Part 06. Nutrition

PART Ⅵ. Nutrition

PART . Nutrition

Chapter 43. Nutritional Requirements

Table 43-1

43.1 Water

water content

    ; infant - 75-80% of BW (7% bl. plasma, 18% interstitial fluid, 45% ICF)

  ; adult - 55-60% of BW

endogenous water ; mixed diet 12g H2O /100Kcal

Water Need   

Table 43- 2,3

    ; *100kcal 필요 수분량은 성인과 동일하다.

    ; normal infant

           - *125~150ml/kg/day

           - insensible water loss(50ml/kg)+urine(50-70ml/kg)+예비(25-50ml/kg)

Daily Fluid Consumption

    ; Infant - 10-15% of BW

    ; adult - 2-4% of BW

87 water retention

    ; 0.5-3% of fluid intake

    ; 9-13ml/24hr for “male reference infant” in 1st yr of life

87 LBW water requirement

    ; 85-170ml/kg/24hr

        - fecal loss : 3-10%

    - insensible loss : 40-50%

    - renal excretion : 40-50%

Water balance : ) fluid intake

                   ) protein & mineral content of diet

                   ) solute load presented for renal excretion

                   ) metabolic & resp. rates

                   ) body temperature  

urine osm. : 300-1,000mOsm/L

   serum      : 293 mOsm/L

   maximum normal urinary cons. : 600-700 mOsm/L

43.2 Energy

*1 Kcal : 1 kg 물을 14.5℃에서 15.5℃로 올리는데 필요한 열량

87 average expenditure of calories in 6-12yr

    ; basal metabolism (50%)

  ; growth (12%)

  ; physical, activity (25%)

  ; fecal loss (8%) : mainly as unabsorbed fat

basal metabolism

  ; room temperature, 10-14hr after meal, physical emotional quiet patient

  ; infant

           - *55 kcal/Kg/24hr

    ; adult

           - 25-30 kcal/Kg/24hr

  ; BT 1 상승시 10% 증가

90 Thermic Effect Of Food (TEF)

  ; food ingestion assimilation으로 인해 basal rate 이상으로 metabolism 증가하는

        - protein 30%, fat 4%, CH 6%

    ; infant - 7-8% of total calorie

    ; older children - 5% of total calorie

requirement for physical activity

    ; 15-25 kcal/Kg/24hr

*Daily Calory Requirement

    ; 1 - 80-120 Kcal/Kg

    ; 이후 3년마다 10 Kcal/Kg 감소

    ; 한글판)

           - *처음 1년동안 110(100~120)kcal/kg/day, 2년째 들어가면, 90~100kcal/kg/day

           - *매년 100kcal 필요함 그러나 체중당 칼로리는 3년마다 10kcal/kg/day감소

well balanced diet  

    ; protein 9-15%

  ; CH    45-55%

  ; fat     35-45%

protein CH ; 4 kcal/g

   FA ; short chain - 5.3 kcal, medium chain - 8.3kcal, long chain 9 kcal

하루 500Kcal 지속적 imbalance 1주에 450g(11b) 변화

43.3 Proteins

; 20% of adult BW

; *infant - 2.0~2.5g/day, after infant - 1.5~2.0g/day

# 9 essential A.A for infant

    ; threonine, valine, leucine, isoleucine, lysine, tryptophan, phenylalanine, methionine, histidine

    ; *한가지만 결핍되도 negative nitrogen balance 초래

# 90 Essential AA For LBW

    ; arginine, cystine, taurine

# Digestive progress

    ; protein oligopeptide, α-AA

  ; in stomach    

           - *chymosin : casein --> paracasein

       - pepsin : other protein

    ; in intestine

           - *trypsin, chymotrypsin, carboxypeptidase : peptones --> peptides

# excessive AA

    ; deamination nitrogenous portion liver에서 urea 전환되어 kidney 배설

43.4 Carbohydrate

; BW 1%미만 (stored as glycogen in liver muscle)

; *가장 좋고, 주된 에너지원

# CH 형태

    ; monosaccharide : glucose, fructose, galactose

  ; disaccharide    : lactose, sucrose, maltose, isomaltose

  ; polysaccharide  : starches, dextrins, glycogen, gums, cellulose

# digestion

    ; salivary pancreatic amylase

       - starch oligosaccharide (dextrin) & disaccharide (주로 maltose)

    ; intestinal amylase

           - * 4mo간↓

    ; disaccharides

           - intestinal brush border에서 흡수

           - *disaccharidase 의해

                   a) maltose : glucose + glucose

               b) sucrose : glucose + fructose

               c) lactose  : glucose + glactose

  ; *glucose galactose : active, fructose : passive

# oxidation

   A. anaerobic (glycolysis) : pyruvic acid

   B. aerobic (tricarboxylic acid cycle) : CO+ HO

   관련 H : ) insulin         ) pit. H        ) adr. H 

        Ez:  ) nicotinic acid                   ) thiamine

             ) riboflavin                       ) panthotenic acid

# metabolic disorder

   )diabetes mellitus

   )glycogen storage ds

   )galactosemia

   )fructose, glucose intolerance

   )deficiency of sugar-splitting enzyme

43.5 Fats

; fat soluble vit ADEK vehicle

; natural fat 98% TG (3FA + glycerol)

; ingested TG

    - hydrolyzed by lingual lipase & emulsified in the stomach

           --> monoglycerides & fatty acids

# 95 long chain FA monoglycerides mucosal cell 의해 diffusion 의해 흡수

  reesterification to TG

  lipoprotein으로 coat되어 chylomicron 형성

    lymph vein

# short medium chain FA

    ; pancreatic or mucosal lipase 의해 *FFA diffusion

# 93 Essential Fatty Acids

    ; linoleic acid : precusor of arachidonic acid, PG, leukotrienes

  ; linolenic acid

    ; Function

   ) growth

   ) skin hair integrity

   ) regulation of cholesterol metabolism

   ) lipotropic activity

   ) decreased PLT adhesiveness

   ) reproduction

# essential FA deficiency

    ; increased serum trienoic acid/tetraenoic acid

    ; *intertrigo, dryness, thickening, desquamation of the skin

# excess unsaturated acids

    ; peroxidation - memb. destruction

43.6 Minerals

-  cations : Ca, Mg, K, Na

-  anions  : P, sulfur, Cl                      

-  iron, iodine, cobalt : organic complex

Table 43-5

# Calcium

    ; *모유 영양아는 40mg/kg/day, 우유 영양아는 70mg/kg/day

# 87,92 Zinc

43.7 Vitamins

Table 43-6

43.8 Miscellaneous Factors

Fiber

; undigestable vegetable fiber 170-300 mg/Kg/24hr in urine

; 89 little fiber intake

    --> constipation, diverticulitis, appendicitis, other intestinal disorder

; high fiber diet

    - *cholesterol, zinc, other essential untrient흡수

Digestability

Satiey

Availability

86,87 Bacterial Synthesis Of Vitamins

; *vitamin K, pantothenic acid, biotin

    - essential to human

    - only supplied bacterial synthesis

; thiamine, riboflavin, niacin, vitamin B6, vitamin B12, folic acid

Antimicrobial Factors

oral broad spectrum AB : nitrogen balance

INH : pyridoxal phosphate combine vit B6 defi.

Endocrine Factors

; ACTH, corticosteroid 투여시 Ca protein 증가, Na 감소         

Radioactivity

Emotional Factors

43.9 Evaluation Of Diet

Chapter 44. Feeding Of Infants And Children.

# 85,87 가능한한 early feeding

    ; Why?

           - maintain normal metabolism and growth during transmission from fetal to extrauterine life

         - promote maternal-infant bonding

           - decrease risk of hypoglycemia, hyperkalemia, hyperbilirubinemia, azotemia

# start feeding by 6hr

 stomach emptying time : 1-4hr

 bottle fed infant : *6-9 feeding/day at 1wk

 3meals/day by 9-12 mo.

# Reasons For Cry For Babies (8)

   hunger

   too much clothing

   soiled, wet, uncomfortable diaper clothing

   colic

   swallowed air

   uncomfortably hot or cold environment

   illness     

      to gain sufficient or additional attention

44.1 Breast Feeding

82,89 Advantages : 한글판 (p71) - 5가지

    1) natural food for full-term infant during 1st Mo.

         ; readily available at proper temperture

           ; no time for preparation

           ; *fresh & free of bacterial contamination

    2) no allergy & intolerance than cows milk

           ; decreased spitting up, colic, atopic eczema

    3) decrease incidence of OM, pneumonia, bacteremia, meningitis, chronic diseases

    4) contains bacterial or viral Ab

           ; high secretory IgA Ab

           ; inhibit growth of microorganism

                   - polio, mumps, influenza, vaccinia, rotvirus, JBE virus

  5) 96 presents macrophage

           ; synthsize complement, lysozyme, lactoferrin

           ; lactoferrin

                   - inhibitory effect on E.coli growth in GI

           ; low stool pH

    ; bile salt stimulated lipase

           - kill Giardia lamblia, E. histolytica

    6) transfer of tuberculin responsiveness

    7) supply necessary nutrient

           ; Except

                   - fluoride

               - vitamin D : 수개월

                   - iron 6-9mo

    8) psychologic advantage

# low vitamin K content

# hemolytic ds. of NB (EF)

    ; no contraindication

    ; *brease milk내의 Ab intestine에서 inactivation되기 때문

# 96 Microorganism In Breast Milk

    ; HIV, CMV, human T-cell lymphotropic virus type I, rubella, hepatitis B, herpes simplex

    ; tubercle, typhoid bacilli, mumps

    ; hepatitis B acitive immunization 철저히 하면, breast feeding 가능

# *2000g이상의 premature

    ; *breast feeding가능

Establishing And Maintaining Milk Supply

# 87 Satisfactory Stimulus To Secretion Of Human Milk

    ; regular & complete emptying of breast

# 87 Cause Of Incomplete Nursing

    ; lack of support

    ; weakness of infant

    ; failure to initiate natural hunger cycle

# Appropriate Care For Tender Or Sore Nipple

  ; exposing nipple to air

  ; applying pure lanolin

  ; *avoiding soap, alcohol, tincture of benzoin

  ; frequently changing disposable nursing pads lining brassiere cups

  ; nursing more frequently

  ; manually expressing milk

  ; nursing in different positions

  ; keeping breast dry between feedings

# critical time for establishing breast feeding

  ; 1st 2wk

Diet

# gastric distress or loose stool in infants

  ; berries, tomatoes, onions, cabbage family, chocolate, spices, condiments

# 85 Drugs Of Contraindication Of Breast Feeding

    ; antithyroid drug, lithium, anticancer agent, INH, phenindione

# 87 Drugs Of Temporary Contraindication Of Breast Feeding

    ; diagnostic radiopharmaceuticals, chloramphenicol, Metronidazole, sulfonamide, anthroquinone-derivative laxatives

# Maternal constipation control

  ; raw & cooked fruits & vegetables, whole wheat bread, adequate water

    ; no use of laxatives

# Transmission Drugs Through Breast Milk

  ) arsenicals   ) barbiturates   ) bromides

  ) iodides      ) lead          ) mecurials

  ) salicylate    ) opium        ) atropine

  ) most antimicrobials

# 91 우유의 모유화(성분 비교)

    ; 3-3

# 92 모유 영양아에서 칼슘제제가 효과적인 이유

    ; phosphate 함량이 적어 흡수가 용이

    ; 높은 lactose 함량으로 장내 낮은 pH 흡수가 용이

Technique of breast feeding

# 2 50% emptying, 4 80-90%

# burping prone or Rt lat. position

  ; emptying of stomach into intestine

  ; regurgitation or aspiration

One Or Both Breast Per Feeding

Dertermining Adequacy Of Milk Supply

# 87 모유 부족 증상

    ; 양쪽 젖을 먹은 만족 (-)

    ; 젖먹은 잠들지 않는다.

    ; 1-2hr 깬다.

  ; 체중 증가 (-)

# *“let-down” or milk-ejection reflex

    ; *successful nursing sign

    ; sucking or psychologic stimuli

   post.pituitary lobe에서 oxytocin, ant. pituitary lobe에서 prolactin분비

   myoepithelial cell contraction, milk secretion in cuboidal cell in acini

   milk squeezing into larger duct

  ; reflex적당할시, nursing초기에 반대쪽 breast에도 milk flow(+)

  ; 소실되는 경우

       - pain, fatigue, emotional distress

# insufficient milk 생각전 고려점

    ; infant inadequate progress 알맞는 feeding technique error

  ; diet, rest, emotional distress 관련된 remediable maternal factor

  ; eating or Wt.gain 방해하는 physical disturance in infant

# 85 prolactin분비 ↑방법

    ; delaying feeding to 2½hr intervals (2hr이내시 prolactin 분비↓)

    ; small dose of chlorpromazine for a few days

    ; Lact-aid등의 device

Expression Of Breast Milk

Supplementary Feeding

Weaning

    ; 6-12 Mo

# methods for early cessation of nursing

    ; tight breast binder & ice bag applicaitn for a few days

    ; restriction of mother's fluid intake

    ; hormone : small dose estrogen for 1-2 days

Contraindicaiton

# 87 Contraindication

    1) mother

           ; sepsis, nephritis, PIH, severe postpartum bleeding, active tuberculosis, typhoid, breast cancer, malaria, chronic malnutrition, drug intoxication, psychosis, debilating state, *some drug substance

    2) baby

           ; PKU, galactossemia, cleft palate, prematurity, lactose intolerance

44.2. Formula Feeding

Technique Of Artificial Feeding

; total protein requirment 4g/24hr during 1st 4Mo

    - high protein intake : whole or evaporated cow milk 3-4g/Kg/day

    - low protein intake : breast milk  1.5-2.5g/Kg/day     

Comparison Of Human Milk Cow's Milk

90,92 Colostrum

; 임신말기에서 출산 2-4일분비( mature breast milk : 3-4 wk )

; deep lemon yellow color

; *alkaline

; SG 1.040-1.060 ( mature milk 1.030 )

; total daily amoumt 10-40 ml

; *mineral, protein

    - *CHO fat(cf.iron)

; unique immunologic factor (+)

Water

Calories

; calorie 0.67 Kcal/ml ( 20Kcal/oz)

Protein

; human milk 1-1.5%

    - 65% whey protein ( lactalbumin, lactoglobulin ), - 35% casein 

; cow's milk 3.3%

    - whey : casein = 22: 78

Carbohydrate

; lactose

; human milk 6.5-7%

; cows milk 4.5%

Fat

; TG olein, palmitin, stearin 으로 구성

; human milk

    - more absorbable olein (x2)

  - volatile FA(butyric, capric, caproic, caprylic) 1.3% (cows milk 9%)

; premature or debilitating infant

    --> cow's milk steatorrhea

           - vegetable fat or human milk 투여

Minerals

; human milk 0.15-0.25%        

; cows milk 0.7-0.75%

; *copper, iron (human = cow) 제외하고 cow's milk

Vitamins

; human milk

    - increased vitamin A, C, D, E, niacin

; cow's milk

    - increased vitamin B1, 2, 6, 12, vitamin K

    - *vitamin C, D부족

Bacterial Content

; 87 Good Culture Media For Pathogenic Bacteria

  - strept.ds

    - diphteria

    - typhoid fever        

    - salmonellosis

  - tuberculosis         

    - brucellosis

Digestibility

# 82 reducing methods for cow's milk curd

  ; boiling

    ; heating required in evaporation

    ; addition of acid or alkali

    ; homogenization

Milk Used In Formulas

Raw Milk

Pasteurized Milk

; 63 30min or 72 15sec rapid cooling to 65or 60

Homogenized Milk

; smaller particle less tough curd

Evaporated Milk(탈수유)

# 장점

    almost universal availability

    unexposed can 수개월 지속 가능 without refrigeration

    fat homogenization

    lactalbumin : less allergenic

    casein curd : smaller softer

    higher conc : 44Kcal/oz

           - 실지로는 *40kcal/oz(140kcal/100ml)

    sugar : unchanged

    vit D 10ug보강

Prepared milk (특수 조제 분유)

  low electrolyte : CHF, nephrogenic DI, marginal renal function 사용

Condensed milk

  1:10-14 dilution

Dried Whole Milk

Dried Skim Milk (탈지유)

  non fat skim milk (fat 0.5%)

  half fat skim milk (fat 1.5%) *

) fat intolerance 사용

) calori 비해 high protein mineral : dehydration

) vit D 보강 (-)*

Acid And Fermented Milk

Goat's Milk

) Na, vit D, Fe, Folic acid

    megaloblastic anemia

) K, Cl, linoleic acid, arachidonic acid

) brucellosis위험성 (+)

Milk Protein

Milk Substitutes Hypoallergenic Milks

) evaporated goat's milk

) amino acid mixture (casein or whey hydrolysate)

) soybeans

Filled And Imitation Milks

Elemental Dietary Substitutes For Milk

Ix    ) intraotable diarrhea

      ) IBD reducing stooling

      ) maximal use of short bowel seg. after surgery

      ) major bowel surgery전후에 bulk bacterial content감소

          시키면서 very ill pt에서 (+) nitrogen balance유지

Milk Formulas

; *20kcal/oz(70kcal/100ml)

; calorie requirement

; fluid requirements

--> *한글판 정리 3-4(p74)

★표3-5(p75)

; *하루 총량은 1000ml 넘지 않도록 한다.

44.3 Other Foods

Vitamins

; vitamin A

  - 1500~2000 IU/day

    - vitamin D 같이 준다.

; vitamin C

    - 50mg

; vitamin D

    - *10ug (400IU)/day

    - *beginning at 2wk

; fluoride

   3-6(p76)

Iron

; *food rich in iron이라 하여도 less available than breast milk

; iron fortified milk formula or medical iron (*2mg/kg upto 15mg/24hr)

    - *effective way to prevent iron deficiency

    - *beginning at 6wk

Solid Foods

; *4-6mo, 체중 6-7kg 시작

# 93 기본 원칙

    ; 이유초기에는 철분이 함유된 곡식을 이용하여 미음같은 반유동식을 숟가락으로 시도한다. 이유중기에는 암죽, 두부같은 부드러운 고형식, 이유후기에는 죽밥 등의 고형식으로 진행

    ; 시간을 정해놓고 주되, 처음에는 오전 10시경이 좋다.

    ; 처음에는 소량으로 시작하여 한번에 한가지씩 준다

    ; * 1-2주마다 한가지씩 첨가하되, 설사,구토,피부발진이 나타나면 중지시킨다.

    ; *수유전에 준다.

3-7(p77)

Cereals

; iron, vitamin B complex포함

Vegetable

; good soources of iron & other minerals, B-complex

; 7mo

Meat, Eggs, And Starchy Foods

; 6mo

44.4 First-Year Feeding Problems

Underfeeding

 suggested by restlessness, crying, failure to wt.gain

 고려되야 할점

   ) frequency

   ) mechanics of feeding

   ) size of hole in nipple

   ) air eructation adequacy

   ) abn' l infant-mother bonding

   ) systemic ds in baby

 Sx

    constipation, failure to sleep, irritability, excessive crying,

    poor wt. gain

Overfeeding

  regurgitation vomiting frequent Sx

Regurgitation Vomiting

; first 6mo까지는 normal

; 87 Regurgitation Reducing Methods

    - adequate eructation of swallowed air during after eating

    - gentle handling

  - avoiding emotional conflict

    - Rt. side for a nap

    - head up position

; *common during first 4-6mo

Loose Or Diarrheal Stools

; breast feeding

    - *naturally softer than cow’s milk feeding

    - *4-6일째 transitional stage로서 loose, greenish yellow, mucus stool

           / 수일이내에 milk stool 된다.

; 89 Formula Feeding

    - 생후1-2주에 overfeeding으로 발생

    - *too concentrated formula & too high sugar content

    - contamination of food

Constipation

; rectal exam

; 90 원인

    - tight or spastic anal sphincter

    - anal fissure or craks

    - aganglionic magacolon

           / *rectal exam no feces

    - insuff. amount of food fluids

    - *too high fat or protein, deficient in bulk

; Tx

    - adding or increasing amounts of cereal, vegetables, fruits

    - prune juice

    - *enema, suppositories never be more than temporary measures

    - milk of mgnesia in dose of 1-2 teaspoonfuls

90 Colic

; *Sx complex of paroxysmal abd. pain, intestinal origin, severe crying

; usually within 3mo

# clinical manifestation

    ; suddenly loud cry

    ; paroxysm for several hrs

    ; flushed face circum oral pallor

  ; distended, tense abdomen

  ; cold feet, clenched hand

  ; *terminate only when infant exhaused & feces, flatus passage

# DDx

    ; intussusception, strangulated hernia, hair in eye, otitis, pyelonephritis

# 86 Tx

    ; holding upright or hot water bottle or heating pad

    ; passage of flatus or feces spontaneously

    ; expulsion of a suppository

    ; enema

    ; sedation

    ; improving feeding technique

44.5 Feeding During Second Year Of Life

Reduced Calorie Intake

Self Selection Of Diet

Self Feeding By Infants

    ) 6mo : bottle hold

      ) 8-9mo : cup hold 

      ) 10-12mo : spoon

 

  baby-bottle synd : sleep bottle of formula or water sucking

                      deciduous teeth enamel erosion 관계

  nutritional requirments

      IN : 110 Kcal/Kg

      15yr : 50 Kcal/Kg

Daily Basic Diet

Eating Habits

# 87 2-5 feeding difficulty

    ; excessive parental insistence & subsequent anxiety when child dose not confirm arbitrary standard

    ; undue mealtime stress

    ; too much confusion at mealtime

  ; insufficient time for eating

  ; food dislikes of other memb. of family

    ; poor prepared & unattractively served food

; *comfortable chair of proper height with a food-set 중요

Snack Between Meats

Vegetarian Diet

1) 특징   ) faster GT transit time

          ) bulkier stool

          ) low serum cholesterol

          ) less diverticulitis appendicitis

2) vegans ( egg or milk 먹지않는 채식주의 )

    ; *vit B12 deficiency

           --> *methylmalonic acidemia

    ; trace mineral defi.

Chapter 45. Nutritional Disorders

45.1 Malnutrition

# 87,89 Diagnosis

  accurate dietary history

  evaluation of present deviations from average Ht, Wt, HC, past rates of growth

  comparative measurements of mid arm circum skin fold thickness

  chemical other test

; skin fold thickness

    --> protein-calorie malnutrition

; midarm muscle circum. (cm) = arm circ. (cm) - (skin fold thickness ×3.14)

; lean body mass

    - 24hr creatinine excretion으로 계산

# *Protein Reserve평가

    ; S-albumin, rapid turnover protein

           - Rapid Turnover Protein

                   / transthyretin :12hr half-life

                   / prealbumin : 1.9days half-life

                   / transferrin : 8 days half-life

# *Severe Malnourished child

  hydroxyproline excretion

  3-methylhistidine excretion

  easily plucked hair

# 83,85 Immunologic Insuff. In Chronic Malnutrition평가

  total lymphocyte < 1500/m3

  anergy to skin test antigens

      ) streptokinsase-streptodornase

      ) candida

      ) mumps

      ) tuberculin

Marasmus (Infantile Atrophy, Inanition, Athrepsia)

 1) Eti.     inadequate caloric intake

 2) Clin.

      failure to Wt. gain, emaciation, loss of skin tugor

      distended abdomen, atrophy of m., hypotonia

      constipation, stravation type diarrhea

86,97 Protein-Calorie Malnutrition (Kwashiorkor, Protein-Calorie Malnutrition)

Kwashiorkor

    ; clinical syndrome resulting from sever defici. of protein inadeq. calorie intake

    ; deposed child

           - no longer suckled

    ; *from early infant to 5yr, usually after weaning from breast

Etiology

; *insufficient intake of protein of good biologic value

; causes

    absorption of protein in chr. diarr. state장애

    abn. loss of protein in proteinuria (nephrosis)

    infection

    hm. or burn

    failure of protein synthesis (chronic liver ds.)

Clinical Manifestation

early

    : lethargy, apathy, irritability

    : edema

advanced

    : inadequate growth, lack of stamina, loss of muscular tissue, infection, edema

*secondary immunodeficiency : measles

*Hepatomegaly, fatty infiltration

renal plasma flow, GFR, renal tubular function

*dermatitis : common

    - irritated area : skin darkening, sunlight exposed area darkening (-)

         cf. Pellagra에서는 (+)

thin hair

    hypochromotrichia : dyspig.으로 gray or red hair color

infection parasitic infestation

weak, thin, atrophic m.

mental change, irritability, apathy

Laboratory data

S-lab. : 특징적

Ketonuria : 초기 (+), 후기에는 소실

low blood blucose : GTT diabetic type

u-hydroxyproline to creatinine excretion

plasma essential aa., aminoaciduria

K, Mg defi.

S-cholest.

S-amylase, lipase, esterase, cholinesterase, transaminase, ALP

anemia : micro, normo, macrocytic

delayed bone growth

GH secretion ↑가능

Differential Diagnosis

Prevention

Treatment

immediate Tx of acute problem

    severe diarrhea, renal failure, shock

missing untrient replacement

mod. or severe dehydration

    eye sign of vit.A def., severe anemia Tx

severe dehydration IV fluid

    불가시 rapid intraosseous or intraperitoneal infusion of

                  70ml/Kg, ½ Ringerlactate solution

parenteral AB for 5-10 ds

dehydration 교정시 milk feeding : small, frequent dilute

skim milk, casein hydrolysate, synthetic aa. mixture

impaired glucose tolerance : 250ug chromium chloride

mental, physical retardation : permanent

Malnutrition In Children Beyond Infancy

; poor eating habit : 5-6yr.  : parental factor

Protenin Excess

 ** dehydration-protein fever : excessive protein intake

    morbidity : in premature

    hyperammonemia : recovery phase of marasmic pt.

    protein intoxication :  +-- liver ds

                               +-- wt. reducing diet with high protein              

45.2 Obesity(=Overnutrition)

# Definition

    ; excess accumulation of body fat

# Childhood Obesity Characteristics

; not a disease but a symptom complex

; weak asso. to adult obesity

; minority(10-30%) of obese adults

; *not a direct predictor of adult obesity

; greater time interval between onset of obesity and adulthood

    --> decrease probability of adult obesity

; *severe childhood obesity, adolescence onset obesity, preexisting pattern of family obesity

    --> increase probability of adult obesity

# Asso. condition

    ; increased plasma insulin levels, elevated blood lipid & lipoprotein levels(obesity-related adult mobidity)

# Measures for DDx

    ; relative weight, weight-stature indices, body circumference, skinfoldness

    ; BMI

           - useful index

Etiology

; excessive intake of food than massive overeating

  --> energy intake exceedis expenditure

    --> positive energy balances

    --> increase in number or size of fat cells, adipocytes

; hyperinsulinism

    --> decrease lipolysis & increase fat synthesis and uptake

Clinical Manifestation

; Three Peak Age

    - in 1yr : *frequently

    - 5-6yr  

    - during adolescence

; *taller & advanced bone age

; pendulous abdomen & white or purple striae

; sexual development

    - *normal or maybe advanced

; imbedded penis in pubic fat

; obesity greater in upper arm & thigh

; relative small hand

; genu valgum

; psychologic disturbance

    - emotional problems

Diagnosis

# 97 Screening for obesity ; two categories

1. adolescents with BMIs at the 95th percentile or more for age and sex

          or whose BMIs are more than 30(whichever is smaller)

    --> consider overweight

    --> definite medical evaluation

2. adolescents whose BMIs at the 85th percentile or more but less than 95th percentile

           or equals to 30(whichever is smaller)

    --> second levels of screening

# Second level screening(5 areas)

    1) Family Hx ; cardiovascular disease, parental elevated total cholesterol level, DM, parental obesity

    2) Blood pressure ; elevated BP

    3) *Total cholesterol ; more than 5.2mmol(200mg/dl)

    4) Large annual incremental increase in BMI ; over 2 units than previous year

    5) Concern about weight ; psychologic, emotional

           --> one or more

           --> medical evalution

# Supplemental consideration

    ; triceps skinfold thickness measurements more than 85th percentile for age and sex

Differential Diagnosis

Table 45-1 Differential Diagnosis of childhood obesity

Complication

Table 45-2 Repoted complication of childhood obesity

# Pickwickian synd.

    ; obesity 인해 *severe cardioresp. distress with alv. hypoventilation, decrease pul, tidal, expiratory reserve volume

    ; polycythemia, hypoxemia, cardiac enlargement, congestive heart failure, somnolence

    ; *high concentrated O2 is dangerous

           - respiration depend solely on chemoreceptor stimulation

Prevention Treantment

# Infancy

    ; feeding shortly after birth

    ; food only at signs of hunger in 1st yr

    ; avoiding cueing by showing atrractive foods

    ; regimening feeding times by the clock

    ; teaching child to eat only when hungry

# childhood

    1) modification of diet and caloric content

    2) definition and utilization of appropriate exercise programs

    3) behavior modification for the child

    4) involvement of family in therapy

    ; vitamin D supplement

    ; psychologic support

Prognosis  

    ; high rate of relapse at 4-10yr

45.3 Vitamins Deficiencies And Excesses

# toxicity : fat soluble vit excess > water soluble vit

Table 45-4

Vit.A Deficiency

       ** carotenemia : sclera (not yellow)

              liver ds.

              DM

              hypothyroidism

              cong. absence of enz. (Provit Acarotenoids)

Etiology

    deficient diet : 2-3세에 많다.

# Inadequate Intestinal Absorption

  ; chronic intestinal ds.  

    ; celiac ds

  ; hepatic panc. ds    

    ; IDA

  ; chr. inf. ds            

    ; *chronic ingestion of mineral oil

# *low intake of dietary fat

# increased vit A excretion

  ; cancer     

    ; urinary tr.ds     

    ; chr. inf ds.

# low protein intake

Pathology

# Role Of Vitamin A

    ; keratinization, cornification, bone metabolism, placental development, growth, spermatogenesis, mucus production

# Changes in Epithelium

    ; *hyperkeratosis, formation of stratified, cornified, squamous epithelium

Clinical Manifestation

# ocular lesion

    ; insidious

    ; night blindness

           - initially due to involvement of post. segment of eye

    ; drying of conjunctiva(xerosis conjunctivae) cornea(xerosis corneae)

           - later sign

           --> *wrinkling clouding of cornea : keratomalacia

    ; *dry, silver gray plaques on bulbar conjunctiva ( Bitot spot )

    ; follicular hyperkeratosis

    ; photophobia

# retardation of mental, physical growth, apathy

# anemia with or without hepatosplenomegaly

# dry scaly skin follicular hyperkeratosis

 cornified vaginal epithelium

epithelial metaplasia of urinary tract

  pyuria hematuria

 IICP

 hydrocephalus

Diagnosis

    dark adaptation test : xerosis conjunctiva

    standard absorption test for vit A

    plasma vit A (slow), carotene (rapid)

Prevention

    infant : 500ug/day

    children adult : 600-1500ug

Treatment

    latent : *1500 ug vit A

    xerophthalmia : * 1500 ug/Kg/24hr for 5 day

                      * 7500 ug 1M daily until recovery

Hypervitaminosis A

# Acute Hypervitaminosis A

    ; 10 ug이상 먹은 경우 ( 30 IU )

  ; *N/V, drowsiness, bulging fontanel, diplopia, papilledema, cranial n.palsy, pseudotumor cerebri

# Chronic Hypervitaminosis A

    ; anorexia, pruritus, wt.gain (-)

    ; *irritability, limited motion, tender swelling of bone

    ; *alopecia, seborrheic skin, fissure on mouth corner

    ; *IICP, craniotabes

    ; hepatomegaly

  ; desquamation of palm sole

# hyperostosis of long bone middle shaft

# 96 severe cong. malformation

  ; acne치료위한 large amount retinoids먹은 mother infant

cortical hyperostosis DDx

   ) Hx

   ) vit A

   ) hyperca, liver cirrhosis가능

Vit.B Complex Defic.

Thiamine Defic. (Beriberi )

Etiology

    function

        coenz. in CHO metabolism

        Ach생성에 관여 : 부족시 impaired n. conuction

        coenz in transketolation decarboxylation of α-keto acid

    Eti.  +-- megaloblastic anemia

             +-- MSUD         

Pathology

     site : heart, periph. n., subcut.tissue, serous cavity

Clinical Manifestation

# early

    ; fatigue, apathy, irritability, depression, drowsiness, poor mental concentration, anorexia, nausea, abd.discomfort

# Progression

    ; pph neuritis with tingling, burning, paresthesia of toe feet

    ; decreased DTR

    ; loss of vibration sense, tenderness and cramping of leg muscles

    ; CHF

    ; psychic disturbance

; ptosis of eyelids and atrophy of optic nerve

; *hoarseness due to laryngeal n. paralysis  

    - chracteristics

; *muscle atrophy & tenderness of nerve trunks

    --> ataxia, loss of coordination, loss of deep sensation

    late    ) IICP

               ) meningismus

               ) coma

    dry beriberi

         plump, pale, flabby, listless dyspneic,

         rapid heart rate, enlarged liver

    wet beriberi

        undernourish, pale, edema, waxy skin

    cardiac sign : cyanosis, dyspnea - 처음

        tachycardia, hepatomegaly, consciousness loss, convulsion

        ECG   +--) QT prolongation

              |  ) inversion of T

              +--) low voltage

Diagnosis

    RBC transketolase

    blood or urine glyoxylate

    thiamine oral loading excretion

 *  clinical response to adm. of thiamine : best

Treatment

      breast fed   +-- mother : 50 mg

                      +-- CH    : 10 mg이상  

Riboflavin Deficiency (Ariboflavinosis)

    - Function

      electron transport 중요

      light adapation

      pyridoxine pyridoxal phosphate

Etiology

    inadequate intake

    faulty abs. ( biliary atresia, hepatitis )

    probenecid, phenothiazine, oral contraceptives

    photoTx B₂파괴

Clinical Manifestation

    ; cheilosis, glossitis, keratitis, conjunctivitis, photophobia, lacrimation, marked corneal vascularization, seborrheic dermatitis

    ; normocytic, normochromic anemia with BM hypoplasia

Diagnosis

    ; U-riboflavin excretion < 30 ug/24hr

Prevention

    ; milk, egg, leafy vegetable, lean meals

Treatment

    ; oral riboflavin 3-10 mg daily

         no response 2mg im 3x daily

Niacin Deficiency ( Pellagra )

Etiology

# Function

  ; electron transfer & glycolysis 중요한 NAD(nicotinamide adenine dinucleotide), NADP(nicotineamide denine dinucleotide phophate) 구성성분

; dietary tryptophan

    - partial substitute of niacin

    - *milk, egg : high tryptophan, good preventive food

Clinical Manifestation

# prodromal Sx

    ; anorexia, lassitude, weakness, burning sense, numbness, dizziness

# Triad : 3D

    ; dermatitis, diarrhea, dementia

    ; appear after long periods

# cutanous Sx

    ; *characeristics

    ; suddenly or insidiously

    ; *elicited by irritants, particularly by intense sunlight

    ; symmetric erythma of exposed area

           --> shraply demarcated from healthy skin

                   / *pellagrous glove & boot

           / *Casal necklace

    ; in some, vesicle & bullae

    ; in others, suppuration beneath the scaly, crused epidermis

    ; pigmentation after healing

# nervous Sx

        depression, disorientation, insomnia, delirium

Diagnosis

    glossitis, Gl Sx, symm.dermatitis

    rapid clinical response to niacin

Treatment

    50-300 mg niacin diet daily

    large dose cholestatic J & hepatotoxicity

    active phase sun-exposure avoid

Pyridoxine (B6) Deficiency

# vit B6

    ; pyridoxal, pyridoxine, pyridoxamine Pyridoxal-5-phosphate

                decarboxylation & transamination of a.a. coenz.

Etiology

    human & cow's milk, cereals

    Vit B6 dependency syndrome

        ) B6 dependent convulsion

        ) B6 responsive anemia

        ) xanthurenic aciduria

        ) cystathioninuria

        ) homocystinuria

    vit B6 요구량 증가하는 경우

        ) INH        ) pregnancy      ) penicillamine

        ) hydralazine           ) oral prog-estrogen contraceptives

Clinical Manifestation

# 4 Clinical Disturbances

    ; convulsion in infants 

    ; peripheral neuritis

    ; dermatitis               

    ; anemia

# convulsion from B6 dependency

    ; birth-6mo 동안

  ; myoclonic with hypsarrhythmic pattern in EEG

# skin lesions

    ; *cheilosis, glossitis, seborrhea around the eyes, nose, mouth

# vit B dependent anemia

  ; microcytic hypochromic

  ; failure of iron utilization for Hgb synthesis

# Xanthurenic aciduria

# Cystathioninuria

# Homocystinuria

Diagnosis

    infantile seizure hypoCa, hypoglycemia, inf.아니면

      100mg of pyridoxine im하여 seizure control

    Tryptophan loading test

  * erythrocyte glutamic pyruvic transaminase

Prevention

     INH 사용시 daily pyridoxine

     daily intake IN 0.3-0.5 mg,  CH 0.5-1.5 mg,  adult 1.5-2.0 mg

Treatment

    100 mg im at convulsion

    dependency 2-10mg im or 10-100mg p.o. daily

Toxicity

    ; *excessive sensory neuropathy

Biotin

      biotin antagonist avidin투여시 발생

      brawny dermatitis, somnolence, hallucination

      hyperesthesia with organic acids

Vitamin C Deficiency(Scurvy)

# Function

  ; essential for formation of collagen

  transient tyrosinemia ( function in Ez activity )

      : LBW, FT with high protein diet common  Tx : vit. C

    defi. megaloblastic anemia 원인

      : folic acid conversion방해

Etiology

  *  vit. C 요구량 증가하는 경우

       ) febrile illness ( inf. & diarr. )    ) iron defi.

       ) cold exposure                   ) protein depletion

       ) smoking

Pathology

    collagen & chondroitin sulfate 형성 (-)

    hemorrhage, loosening of teeth

    loose periosteum & subperiosteal hm

    skeletal m, degeneration, cardiac hypertrophy, BM depression

Clinical Manifestation

; *rare in newborn, mostely 6-24mo

; irritability, tachypnea, digestive disturbance, loss of appetite

; *general tenderness

    - esp. leg

    - *pseudoparalysis

    - frog position

; edematous swelling along shafts of legs

; *subperiosteal hemorrhage is palpated at the end of femur

; gum change : bluish purple, spongy swelling

; *scorbutic rosary at costochondral junction & sternal depression

    - rachitic rosary 비해 sharper angulation

  - softend epiphysis widening 의한 것이 아니고 subluxation of sternal plate때문

; petechial hm., hematuria, melena, anemia

; low grade fever, delayed wound healing

; swollen jt. & follicular hyperkeratosis

; sicca synd. of Sjogren     

    - collagen disorder

  - xerostomia, keratoconj.sicca

  - sal.gl. enlargement

Roentgenographic Manifestations

# Knee Jt

    ; *great changes

# early stage : simple atrophy of bone유사

      ) ground glass app.

      ) pencil point thin cortex

      ) white line of Fraenkel : zone of well calcified cart.

      ) white ring

      ) zone of rarefaction : prox. & parallel to white line

      ) spur : lat. prolongation of white line

      ) epiphyseal separation

      ) healing elevated periosteum calcified

          dumbbell or club shape

Diagnosis

    clinical

    X-ray finding of long bone

    Hx of poor intake of vit C

    Lab. test

       ) fasting plasma vit C level > 0.6 mg% R/O

       ) white cell-PLT layer  (buffy layer) of centrifuged blood

           ascorbic acid content

       ) sat. of tissue with vit C

       ) nonspecific aminoaciduria

       ) tyrosine loading 미숙아와 유사한 대사물 배설

       ) PT ↑↑

 6) DDx

     arthritis or acrodynia

     rheumatic fever

     suppu. arthritis, osteom.

     pseudoparalysis of syphilis

     poliomyelitis

     H-S purpura, ITP, leukemia, meningitis, nephritis

 7) Prevention

     formula fed 35 mg daily

     lactating mother 100 mg   

     children or adult 45-60mg/24hr

 

 8) Tx

     3-4 oz of orange juice or tomato juice

     100-200 mg of ascorbic acid p.o. or parenteral

Rickets Of Vit D Deficiency

# rickets : failure in mineralization in growing bone    

# osteomalacia :       "              mature bone

# 2 forms of vit D

    vit D ( calciferol ) : irradiated ergosterol dietary or

                             therapeutic vit D          

    vit D     7-dehydrocholesterol in skin : provit. stage

                        UV

                   cholecalciferol

                       

                   25 OH-cholecalciferol in liver

                        

                   1, 25 (OH)cholecalciferol in kidney

# 1, 25 (OH)2 cholecalciferol기능

   intestinal absorption of Ca & P

   kidney phosphorus reabsorption

   bone dissolution & mineralization

 Predisposition to vit D defic.

   lack of dietary vit D

   lack of exposure to UV

   rapid growth ( LBWI, adol )

   abs.장애 ( celiac ds, steatorrhea, pancreatitis, CF ) 

   anticonvulsant (Pb, phenytoin)

   glucocorticoid

   black children

Pathology

     bone growth 관련 factors

         ) phosphorus      ) Ca      ) fluoride      ) GH

     Lab

          ) inorganic P : 1.5-3.5 mg/dl (N: 4.5-6.5)

          ) S-Ca : usually n (PTH)

          ) S-ALP: 500 IU/dl (n : 200)

   *  Ca흡수 ↑경우

           ) dietary Ca : P = 2 : 1 (P↑시 Ca흡수↓)

           ) acidity of intestinal content

           ) dietary suger lactose 경우

   *  Ca흡수 ↓경우

           ) EDTA Phytate of cereals

           ) dietary iron

           ) high stearic & palmitic acid

Clinical Manifestation

# osseous changes

    ; recognized after several months of vitamin D deficiency

    ; *4 Mo-2 사이 호발

         -  osteomalacia mother breast feeding 2mo이내에도 발생가능

    ; Florid Rickets

           - *1세말-2

# Early Signs

    ; craniotabes

           - *disappear before the end of 1yr

  ; rachitic rosary

  ; thickening of wrist & ankle

  ; increased sweating ( esp. head )

Head

: craniotabes ( 1세말에 소실)

           large ant.fontanel & delayed closure

           caput quadratum

Thorax

: rachitic rosary Harrison groove  pigeon chest

Spinal Column

: kyphoscoliosis

Pelvis

: narrow entrance by ant. projection of promontary

Extremity

: epiphyseal flaring & widening of ankle & wrist

             * late bow leg, knock knee

               coxa vara, greenstick Fx, rachitic dwarfism

Ligaments

: laxation

Muscles

 tone : Potbelly    

Diagnosis

     Hx of inadequate intake & Sx

     Lab       ) S-Ca : n or

                  ) S-P < 4mg/dl

                  ) S-ALP

                * ) urinary cAMP

                  ) serum 25-hydroxyucholecalciferol

   * X-ray

         A. active R. : *wrist-best for early Dx

             ) distal end : widened, cupping, frayed

             ) distal end of U & R metacarpal bone 가격↑

                 due to not-calcified large rachitic mataphysis

             ) decreased shaft density, prominent trabeculae

      *  B. healing R.

             ) line of preparatory calcif.출혈

             ) shaf zone of preparatory calcif. 으로 grow되어 united

Differential Diagnosis

      craniotabes      ) immediate postnatal period

                          ) hydrocephalus

                          ) osteogenesis imperfecta

      rosary           ) rickets

                          ) scurvy

                          ) chondrodystrophy 

      epiphseal lesion  ) cong. epiphy. dysplasia

                           ) cytomegalic ds

                           ) syphilis

                           ) rubella

                           ) copper deficiency

      bow legs : family Hx

      vit. D resistant R. 

Complication

      resp. inf. ( bronchitis, bronchopn. )

      pul. atelectasis

      IDA & anemia due to inf.

Prevention

      UV exposure

      oral vit. D 10ug or 400 IU/day

Treatment

   · 2-4 wk Tx X-ray 호전

    oral vit D 50-150 ug daily

      1, 25 (OH)cholecalciferol : 0.5-2 ug

    15,000ug vit D single does

    **  장점  ) more rapid healing

              ) earlier DDx from vit. D resistant R

              ) less dependent on parent for daily adm. of vit. D

              * no responce : vit D RR

             complete healing vit. D 10 ug/daily

Tetany Of Vit D Deficiency

  ** -age : 4mo-3yr

     - S-Ca 7-7.5 mg/dl ↓시 muscular irritability

     - clinical

         ) latent tetany ( S-Ca < 7-7.5 mg/dl )

              : aSx, Chvostek, Trousseau, Erb procedure 의해 elicited

         ) manifest tetany ( < 7 mg/dl )

              : carpopedal spasm, laryngospasm, convulsion

     -  Dx

         rickets + low S-Ca + tetany Sx

     -  DDx

        hypoparathyroidism, hypoMg, phenothiazine ingestion

     -  Tx 

          ) 1-2% sol. CaClin milk

          ) 5-10ml of 10% calcium gluconate

          ) calcium lactate : 10-12 g/day for 10 days

Hypervitaminosis D

      - idiopathic hypercalcemia 증세 비슷

      - large intake for 1-3mo

      -  sx : hypotonia, anorexia, pallor, proteinuria,

            irritability, constipation, polydipsia, polydipsia, polyuria

      - X-ray of long bone : metastatic calcification + generalized osteoporosis   

    *  Tx    ) vit D stop, Ca intake

             ) aluminum hydroxide : po

             ) cortisone

             ) sodium versenate

Vitamin E Deficiency

; vit E (α-tocopherol) : fat soluble antioxidant

 경우  **) malabs. : CF, acanthocytosis

         ) diets high in unsaturated F, A,

         ) excessive iron adm.

Clinical Manifestation

; *creatinuria, ceroid depostion in smooth muscle, focal necrosis of striated muscle, muscle weakness

; cause of anemia in Kwashiorkor

; *hemolytic anemia of premature in 6-10wk

; *thrombocytosis, increase in platelet adlhesiveness

; denegerative, reversible, neurologic syndrome

    - *cerebellar ataxia, peripheral neuropathy, post. column abnormalities

Diagnosis

Prevention

   ) 최소 하루 요구량 0.7mg/g of unsat.fat in diet

   ) premature 15-25 IU/24hr 투여

Vitamin K Deficiency

 naphthoquinone으로 oxidative phosphorylation 관여

# vit K dependent factor

   ) prothrombin (II)

   ) proconvertin (VII)

   ) plasma thromboplastin component (IX)

   ) Stuart-Prower factor (X)

 natural vit K : vit K(2-methyl-3-phytyl-1,4-naphthoquinone)

 cow milk > human milk

Clinical Manifestation

 Eti.

   ) abs. & utilization of fat 장애

   ) intestinal synthesis 장애 : prolonged AB

   ) diarrhea esp. breast fed

   ) liver ds

 * ) dicumarol : liver에서 vit K 이용 장애로 hypoprothrombinemia

       salicylic acid : degradation product of dicumarol

 Treatment

; mild prothrombin deficiency

    - vit K 2mg po

; severe prothrombin deficiency & hemorrhagic manifestations

    - vit K, 5mg parenteral

# *large dose of synthetic vit K not vitamin K1

    ; hyperbilirubinemia, kernicterus in G-6-PD defi. or premature