Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter II.1. Nutrition Overview
Caron M. Hong
February 2003

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This is a 4 month old boy who is not growing well. His birthweight was 3.5 kg and his current weight is 4.0 kg (less than the 5th percentile). Mother states that he drinks 6 ounces of infant formula every 4 hours (six feeding per day). She also feeds him a small amount of rice cereal, but he is having difficulty holding this in his mouth. There is no history of vomiting or diarrhea. He has about 6 wet diapers per day and stools once or twice daily. His review of systems is negative.

Exam: VS T 37.4 (rectal), P 110, R 30, BP 75/55, oxygen saturation 100% in room air. Weight 4.0 kg (less than the 5th percentile), height 57 cm (10th percentile), head circumference 41 cm (40th percentile). He is thin appearing, but not acutely ill. Head is normocephalic. Anterior fontanelle is flat and soft. HEENT is otherwise normal. Heart regular, without murmurs. His lungs are clear. His abdominal exam is normal. His genitalia are normal. His extremities are thin. His visible perfusion is good. Muscle tone and reflexes are normal.

Based on history, his fluid intake is calculated at 270 cc/kg and his caloric intake is calculated at 180 calories/kg, plus additional calories from rice cereal. His maintenance caloric intake should only be 100 cal/kg. Thus, it is estimated that his caloric intake is well in excess of maintenance nutritional requirements and he should be growing better than this. He is hospitalized for evaluation. Admission laboratories including a complete blood count and comprehensive chemistry panel are normal. He gains 100 grams daily for the first three days of hospitalization on formula alone, which is calculated at 280 cc/kg and 187 calories/kg. Since this is not much different from what he was getting at home (by history), the medical staff suspect that something in the history is not correct. Upon further questioning, mother was not feeding him 6 ounces of formula per feeding as she had initially stated. Instead, she was offering him some juice and she added extra water to the formula to make it go farther.

Nutritional requirements of infants and young children differ from that of adults in a number of aspects due to energy expenditure (i.e., basal metabolism, metabolic response to food, and physical activity), rate of growth, new growth, body composition, and physiological changes (e.g., puberty). Due to the high nutritional needs of infants and young children, there is an increased risk for nutritional disruptions (i.e., undernutrition and overnutrition). This risk may be compounded by lack of knowledge or awareness of signs and symptoms on the part of the caregiver. Regular well child care visits aid in the prevention and screening of such disruptions and can alleviate associated detrimental effects.

A good nutritional assessment includes a family history, developmental assessment, medical history (including growth history), and physical examination, especially growth parameters (Table 1). Anthropometrics is the measurement of the physical dimensions of the human body at different ages (1). Reference curves derived from the normal population are used to plot each child to monitor and follow development and growth. Anthropometric parameters include weight, length, head circumference and body mass index (BMI).

Table 1. Aspects of Nutritional Assessment
Dietary evaluation
Growth (weight, height, head circumference)
Upper arm and skinfold measurements (optional)
BMI (body mass index)
Additional corrections for:
. . . . . gestational age (premature infants)
. . . . . delayed/precocious growth (radiographic bone age)
. . . . . sexual maturity (Tanner stage)
Clinical evaluation (medical history, physical examination and anthropometry)
Laboratory data (e.g., hemoglobin, iron, serum proteins) (optional)

The guidelines for nutritional requirements incorporate dietary reference intake values including recommended daily allowances (RDA) and adequate intake (AI) values. These values should be used as a guideline and should be modified as needed (e.g., rapid changes in requirements that occur during infancy). General nutritional requirements are based on age, body size, growth rate, physiological losses and caloric intake. Therefore, a child's rate and stage of growth usually parallels nutritional needs (including physical activity, body size, basal energy expenditure and state of illness). In infants, 9-15% of calories should be from protein, 45-55% from carbohydrate and 35-45% from fat. In older children, 10-15% of calories should be from protein, 55-60% from carbohydrate and 30% from fat. On average, carbohydrate and protein contains 4 calories per gram, while fat contains 10 calories per gram. Nutritional calories are actually chemistry kilocalories. Vitamin deficiency states are covered in a separate chapter.

Breastfeeding is recommended for newborns. Breast milk is the natural food for full-term and premature infants during the first months of life (1,2). There are nutritional, practical, psychological, immunological and physiological benefits to breastfeeding (refer to the chapter on breast feeding). Contraindications to breastfeeding include: mother receiving chemotherapy or radioactive compounds, maternal HIV/AIDS, active untreated maternal TB, maternal primary Herpes or Herpes in the breast region, certain medications (anti-thyroid drugs, chloramphenicol), use of alcohol and drug abuse.

It is strongly recommended by WHO (World Health Organization) that infants receive human milk exclusively through the first 6 months of life and that complementary foods are added thereafter through at least the 1st year of life (1). The alternative for human milk is infant formula based on cow's milk or soy protein (refer to the chapter on infant formulas). Human and cow's milk differ in composition with regard to protein, fat type and quantity of minerals and vitamins. Although technological advances have improved formula composition, formula still lacks the immunological advantages of breast milk.

Fluid maintenance can be calculated at 100 cc/kg/day for the first 10 kg, then 50 cc/kg/day for the next 10 kg, then 20 cc/kg/day thereafter. Maintenance caloric requirements can be estimated by the same numbers. Thus a 14 kg child has a maintenance fluid volume of 1200 cc/day and a maintenance caloric requirement of 1200 calories per day. The caloric density of infant formula is 20 calories per ounce (or 2/3 of a calorie per cc). Human breast milk has a variable caloric density, but it is usually less than 20 calories per ounce. Since the maintenance fluid and calorie calculations are the same, and formula is less than one calorie per cc, infants must take in more than maintenance volume in order to consume maintenance calories (i.e., for an infant to get 1200 calories per day, he/she would have to take in 1800 cc of formula). Growing and thriving infants must consume more than maintenance calories to cover maintenance needs plus the requirements for growth. Thus, they will often consume 200 to 300 cc/kg/day of formula. The addition of solid foods after infancy which have a higher caloric density (calories per cc) permit them to consume more solids and less fluid in order to grow and thrive.

Maintenance caloric calculations are estimates. Clinical conditions associated with increased metabolic needs (e.g., congestive heart failure) or increased catabolism (e.g., burns), will have higher maintenance caloric needs. Conversely, clinical conditions which lower metabolism (e.g., paralysis), have lower caloric requirements.

By 6 months of age, babies' swallowing mechanisms have developed sufficiently enough for them to be started on solid foods. Toward the end of the 1st year (12 months), weaning from breast or bottle to cup use is advised. However, it is very common for children to continue to drink from bottles beyond this age. Children who continue to drink from bottles for prolonged periods (past 15 months of age) have a high incidence of dental caries and this practice possibly adds to the risk for otitis media. Dietary recommendations during growth and development are summarized below:

0-12 months: Vegetarian diet NOT recommended for the first 2 years of life. 2% or skim milk is NOT used since fat is needed for neural development (whole milk contains 4% fat, 2% milk contains 2% fat, skim milk contains no fat). Whole cow's milk is not recommended before 9 months of age (high renal solute load, poor protein ratio composition, poor Fe absorption and inappropriate energy distribution). Breast milk and/or formula can be used exclusively (no other foods are necessary) until 6 months of age. Some vitamin supplementation may be necessary (e.g., vitamin K given at birth, vitamin D to prevent rickets). Adequate iron intake must be assured (some formulas called "low iron", do not have enough iron). Daily fluoride supplements should be started at 6 months of age and continued until 12-16 years of age, to reduce the incidence of dental caries, in areas that lack fluoridation of the water supply (e.g., Hawaii).

6-9 months: This is the age at which solid foods are introduced. Iron enriched cereals (e.g., rice cereal) should be started first because they are less allergenic. New foods can be added gradually (only one to two new foods per week to determine hypersensitivity and/or food intolerance). Pureed yellow/orange vegetables (e.g., carrots, squash) should be added next. Pureed green vegetables should be introduced after yellow/orange vegetables because they have more bulk. Vegetables with high nitrite contents (e.g., beets, spinach, turnips) should be avoided. Vegetables are generally offered before fruits because the sweet taste of fruits may cause infants to reject other foods. Pureed fruits and juices, pureed meats, fish, poultry, and egg yolk can be introduced after the infant demonstrates tolerance to pureed vegetables. Avoid egg whites until 12 months because of the risk of allergy. Avoid desserts, since these have no significant nutritional value and their sweet taste may cause infants to reject other foods.

9-12 months: Finger foods, peeled fruits, cheese and soft cooked vegetables may be. Avoid peanuts and raw, hard vegetables until 3-4 years old, because of the risk of aspiration. Avoid added sugar, salt, fat or seasonings.

1-2 years: Eating habits formed from 1-2 years of life affect subsequent years. A vegetarian diet is not recommended for the first 2 years of life. Very soft table foods can be offered. High protein foods contribute to their growth potential. Carbohydrates and fats contribute to meeting their energy requirements.

2 years: Snacks may be included (e.g., juice and crackers), but this should be encouraged. This age (also known as the terrible two's) is typically associated with a decreased appetite (due to social interactions/refusal of food) and poor weight gain. Parents often unintentionally reward the wrong behavior. For example, if a child does not eat much at lunch or dinner, parents feel sorry for them and want them to grow, so the child is given a snack (e.g., cookies, chips, ice cream) between meals. Because these snacks are never as nutritious as what is served at dinner, and the snacks often taste better, the child learns that if he/she refuses lunch or dinner, they will get a better tasting snack later. Poor growth typically results. Parents unintentionally reward the child to eat poorly at mealtime (i.e., if you eat poorly at dinner time, I'll reward you by giving you ice cream and cookies later). Proper counseling advises parents to avoid all snacks. Even if the child refuses lunch or dinner, he/she must learn that there will be no food until the next meal. When this is practiced consistently and reinforced, they will eat well at meal time, which is when the most nutritious food is served.

2-5 years (toddler years): Restrict fat to less than 30% of calories (saturated fats <10%). This can be accomplished by switching to low-fat milk (2% or skim), low use of butter/margarine and removing visible fat from foods. Dietary choices expand to the adult range of foods (i.e., most table foods). Emphasize the importance of adequate protein in the diet. Vegetarians should be cautioned that the absence of all animal proteins may lead to a deficiency of vitamin B12. In addition, the quantity of protein in plant substances (e.g., soy) is small compared to that in meat, chicken, fish and eggs. Since the body is largely comprised of protein, strict vegetarians are less likely to gain height as fast as their non-vegetarian peers.

Childhood obesity is a growing and serious problem. The prevalence of type 2 diabetes among school aged children is increasing. There are no easy solutions, but dietary counseling to reduce fat and total calorie consumption at an early age when obesity is first detected is appropriate. Caloric consumption increases markedly in the pubertal period and adolescent years. Adolescent activity ranges from very active to very sedentary (TV, video games and computers have contributed to this). Sedentary individuals may actually consume more calories and are at high risk for obesity. In females, attention should be given to iron and calcium intake. Calcium intake during the time of accelerated growth and skeleton formation is an important factor in reducing the risk of osteoporosis decades later. During adolescence, it is important to recognize the potential for eating disorders such as anorexia and bulimia nervosa (see chapter on eating disorders). With the exception of eating disorders, adolescents are at higher risk of over eating rather than under eating. Dietary counseling during adolescence is likely to contribute to healthier eating habits as an adult.


1. True/False: Technological advances in formula have eliminated the immunological difference between human milk and commercial infant formula (cow's milk and soy protein).

2. True/False: Vegetarian diets are acceptable in a 1 year old child.

3. True/False: During the second year of life, there is a decrease in appetite and low weight gain as children follow normal growth curves.

4. Should fluoride be supplemented? If so, when and under what circumstances.

5. Which of the following is NOT true about breast feeding?
. . . . . a. Recommended food for infants both term and preterm
. . . . . b. 50% of energy from proteins
. . . . . c. Contains immunological benefits (i.e. IgA, active lymphocytes)
. . . . . d. Promotes growth of lactobacillus in GI
. . . . . e. Decreases incidence of allergic disorders

6. Is a 9 kg child who is consuming 8 ounces of formula 5 times a day, likely to grow? Calculate cc/kg/day, calories/kg/day. 1 ounce = 30cc. Formula contains 20 calories per ounce.

7. Calculate the total number of calories for a serving of chicken noodle soup: Serving size=4 ounces, total fat per serving=2 grams, total carbohydrate per serving 8 grams, total protein per serving 3 grams, total sodium per serving 890 mg. Calculate the total calories from carbohydrate, protein and fat separately.

8. A premature infant in the neonatal ICU weighing 850 grams is receiving total parenteral nutrition (TPN). He is getting intralipids 10% (10 grams per 100cc) at 1 cc/hr and a separate infusion at 5.5 cc/hr of crystalloid which contains D12.5% (12.5 grams of dextrose per 100cc) and 2 grams of amino acids per 100cc. How many calories from carbohydrate, protein and fat is the patient receiving per day? How many calories per kg is the patient getting per day? Is this enough to gain weight?


1. Hendricks KM, Duggan C, Walker WA (eds). Manual of Pediatric Nutrition, 3rd edition. 2000, Hamilton, Ontario: B.C. Decker, Inc. Hamilton, Ontario.

2. Curran JB, Barness LA. Chapter 40 Nutrition. In: Behrman RE, Kliegman RM, Jenson HB (eds). Nelson Textbook of Pediatrics, 16th edition. 2000, Philadelphia: W.B. Saunders Company, pp. 138-188.

3. Forbes GB, Eiger MS. Chapter 17 - Nutrition. In: Adam HM, Nelson NM, Weitzman ML, et al (eds). Primary Pediatric Care, 4th edition. 2001, St. Louis: Mosby/Harcourt Health Sciences Company, pp. 171-198.

4. Finberg L. Chapter 89 - Feeding the Healthy Child. In: McMillan JA, DeAngelis CD, Feigin RD, et al (eds). Oski's Pediatrics, 3rd edition. 1999, Philadelphia: Lippincott Williams & Wilkins, pp. 470-479.

5. Chumlen WC, Guo SS. Chapter 1 - Physical Growth and Development. In: Samour PQ, Helm KK, Lang CE (eds). Handbook of Pediatric Nutrition, 2nd edition. 1999, Gaithersburg, MD: Aspen Publishers, Inc., pp. 3-16.

6. Bessler S. Chapter 2 - Nutritional Assessment. In: Samour PQ, Helm KK, Lang CE (eds). Handbook of Pediatric Nutrition, 2nd edition. 1999, Gaithersburg, MD: Aspen Publishers, Inc., pp. 17-38.

7. Akers SM, Groh-Wargo SL. Chapter 4 - Nutrition During Infancy. In: Samour PQ, Helm KK, Lang CE (eds). Handbook of Pediatric Nutrition, 2nd edition. 1999, Gaithersburg, MD: Aspen Publishers, Inc., pp. 65-94.

8. Lucas B. Chapter 5 - Nutrition of infants and adolescents. In: Samour PQ, Helm KK, Lang CE (eds). Handbook of Pediatric Nutrition, 2nd edition. 1999, Gaithersburg, MD: Aspen Publishers, Inc., pp. 99-117.

9. Coughlin CM. Chapter 7 - Vegetariansim in Children. In: Samour PQ, Helm KK, Lang CE (eds). Handbook of Pediatric Nutrition, 2nd edition. 1999, Gaithersburg, MD: Aspen Publishers, Inc., pp. 133-146.

10. MacLean WC, Lucas A. Chapter 1 - Pediatric Nutrition. In: Walker WA, Watkins JB (eds). Nutrition in Pediatrics, 2nd edition. 1997, Hamilton, Ontario: B.C. Decker Inc., pp. 1-6.

11. Hubbard VS, Hubbard LR. Chapter 2 - Clinical Assessment of Nutritional Status. In: Walker WA, Watkins JB (eds). Nutrition in Pediatrics, 2nd edition. 1997, Hamilton, Ontario: B.C. Decker Inc., pp. 7-28.

12. Carlson SE, Barnes LA. Chapter 6 - Macronutrition Responsible for Growth. In: Walker WA, Watkins JB (eds). Nutrition in Pediatrics, 2nd edition. 1997, Hamilton, Ontario: B.C. Decker Inc., pp. 81-90.

13. Krebs NF, Hambidge KM. Chapter 7 - Trace Elements in Human Nutrtition. In: Walker WA, Watkins JB (eds). Nutrition in Pediatrics, 2nd edition. 1997, Hamilton, Ontario: B.C. Decker Inc., pp. 91-114.

14. Kleinman RE, et al. Committee on Nutrition, American Academy of Pediatrics. Pediatric Nutrition Handbook, 4th edition. 1998, Elk Grove Village: American Academy of Pediatrics.

15. Krebs NF, Hambidge KM, Primak LE. Chapter 10 - Normal Childhood Nutrition and Its Disorders. In: Hay WW, Hayward AR, Sondheimer J, et al (eds). Current Pediatric Diagnosis and Treatment, 15th edition. 2001, Stamford, CT: Appleton and Lange.

Answers to questions

1. False. Formula still lacks the immunological advantages of breast milk.

2. False. Vegetarian diets are NOT recommended for the first two years of life. 3. True.

4. Yes, at 6 months in children in a community with a non-fluorinated water supply.

5. b. 50% of energy from FAT.

6. No, this child will lose weight (failure to thrive). This child is consuming 40 ounces per day which is only 800 calories per day. This child needs 900 calories (100 cal/kg/day) just for maintenance alone. Growth requires a caloric intake in excess of maintenance.

7. Roughly 64 calories. Protein=4 calories/gram, carbohydrate=4 calories/gram, fat=10 calories/gram. 12 calories from protein, 32 calories from carbohydrates, 20 calories from fat, no calories from sodium total calories=64 calories (roughly).

8. This child is receiving 10% (10 gram/100cc) intralipids at 1cc/hr, or 24 cc/day, which is 2.4 grams per day, which is 24 calories from fat per day. He is getting D12.5% (12.5 gm/100c) at 5.5cc/hr, or 132 cc/day, which is 16.5 grams of dextrose per day, which is 66 calories from carbohydrates per day. He is getting 2 grams of amino acids per 100cc, which means that he gets 2.64 grams of amino acids per day, which is 10.5 calories from protein per day. He is getting a total of 100.5 calories per day, which is 118 calories per kg/day. Since his maintenance caloric requirement is 100 calories/kg/day, he is getting more than maintenance which should give him the potential to grow.

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