of a
• food as percentage of increase following ingestion of a standard food (glucose).
• The glycaemic index of glucose is 100%; rice, 72%; wheat, 65%; ice
• cream, 42%; potato, 90%; soyabean and peanut, 20%; apple, 40% etc, This
• may vary from time to time depending upon whether it is taken on empty
• stomach or full stomach etc., and hence it is not of much practical significance.
• 5. Exercise
• Exercise will reduce insulin requirement, reduce LDL cholesterol, increase
• HDL cholesterol and avoid obesity. Extra calories for exercise may have to be
• provided

41. • 1 exchange = 10 g carbohydrate
• * '/2 slice bread
• * 2 cream crackers
• * 2/3 cup unsweetened orange juice
• * 1 medium apple or orange
• * 2/3 cup cornflakes
• * 1 small potato
• * 1 plantain (small)
• * 1 glass milk
• * 1 cup porridge
• * 1 cup thin soup
• * 1 glass yogurt (curd)
• * ’/2 banana

42. Insulin
Usually 1 unit/kg/day is the requirement. It can be given as 2 rations; 2/3 in
the morning and 1/3 in the evening, 20 minutes prior to food. Each ration
should be 2/3 intermediate acting and 1/3 plain insulin. This can be given by
mixing the two or using commercial combinations, e.g., Mixtard (Bovine/
Porcine). When the requirement is >2 U/kg/day, it indicates insulin antibodies
and then switch over to Human Mixtard. Bovine insulin varies from human
insulin in three amino acids and porcine in one amino acid; both induce
antibodies. Human insulin is the best, but very expensive. It does not evoke
insulin antibodies.
and 10-15 g/hr fruit or starch exchange
Severe 50 g before exercise
and 10-15 g/hr
1 sandwich + 1 glass milk and 1
fruit or starch exchange
6.

43. • 7. Sweeteners
• Non-nutritive sweeteners (saccharin, aspartame, sucramate
and acesulphame
• K) are used in diabetic diet for improving palatability
without increasing
• energy intake. Nutritive sweeteners (sorbitol and fructose)
are useful in baking.
• They increase energy intake and tend to have GI side
effects when > 50
• g/day is consumed. Fructose in excess may be channelled
into glucose pathway.
• Saccharin in very high doses is thought to produce hepatic
malignancy.