Nutrition in Early Childhood

1. Nutrition in Early Childhood Dr. Sheela Sharma MBBS, MD (Obstetrics and Gynaecology)

2. ENERGY 5.1. ENERGY • Children need energy for deposition of tissues. • Energy is also required for physical activity of daily life. • When individual is in a state of complete rest, energy is expended • for basal metabolism. Carbohydrates, fats and proteins in • the food are the chief energy yielding nutrients and are • aptly labelled as macronutrients. Minerals and vitamins are • non energy yielding nutrients but most essential for cell • function. Because of their requirement in smaller quantities, • these are known as micronutrients. The energy obtained • from the food is usually expressed in terms of • Thermo chemical kilocalories. These are often loosely • referred to as kilocalories or simply Calories.

3. ENERGY • One gram of carbohydrate or 1 gram of protein provides 4 kcal or 16.7 KJ; while 1 gm of fat releases 9 kcal or 37.7 KJ. • Infants require (up to 1 year of age) on an av 103 kcal /kg/day.

4. Calorie requrement in Boys and Girls • Age boys girls • 1 to 2 years 1200 1140 • 2 to 3 years 1410 1310 • 3to4 year s 1560 1440 • 4to5years 1690 1540 • 5to6years 1810 1630 • 6 to 7 years 1900 1700 • lm8years 1990 1770 • 8 to 9 years 2070 1830 • 9 to 10 years 2150 1880 • 10 to 11 years 2140 1910 • 11 to 12 years 2240 1980 • 12m 13 years 2310 2050 • 13 to 14 years 2440 2120 • 14 to 15 years 2590 2160 • 15 to 16 years 2700 2140 • 16 to 17 years 2800 2130 • 17 to 18 years 2870 2140

5. Proteins • Protein is the second most abundant substance in the body, • next to water. These are made up of twenty different amino • aclds. The proteins differ in their arrangement and quantity • of amino acids. A few amino acids can be adequately • synthesized in the body (non-essential amino acids), while • others must be supplied in the diet (essential amino acids). • Essential amino acids include leucine, isoleucine, lysine, • methionine, phenylalanine. threonine, tryptophan and val~r;. • Histidine and arginine are essential during infancy because • the rate of their synthesis is inadequate for sustaining the • growth.

6. Proteins (contd…) • Functions of protein. (i) Protein helps the child to • mw as the constituent amino acids are necessary /B , . . . for the synthes~osftlssues m the body.( ii) Protein is essential for • the formation of digestive juices. hormones, plasma • proteins, enzymes, vitamins and hernoglobin etc. (iii) • Proteins also act as powerful buffers to maintain acid base • equilibrium in the body. (iv) It is also a source of energy • for the body. • Excess protein, not used for building tissues or • providing energy, is convened by the liver in to fat and • stored in body tissues.

7. Proteins (contd…) • Requirements: Protein requirements of children given table (next slide). Indian estimates are higher as these are • calculatedin terms of the proteins actually present in Indian • diets. An average adult requires 1.0 g/kg body weight of • protein daily. During later half of pregnancy, an additional • protein intake of 15 g per day is required. During lactation, • an additional daily intake of 25 g during the fist six months

8. Protein requirement table: • 2-3 months 2.25 • 3 4 months 1.82 • 4-5 months 1.47 • 5-5 months 1.34 • 6 9 months 1.30 • 9-12 months 1.25 • 1-2 years 1.15 • 2-3 years 1.25 • 3 4 years 1.13 • 4 – yeas 1.09 • 5-5 years 1.06 • 6 9 yeaan 1.0 • 10-12 years 1.48 • 13-15 years 1.0

9. NPU • These protein requirements are given in terms of mixed vegetable protein contained in Indian diets, the net protein utilization • (NPU) of which is assumed to be 65. If the protein in the • diet is obtained from animal sources like egg, meat, fish or • milk, lower intake of protein will usually be sufficient. • The NPU of a protein is the proportion of ingested nitrogen • that is retained in the body under specified conditions. NPU • is a combined measure of digestibility and the efficiency • of utilization of the absorbed amino acids.

10. Protein Quality • Protein Quality • A complete protein contains all of the essential amino acids • in relatively the same amount as humans require for • maintenance of good health and optimal growth. Protein • in the food is obtained either from the animal or vegetable • sources. The proteins of animal origin generally have a • higher content of essential amino acids. 'These are, • therefore, classified as biologically complete protein. • Proteins from vegetable sources are often biologically • incomplete, as these usually lack one or more of the • essential amino acids. However, proteins of !,egetable origin • may be used together in a judicious combination so that • limiting essential amino acidin one of these is compensated • for by an excess of that amino acid in the complementing • protein. Proteins of rice and potato are considered good • vegetable proteins.

11. Protein Quality • A high quality protein should be complete as well as • digestible. This is measured best by the biological value of • the protein. Biological value (BV) is calculated as thc • fraction of absorbed nitrogen retained in the body for • growth or maintenance. Egg protein is considered a • referenceprotein in this context as it is complete and well • digested. The biological value of egg protein is 100. BV of • milk, rice and fish are 75, 67 and 75 respectively. The • combination of vegetable proteins may provide all the • essential amino acids as in the reference protein. For • example protein from !egumes has an excess of • which can compensate for the low lysine content of wheat • protein.

12. LIPIDS • Lipids are a concentrated source of energy and provide insulation to the body. These also act as carriers for fat soluble vitamins. • A healthy European or American obtains 35 to 40 percent of his caloric needs from fats. Diet of persons in the less affluent societies may provide less than 10 percent of calories from fat. Lipids include triglycerides

13. LIPIDS (contd…) • LIPIDS: TRIGLYCERIDES (FATS AND OILS); PHOSPHOLIPIDS(LECITHIN); STEROLS(CHOLESTEROLS) • TRIGLYCERIDES: SATURATED FA (animal sources + COCONUT: solid at room temp); UNSATURATED FATTY ACIDS (vegetable nuts+ seed sources: liquid at room temp); • UNSATURATED FA: Mono saturated FA (oleic acis); PUFA;

14. PUFA • PUFA: OMEGA 6 FA (linoleic acid + arachidonic acid); Omega 3 FA (linolenic acid+EPA+DHA); • PUFA can not be adequately synthesized in the body hence should be supplemented in the diet;

15. FUNCTIONS OF PUFA • Important component of cell membranes; • They lower the blood cholesterol and triglyceride concentration.

16. LIPIDS (CONTD…) • Deficiency of EFA in the diet may result in growth retardation, reproductive failure, skin disorders, increased susceptibility to infections, decreased myocardial contractility, renal hypetension and hemolysis. • Selective deficiency of omega-6 fatty acids leads to skin changes • while lack of omega-3 results in neurological and visual symptoms.

17. LIPIDS (CONTD…) Lecithin is the most important phospho lipid. It is a major constituent of cell membranes. Lecithins are not essential in diet as they can be synthesized in the body by liver. Phospholipids also act as emulsifying agents.

18. LIPIDS (CONTD…) • cho l e s t e r o l is a lipid essential for good health. • Cholesterol deficiency does not usually occur as it can • also be synthesized in the human body in the liver from • carbohydrates, protein or fat. It is an important constituent • of cell membrane. Cholesterol can be transformed into • related compounds like hormones, bile and vitamin D. • Cholesterol is found only in animal foods including eggs, • liver, kidney, cheese and ghee. EPA are essential for • transport and breakdown of cholesterol. Excess cholesterol • is stored and may lead to atherosclerosis.

19. LIPIDS (CONTD…) • Recommended intake. Total fat intake should provide • no more than 30 percent of daily energy intake. Saturated • fats should not exceed 10 percent of total fat intake. A • minimum of 3 percent of energy should be derived from • linoleic and 0.3 percent from linolenic acid. Cholesterol • intake should be limited to a maximum of 300 mg per day. • Excess fat contributes to obesity, NIDDM, cancer, • hypertension and atherosclerosis; it is better to avoid excess of total fats, saturated fats and cholesterol, in that order of priority.

20. LIPIDS (CONTD…) • LIPIDS in circulation are bound with proteins that serve • as transport vehicles. The lipid-protein complex is called • lipoprotein. Four main types of lipoproteins are formed • differing in their size and density. These are known as • chylomicrons (rich in triglycerides), high density • Lipoproteins (H DL), low density lipoprotein (LDL) and very • low density lipoprotein (VLDL). Lipoproteins with a higher • percentage of lipids have a lower density i.e., LDL and • VLDL; those with a higher percentage of proteins have a • higher density (HDL). Composition of these lipoproteins • is depicted in Table 5.3.

21. LIPIDS (CONTD…) • High levels of chylornicrons and LDL are associated • with a higher risk of cardiovascular diseases. HDL is a • protective lipoprotein and high levels tend to protect agalnst • the hem diseases. • Cells all over the body remove fat from the passing by • chylomicrons. Few remnants, that loiter for long, are • removed by the liver. Liver is also an active site of iipid • synthesis. The synthesized lipids are transported as VLDL • to various organs that need them. The body cells remove • triglycerides from the VLDL and convert them to LDL. • Liver cells also have special receptors that remove LDL • fro+ circulation.

22. CARBOHYDRATES • Carbohydrates provide energy, contribute to taste and • texture of foods, preserve foods and are essential for • digestion and assimilation of other foods. They also protect • the proteins from being used for energy. Monosaccharides • (glucose, fructose, galactose, ribose, deoxyribose) and • disaccharides (sucrose, lactose and maltose) are known • as simple carbohydrates while polysaccharides (starch, • glycogen, fiber) are referred to as complex carbohydrates. • Grains are the richest food source of starch. A starch • typically consists of thousands of glucose molecules linked • together. Other important source of starch are legumes • (beans and peas) and tubers (potato, cassava etc.). • Glycogen is a more complex storage form of glucose an6 • is not found in plants. Body converts all carbohydrates • (except those coming from fiber) to glucose. Glucose is • used as a fuel by brain and muscle tissue or convened tc • glycogen and stored by liver and muscles. Excess carbohydrates are converted to fat.

23. CARBOHYDRATES • Carbohydrates constitute 55-60% of total energy intake; and preferably obtained from grains, legumes, vegetables and fruits. Such a diet is lower in fat and energy and higher in fiber, vitamin and minerals. • These diets also contribute to lower rates of under nutrition, obesity, tooth decay, cardiovascular disease and diabetes. • Excessive carbohydrate consumption in form of • concentrated sweets is associated with dental caries. • obesity, ischemic heart diseases and cataract (glucose • cataract ln diabetes, galactose cataract in galactosemia). • Lack of carbohydrates may produce ketosis, loss of • energy, depression and breakdown of body proteins.

24. FIBRE • High fiber diet is advocated for chronic constipation, diabetes, obesity and hypercholesterolemia. • Low fiber diet is particularly useful in irritable bowel syndrome, chronic colitis and partial chronic G1 obstruction.

25. FIBRE • Fiber components include polysaccharides such as • cellulose, hemicellulose, pectins, gums, mucilages and non • polysaccharide lignins. Fibers are considered important • because of their water-holding capacity, bile acid binding • capacity and for the growth of the normal microflora of • the intestines. Water soluble fiber e.g., gums and pectins • help in lowering blood cholesterol and limit glucose • absorption. Fibers insoluble in water result in softening of • stools and acceleration of intestinal transit time.

26. MICRONUTRIENT(S) • INTRODUCTION • micronutrients are nutrients needed in tiny amounts, may, be a few mg or micrograms per day and include various minerals and vitamins. They do not contribute to the energy intake but normal healthy living is not possible without them.

27. MICRONUTRIENT(S) • Micronutrient Deficiency: A Global Issue • Micronutrient malnutrition continues to affect over 2000 • millon people worldwide. There are several reasons for • such deficiencies. The population may be deficient because • have poor access to 111icronutrient rich food due to \ • poverty, defective crop growing pattern, \i" deficient soil quality, inappropriate climate or geographical isolation. • Traditional dietary fads may also hinder intake, absorption • or utilization of micronutrient rich foods.

28. MICRONUTRIENT(S) • Micronutrient deficiency is clinically evident only in the later stage of the disease and therefore may result in grave consequences. The end results of such deficiencies include learning disability, impaired work capacity, increased susceptibility to infections and greater risk of dying. For the nation it means increased investment on health services, inferior economic productivity and poor gains on educational ventures.

29. MICRONUTRIENT(S) • Vitamins • Vitamins are essential for life and maintenance of normal health. These act as cofactor in many enzyme systems and are therefore cardinal for various bodily functions such as energy production, hemopoiesis, reproduction, neurological functions, hydroxylation and synthesis of fats,

30. VITAMINS • Any aberrations in these critica l mechanisms cause profound changes in the nervous system and integrity of skin, mucous membrane, synthesis and repair of connective tissues and drug metabolism.

31. VITAMINS • Vitamins are required in very minute quantities in the • diet. The fetus and the infant get adequate vitamins from • the mother during pregnancy and lactation. Dietary intake • of vitamins may be low or marginal during infancy and • early childhood. There is increased requirement of vitamins • in preterm babies, during post-operative stress, infections • and in some genetic metabolic disorders. Intestinal • absorption of vitamins is impaired in chronic diarrhea, • malabsorption, and bacterial overgrowth in intestines. • Certain drugs may have an adverse effect on the enzyme • systems, which require the vitamin. Thus, these may • inactivate the vitamin and its effects.

32. VITAMINS • \/itamins are classified into two broad groups viz., fatsoluble and the water-soluble vitamins. • Fat-soluble vitamins include vitamin A, vitamin D, vitamin E, and vitamin K. • Vitamin B complex and vitamin C are the water-soluble

33. MINERALS • These are small inorganic elements and are indestructible unlike other major nutrients and vitamins Calcium, phosphorus, potassium, sodium, chloride. magnesium and sulfur are known as macrominerals and are usually required in amounts more than 100 mg per day. as they are present in relatively higher amounts in body tissues.

34. TRACE ELEMENTS • The tern trace is applied to concentrations of element not • excceding 250 micro g per g of matrix. The definitive feature • of a nutritionally significant trace element is either its • essential intervention in physiological processes or its • potential toxicity when present at low concentrations in • tissues, food or drinking water. A WHO expert consultation • has divided nutritionally significant trace elements into three • groups: (i) essential elements such as Iron, Iodine, Zinc, • Selenium, Copper, Molybdenum and Chromium; (ii) • elements which are probably essential, i e . , Manganese, • Silicon, Nickel, Boron and Vanadium; and potentially toxic elements that have essential functions at low levels. F, Pb, Cd, Hg, As, Al, Li, Sb.

35. VITAMIN A DEFICIENCY • Vitainin A deficiency (VAD) results in blinding several • hundred thousand children a year. It is now recognized • not only to harm the eyes but also to increase childhood • and maternal mortality. Globally. 21% ol children have • vitamin A deficiency and suffer increased rates of death from diarrhea, measles and malaria. About 800,000 deaths • In chldren and women of reproductive age are attributable • to vitamin A deficiency which, along with the direct effects • on eye disease, account for 1.8% of global DALYs. • (disability adjusted life yeas). This appears to be lower • than previous estimates, possibly because of vitamin A • supplementation or food fortification programs during the • last decade.

36. VITAMIN A DEFICIENCY • Vitamin A is a subgroup of retinoids exhibiting the biological activity of retinol. Naturally occuring retinoids include retinol (vitamin A alcohol), retinyl ester (vitamin A ester), retinal (vitamin A aldehyde) and retinoic acid (vitamin A acid). Retinoic acid is the most active form of the vitamin.

37. VITAMIN A DEFICIENCY • Physiology. Vitamin A is essential for normal • maintenance and function of body tissues, for vision, • Cellular integrity, immune competence andgmwth. Vitamin • A deficiency is therefore a systemic disease, most specific • effects involving the eye. Vitamin A is also termed as an • anti-infective vitamin. This is attributed to its role in • maintaining integrity of epi thelial tissue for resisting invasion by pathogens and for functional immune response.

38. VITAMIN A SOURCES • Sources. Rich sources of pre-formed vitamin A or retinol are cod liver oil, shark liver oil and liver Moderate sources are butter, ghee (butter oil). and egg yolk. Best source of carotene is red palm oil. • Provitamin A carolenoids are present in good amounts in carrots, green leafy and yellow red vegetables and ripe mangoes.

39. VITAMIN A DEFICIENCY: SUBCLINICAL • Subclinical deficiency. Respiratory system, urinary tract, intestinal epithelium and immune system are affected before the deficiency manifests clinically. • Subclinical vitamin A deficiency contributes to an increased severity of certain infections and an increased risk of dying from these.

40. VITAMIN A DEFICIENCY: Early FEATURES • EARLY features. Defective dark adaptation is the most characteristic early clinical feature. resulting in night blindness.

41. VITAMIN A DEFICIENCY: XEROPHTHALMAI • Prolonged deficiency of VIT A in dlet results in a syndrome of xerophthalmia, especially prevalent in 6-36 month olds. It is often combined with general malnutrition. There is pigmentation of the caruncle with loss of normal lustre and moist appearance of palpebral conjunctiva, which appears dry and wrinkled. Bitot spots appear as chalky grey spots on the temporal side of cornea-scleral junction. Cornea is softened and ulcerated (keratomalacia). Eventually it is infected and perforation of cornea occurs, resulting in opacification and blindness. On fundoscopy, pale yellow spots can be visualised near the course of retina1 vessels and also in the periphery.

42. VITAMIN A DEFICIENCY: OTHER FEATURES • OTHER FEATURES: Skin becomes scay and toad like. Toad skin is now believed to be due to essential fatty acids deficiency. Squamous metaplasia of respiratory mucosa makes these children more prone to respiratory infections. Alterations in mucosa of renal pelvis urinary bladder predispose to formation of renal and , vesical calculi. Atrophy of the germinal epithelium may . interfere with the reproductive functions. Vitamin A : deficiency may rarely lead to hydrocephalus.

43. VITAMIN A DEFICIENCY: • Factors influencing vitamin A status. lntake of < 180 micro g of retinol per day places a person at risk of vitamin A deficiency. Diarrhea. worms an'd other intestinal orders impair vitamin A absorption, while measles, resi r a t o r y tract infections and other febrile illnesses, increase the metabolic demands. PEM interferes with : absorption, storage and utilization of vitamin A. In protein deficiency, RBP is not synthesized in adequate amounts.

44. VITAMIN A DEFICIENCY: • Retinol is actively accumulated in the last trimester of pregnancy. Levels of retinal in the breast milk are almost equal to the concentration of vitamin A in the maternal serum. Preterm infants have lower retinal levels and are at high risk for developing vitamin A deficiency specially at a time when epithelia1 cell function is of greatest significance.

45. TREATING VAD • Specific. Immediately on diagnosis, oral vitamin A is • administered in a dose of 50,000, 1 lakh, and 2 lakh • international units in children aped < 6 months, 6-12 • months, and > 1 year, respectively. The same dose is • repeated next day and 4 weeks later. Parenteral, watersoluble vitamin A administration is recommended (in half >doses suggested above for 6-12 months and Uth in • <6 months of age) in cases with impaired oral intake, • persistent vomiting and severe malabsorption. Oil based • injections should not be used to treat xerophthalmia.

46. PREVENTING VAD • Infants who are not breasrfed should receive a 50,000 IU supplem e n t of vitamin A by 2 months of age (or two doses of 25,000 IU each with I month interval in between) in areas of endemic vitamin A deficiency. Every infant should be administered one dose of I lac units of vitamin A along with measles vaccine at 9 months followed by four more doses of 2 lakh 1U each at 18, 24. 30 and 36 months.

47. IRON DEFICIENCY: ANAEMIA • Iron deficiency affects about two billion people globally. Recent estimates find that Iron deficiency anemia (IDA) is responsible for a fifth of early neonatal mortality and a tenth of maternal mortality. It also affects growth and development, limits the leaming capacity, reduces cognitive development and reduces work capacity of the affected.

48. IRON: SOURCES • Av in liver, kidney, egg yolk, green vegetables, and fruits.

49. IDA: TREATMENT • The optimal dose of elemental iron is 3 -6 mg per kg of body weight given orally in three divided does. With this hemoglobin level should rise by about 0.4 g!dL per day. Iron absorption improves in presence of vitamin C, when given on empty stomach or in between the meals. • The phytates in cereals and phosphates in the milk diminish iron absorption. Therefore, iron should not be given just after the milk-feeds or after food.

50. IDA: TREATMENT • With iron therapy, the activity of iron containing enzymes in the cells improves. The child becomes less irritable and his appetite improves within 24 hours. Initial bone marrow response is observed within 48 hours. Rise ret i c u l o c y t e count occurs by the second to third day. • This is followed by elevation of hemoglobin level. It may take up to two months depending on the severity of anemia. Body iron stores are repleted after correction of the hemoglobin levels.