Part 06. Nutrition
PART ¥µ. Nutrition
Chapter 43. Nutritional Requirements
Table 43-1
43.1 Water
¨ç water content
; infant - 75-80% of BW (7% bl. plasma, 18% interstitial fluid, 45% ICF)
; adult - 55-60% of BW
¨è endogenous water ; mixed diet½Ã 12g H2O /100Kcal
¨é Water Need
¡ÚTable
43- 2,3
;
*100kcal´ç
ÇÊ¿ä ¼öºÐ·®Àº
¼ºÀΰú µ¿ÀÏÇÏ´Ù.
; normal infant
-
*125~150ml/kg/day
- insensible water loss(50ml/kg)+urine(50-70ml/kg)+¿¹ºñ(25-50ml/kg)
¨ê Daily Fluid Consumption
; Infant - 10-15% of BW
; adult - 2-4% of BW
¨ë ¡Ø87 water retention
;
0.5-3% of fluid intake
;
9-13ml/24hr for ¡°male reference infant¡± in 1st yr of life
¨ì ¡Ø87 LBW water requirement
; 85-170ml/kg/24hr
- fecal loss : 3-10%
- insensible loss : 40-50%
- renal excretion : 40-50%
¨í Water balance : ¥¡) fluid intake
¥¢) protein & mineral content of diet
¥£) solute load presented for renal excretion
¥¤) metabolic & resp. rates
¥¥) body temperature
¨î urine osm. : 300-1,000mOsm/L
serum : 293 mOsm/L
maximum normal urinary cons. : 600-700 mOsm/L
43.2 Energy
¨ç *1
Kcal : 1 kgÀÇ ¹°À» 14.5¡É¿¡¼ 15.5¡É·Î
¿Ã¸®´Âµ¥ ÇÊ¿äÇÑ
¿·®
¨è ¡Ø87 average expenditure of calories in 6-12yr
; basal metabolism (50%)
; growth (12%)
; physical, activity (25%)
; fecal loss (8%) : mainly as unabsorbed fat
¨é 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¡É »ó½Â½Ã 10%¾¿ Áõ°¡
¨ê ¡Ø90 Thermic Effect Of Food (TEF)
; food ingestion°ú assimilationÀ¸·Î ÀÎÇØ basal rate ÀÌ»óÀ¸·Î metabolismÀÌ Áõ°¡ÇÏ´Â °Í
- protein 30%, fat 4%, CH 6%
; infant - 7-8% of total calorie
; older children - 5% of total calorie
¨ë requirement for physical activity
; 15-25 kcal/Kg/24hr
¨ì *Daily
Calory Requirement
; 1¼¼ - 80-120 Kcal/Kg
; ÀÌÈÄ 3³â¸¶´Ù 10 Kcal/Kg¾¿ °¨¼Ò
; ÇÑ±ÛÆÇ)
-
*óÀ½ 1³âµ¿¾È
110(100~120)kcal/kg/day, 2³â° µé¾î°¡¸é, 90~100kcal/kg/day
-
*¸Å³â 100kcal¾¿ ´õ
ÇÊ¿äÇÔ ±×·¯³ª
üÁß´ç Ä®·Î¸®´Â 3³â¸¶´Ù 10kcal/kg/day°¨¼Ò
¨í well balanced diet
; protein 9-15%
; CH 45-55%
; fat 35-45%
¨î protein £¦ CH ; 4 kcal/g
FA ; short chain - 5.3 kcal, medium chain - 8.3kcal, long chain 9 kcal
¨ï ÇÏ·ç 500KcalÀÇ Áö¼ÓÀû imbalance½Ã 1ÁÖ¿¡ 450g(11b)ÀÇ º¯È
43.3 Proteins
; 20% of adult BW
; *infant
- 2.0~2.5g/day, after infant - 1.5~2.0g/day
# ¡Ú9 essential A.A for infant
; threonine, valine, leucine, isoleucine, lysine, tryptophan, phenylalanine, methionine, histidine
;
*ÇѰ¡Áö¸¸
°áÇ̵ǵµ negative nitrogen
balance ÃÊ·¡
# ¡Ø90 Essential AA For LBW
; arginine, cystine, taurine
# Digestive progress
; protein ¡æ oligopeptide, ¥á-AA
; in stomach
-
*chymosin : casein -->
paracasein
- pepsin : other protein
; in intestine
-
*trypsin, chymotrypsin,
carboxypeptidase : peptones --> peptides
# excessive AA
; deaminationÈÄ nitrogenous portionÀÌ liver¿¡¼ urea·Î ÀüȯµÇ¾î kidney·Î ¹è¼³
43.4 Carbohydrate
; BWÀÇ 1%¹Ì¸¸ (stored as glycogen in liver £¦ muscle)
; *°¡Àå
ÁÁ°í, ÁÖµÈ
¿¡³ÊÁö¿ø
# CHÀÇ ÇüÅÂ
; monosaccharide : glucose, fructose, galactose
; disaccharide : lactose, sucrose, maltose, isomaltose
; polysaccharide : starches, dextrins, glycogen, gums, cellulose
# digestion
; salivary £¦ pancreatic amylase
- starch ¡æ oligosaccharide (dextrin) & disaccharide (ÁÖ·Î maltose)
; intestinal amylase
-
*ù 4mo°£¡é
; disaccharides
- intestinal brush border¿¡¼ Èí¼ö
-
*disaccharidase¿¡
ÀÇÇØ
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©ü+ H©üO
°ü·Ã 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 ADEKÀÇ vehicle
; natural fatÀÇ 98%°¡ TG (3FA + glycerol)
; ingested TG
- hydrolyzed by lingual lipase & emulsified in the stomach
--> monoglycerides & fatty acids
# ¡Ø95 long chain FA £¦ monoglycerides´Â mucosal cell¿¡
ÀÇÇØ
diffusion¿¡ ÀÇÇØ Èí¼ö
¡æ reesterification to TG
¡æ lipoproteinÀ¸·Î coatµÇ¾î chylomicron Çü¼º
¡æ lymph ¡æ vein
# short £¦ medium chain FA
;
pancreatic or mucosal lipase¿¡ ÀÇÇØ *FFAÈÄ diffusion
# ¡Ø93 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
# ¢¾essential
FA deficiency
; increased serum trienoic acid/tetraenoic acid
;
*intertrigo, dryness, thickening,
desquamation of the skin
# excess unsaturated acids
; peroxidation ¡è- memb. destruction
43.6 Minerals
- cations : Ca, Mg, K, Na
- anions : P, sulfur, Cl
- iron, iodine, cobalt : organic complex
¢ÞTable
43-5
# Calcium
;
*¸ðÀ¯
¿µ¾ç¾Æ´Â 40mg/kg/day, ¿ìÀ¯
¿µ¾ç¾Æ´Â 70mg/kg/day
# ¢Þ87,92 Zinc
43.7 Vitamins
¡ÚTable
43-6
43.8 Miscellaneous Factors
Fiber
; undigestable vegetable fiber 170-300 mg/Kg/24hr in urine
; ¡Ø89 little fiber intake
--> constipation, diverticulitis, appendicitis, other intestinal disorder
; high fiber diet
-
*cholesterol, zinc, other
essential untrientÈí¼ö ¡é
Digestability
Satiey
Availability
¡Ø86,87 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
¨ç oral broad spectrum AB : nitrogen balance ¡é
¨è INH : pyridoxal phosphate combine ¡æ vit B6 defi.
Endocrine Factors
; ACTH, corticosteroid Åõ¿©½Ã Ca £¦ protein Áõ°¡, Na °¨¼Ò
Radioactivity
Emotional Factors
43.9 Evaluation Of Diet
Chapter 44. Feeding Of Infants And Children.
# ¡Ø85,87 °¡´ÉÇÑÇÑ
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)
¨ç hunger
¨è too much clothing
¨é soiled, wet, uncomfortable diaper £¦ clothing
¨ê colic
¨ë swallowed air
¨ì uncomfortably hot or cold environment
¨í illness
¨î to gain sufficient or additional attention
44.1 Breast Feeding
¡Ø82,89 Advantages : ÇÑ±ÛÆÇ
(p71) - 5°¡Áö
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 cow¡¯s 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) ¡Ø96ÁÖ 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
;
¡ÚExcept
- fluoride
- vitamin D : ¼ö°³¿ù ÈÄ
- iron 6-9moÈÄ
8) psychologic advantage
# low vitamin K content
# hemolytic ds. of NB (EF)
;
no contraindication
;
*brease milk³»ÀÇ Ab°¡ intestine¿¡¼ inactivationµÇ±â ¶§¹®
# ¡Ø96 Microorganism In Breast Milk
; HIV, CMV, human T-cell lymphotropic virus type I, rubella, hepatitis B, herpes simplex
; tubercle, typhoid bacilli, mumps
; hepatitis B´Â acitive immunization¸¸ öÀúÈ÷ Çϸé, breast feeding °¡´É
# *2000gÀÌ»óÀÇ premature
;
*breast feeding°¡´É
Establishing And Maintaining Milk Supply
# ¡Ø87 ¡ãSatisfactory
Stimulus To Secretion Of Human Milk
; regular & complete emptying of breast
# ¡Ø87 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
# ¡Ø85 Drugs Of Contraindication Of Breast Feeding
; antithyroid drug, lithium, anticancer agent, INH, phenindione
# ¡Ø87 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
¥ª) most antimicrobials
# ¡Ø91 ¿ìÀ¯ÀÇ ¸ðÀ¯È(¼ººÐ ºñ±³)
; ǥ3-3
# ¡Ø92 ¸ðÀ¯ ¿µ¾ç¾Æ¿¡¼ Ä®½·Á¦Á¦°¡
È¿°úÀûÀÎ ÀÌÀ¯
; phosphate ÀÇ ÇÔ·®ÀÌ Àû¾î Èí¼ö°¡ ¿ëÀÌ
; ³ôÀº lactoseÀÇ ÇÔ·®À¸·Î Àå³» ³·Àº pH·Î Èí¼ö°¡ ¿ëÀÌ
Technique of breast feeding
# ù 2ºÐ 50% emptying, ù4ºÐ 80-90%
# burping ÈÄ prone or Rt lat. position
; ¡èemptying of stomach into intestine
; ¡éregurgitation or aspiration
One Or Both Breast Per Feeding
Dertermining Adequacy Of Milk Supply
# ¡Ø87 ¸ðÀ¯ ºÎÁ· Áõ»ó
; ¾çÂÊ Á¥À» ¸ÔÀº ÈÄ ¸¸Á· (-)
; Á¥¸ÔÀº ÈÄ ÀáµéÁö ¾Ê´Â´Ù.
; 1-2hr ÈÄ ±ü´Ù.
; üÁß Áõ°¡ (-)
# *¡°let-down¡±
or milk-ejection reflex
;
*successful nursing sign
; sucking or psychologic stimuli
¡æ post.pituitary lobe¿¡¼ oxytocin, ant. pituitary lobe¿¡¼ prolactinºÐºñ
¡æ myoepithelial cell contraction, milk secretion in cuboidal cell in acini
¡æ milk squeezing into larger duct
; reflexÀû´çÇÒ½Ã, nursingÃʱ⿡ ¹Ý´ëÂÊ breast¿¡µµ milk flow(+)
; ¼Ò½ÇµÇ´Â °æ¿ì
- pain, fatigue, emotional distress
# ¡Øinsufficient milk »ý°¢Àü
°í·ÁÁ¡
; infantÀÇ inadequate progress¿¡ ¾Ë¸Â´Â feeding techniqueÀÇ error
; diet, rest, emotional distress¿¡ °ü·ÃµÈ remediable maternal factor
; eating or Wt.gainÀ» ¹æÇØÇÏ´Â physical disturance in infant
# ¡Ø85 prolactinºÐºñ
¡è¹æ¹ý
; delaying feeding to 2¨öhr intervals (2hrÀ̳»½Ã prolactin ºÐºñ¡é)
; small dose of chlorpromazine for a few days
; Lact-aidµîÀÇ 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
# ¡Ø87 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
¡Ø90,92
Colostrum
; ÀӽŸ»±â¿¡¼ Ãâ»ê 2-4ÀϺкñ( 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¡è
-
*CHO £¦ fat¡é(cf.iron¡é)
; 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%
; cow¡¯s milk 4.5%
Fat
; TG olein, palmitin, stearin À¸·Î ±¸¼º
; human milk
- more absorbable olein (x2)
- volatile FA(butyric, capric, caproic, caprylic) 1.3% (cow¡¯s milk 9%)
; premature or debilitating infant
--> cow's milk½Ã steatorrhea
- vegetable fat or human milk Åõ¿©
Minerals
; human milk 0.15-0.25%
; cow¡¯s milk 0.7-0.75%
; *copper,
iron (human = cow) Á¦¿ÜÇϰí cow's milk¿¡
¡è
Vitamins
; human milk
- increased vitamin A, C, D, E, niacin
; cow's milk
- increased vitamin B1, 2, 6, 12, vitamin K
-
*vitamin C, DºÎÁ·
Bacterial Content
; ¡Ø87 Good Culture Media For Pathogenic Bacteria
- strept.ds
- diphteria
- typhoid fever
- salmonellosis
- tuberculosis
- brucellosis
Digestibility
# ¡Ø82 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¡É 30min or 72¡É 15secÈÄ rapid cooling to 65¡Éor 60¡É
Homogenized Milk
; smaller particle £¦ less tough curd
Evaporated Milk(Å»¼öÀ¯)
# ÀåÁ¡
¨ç almost universal availability
¨è unexposed can½Ã ¼ö°³¿ù Áö¼Ó °¡´É without refrigeration
¨é fat homogenization
¨ê lactalbumin : less allergenic
¨ë casein curd : smaller £¦ softer
¨ì higher conc : 44Kcal/oz
-
½ÇÁö·Î´Â *40kcal/oz(140kcal/100ml)
¨í sugar : unchanged
¨î vit D 10ugº¸°
Prepared milk (Ư¼ö Á¶Á¦ ºÐÀ¯)
low electrolyte : CHF, nephrogenic DI, marginal renal function½Ã »ç¿ë
Condensed milk
1:10-14 dilution
Dried Whole Milk
Dried Skim Milk (Å»ÁöÀ¯)
non fat skim milk (fat 0.5%)
half fat skim milk (fat 1.5%) *
¥¡) fat intolerance½Ã »ç¿ë
¥¢) calori¿¡ ºñÇØ high protein £¦ mineral : dehydration
¥£) vit D º¸° (-)*
Acid And Fermented Milk
Goat's Milk
¥¡) Na, vit D, Fe, Folic acid¡é
¡æ megaloblastic anemia
¥¢) K, Cl, linoleic acid, arachidonic acid¡è
¥£) brucellosisÀ§Ç輺 (+)
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
¥¢) IBD½Ã reducing stooling
¥£) maximal use of short bowel seg. after surgery
¥¤) major bowel surgeryÀüÈÄ¿¡ bulk¿Í bacterial content°¨¼Ò
½ÃŰ¸é¼ very ill pt¿¡¼ (+) nitrogen balanceÀ¯Áö
Milk Formulas
; *20kcal/oz(70kcal/100ml)
; calorie requirement
; fluid requirements
--> *ÇÑ±ÛÆÇ
Á¤¸® Ç¥3-4(p74)
¡ÚÇ¥3-5(p75)
; *ÇÏ·ç
ÃÑ·®Àº 1000mlÀ»
³ÑÁö ¾Êµµ·Ï
ÇÑ´Ù.
44.3 Other Foods
Vitamins
; vitamin A
- 1500~2000 IU/day
- vitamin D¿Í °°ÀÌ ÁØ´Ù.
; vitamin C
- 50mg
; vitamin D
-
*10ug (400IU)/day
-
*beginning at 2wk
; fluoride
Ç¥3-6(p76)
Iron
; *food
rich in ironÀ̶ó ÇÏ¿©µµ less available than breast milk
; iron fortified milk formula or medical iron (*2mg/kg upto 15mg/24hr)
-
*¡ãeffective way to prevent iron deficiency
-
*beginning at 6wk
Solid Foods
; *4-6mo,
üÁß 6-7kg¿¡
½ÃÀÛ
# ¡Ø93ÁÖ ±âº» ¿øÄ¢
; ÀÌÀ¯Ãʱ⿡´Â öºÐÀÌ ÇÔÀ¯µÈ °î½ÄÀ» ÀÌ¿ëÇÏ¿© ¹ÌÀ½°°Àº ¹ÝÀ¯µ¿½ÄÀ» ¼ù°¡¶ôÀ¸·Î ½ÃµµÇÑ´Ù. ÀÌÀ¯Á߱⿡´Â ¾ÏÁ×, µÎºÎ°°Àº ºÎµå·¯¿î °íÇü½Ä, ÀÌÀ¯Èı⿡´Â Á×¹ä µîÀÇ °íÇü½ÄÀ¸·Î ÁøÇà
; ½Ã°£À» Á¤Çسõ°í ÁÖµÇ, óÀ½¿¡´Â ¿ÀÀü 10½Ã°æÀÌ ÁÁ´Ù.
; óÀ½¿¡´Â ¼Ò·®À¸·Î ½ÃÀÛÇÏ¿© Çѹø¿¡ ÇѰ¡Áö¾¿ ÁØ´Ù
; *¸Å 1-2ÁÖ¸¶´Ù ÇѰ¡Áö¾¿ ÷°¡ÇϵÇ, ¼³»ç,±¸Åä,ÇǺιßÁøÀÌ ³ªÅ¸³ª¸é ÁßÁö½ÃŲ´Ù.
;
*¼öÀ¯Àü¿¡
ÁØ´Ù.
¢ÞÇ¥3-7(p77)
Cereals
; iron, vitamin B complexÆ÷ÇÔ
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
°í·ÁµÇ¾ß ÇÒÁ¡
¥¡) frequency
¥¢) mechanics of feeding
¥£) size of hole in nipple
¥¤) air eructationÀÇ adequacy
¥¥) abn' l infant-mother bonding
¥¦) systemic ds in baby
Sx
constipation, failure to sleep, irritability, excessive crying,
poor wt. gain
Overfeeding
regurgitation £¦ vomitingÀÌ frequent Sx
Regurgitation £¦ Vomiting
; first 6mo±îÁö´Â normal
; ¡Ø87 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 feeding½Ã
-
*naturally softer than cow¡¯s milk
feeding
-
*4-6Àϰ transitional stage·Î¼
loose, greenish yellow, mucus stool
/ ¼öÀÏÀ̳»¿¡ ¡°milk stool¡±ÀÌ µÈ´Ù.
; ¡Ø89 Formula Feeding½Ã
- »ýÈÄ1-2ÁÖ¿¡ overfeedingÀ¸·Î ¹ß»ý
-
*too concentrated formula &
too high sugar content
- contamination of food
Constipation
; rectal exam é©
; ¡Ø90 ¿øÀÎ
- tight or spastic anal sphincter
- anal fissure or craks
- aganglionic magacolon
/
*rectal exam½Ã 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
¢Þ90 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
# ¡Ø86 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
¨ç ¥¡) 6mo : bottle hold
¥¢) 8-9mo : cup hold
¥£) 10-12mo : spoon
¨è baby-bottle synd : sleep½Ã bottle of formula or water suckingÀÌ
deciduous teethÀÇ enamel erosion°ú °ü°è
¨é nutritional requirments
IN : 110 Kcal/Kg
15yr : 50 Kcal/Kg
Daily Basic Diet
Eating Habits
# ¡Ø87 2-5¼¼
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-setÀÌ Áß¿ä
Snack Between Meats
Vegetarian Diet
1) Ư¡ ¥¡) faster GT transit time
¥¢) bulkier stool
¥£) low serum cholesterol
¥¤) less diverticulitis £¦ appendicitis
2) vegans ( egg or milk ¸ÔÁö¾Ê´Â ä½ÄÁÖÀÇ )
;
*vit B12 deficiency
-->
*methylmalonic acidemia
; trace mineral defi.
Chapter 45. Nutritional Disorders
45.1 Malnutrition
# ¡Ø87,89 Diagnosis
¨ç accurate dietary history
¨è evaluation of present deviations from average Ht, Wt, HC, past rates of growth
¨é comparative measurements of mid arm circum £¦ skin fold thickness
¨ê chemical £¦ other test
; skin fold thickness ¡é
--> protein-calorie malnutrition
; midarm muscle circum. (cm) = arm circ. (cm) - (skin fold thickness ¡¿3.14)
; lean body mass
- 24hr creatinine excretionÀ¸·Î °è»ê
# *Protein
ReserveÆò°¡
; S-albumin, rapid turnover protein
-
¡ÚRapid Turnover Protein
/ transthyretin :12hr half-life
/ prealbumin : 1.9days half-life
/ transferrin : 8 days half-life
# *Severe
Malnourished child
¨ç hydroxyproline excretion ¡é
¨è 3-methylhistidine excretion¡è
¨é easily plucked hair
# ¡Ø83,85 Immunologic Insuff. In Chronic MalnutritionÆò°¡
¨ç total lymphocyte < 1500/m3
¨è 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
¢Þ86,97 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
¨ç absorption of protein in chr. diarr. stateÀå¾Ö
¨è abn. loss of protein in proteinuria (nephrosis)
¨é infection
¨ê hm. or burn
¨ë failure of protein synthesis (chronic liver ds.)
Clinical Manifestation
¨ç early
: lethargy, apathy, irritability
: edema
¨è advanced
: inadequate growth, lack of stamina, loss of muscular tissue, infection¡è, edema
¨é *secondary
immunodeficiency : measles
¨ê *Hepatomegaly,
fatty infiltration
¨ë renal plasma flow, GFR, renal tubular function¡é
¨ì *dermatitis
: common
- irritated area : skin darkening, sunlight exposed area darkening (-)
cf. Pellagra¿¡¼´Â (+)
¨í thin hair
hypochromotrichia : dyspig.À¸·Î gray or red hair color
¨î infection £¦ parasitic infestation
¨ï weak, thin, atrophic m.
¨ð mental change, irritability, apathy
Laboratory data
¨ç S-lab.¡é : Ư¡Àû
¨è Ketonuria : Ãʱâ (+), Èı⿡´Â ¼Ò½Ç
¨é low blood blucose : GTT´Â diabetic type
¨ê u-hydroxyproline to creatinine excretion¡é
¨ë plasma essential aa.¡é, aminoaciduria¡é
¨ì K, Mg defi.
¨í S-cholest.¡é
¨î S-amylase, lipase, esterase, cholinesterase, transaminase, ALP¡é
¨ï anemia : micro, normo, macrocytic
¨ð delayed bone growth
¨ñ GH secretion ¡è°¡´É
Differential Diagnosis
Prevention
Treatment
¨ç immediate Tx of acute problem
severe diarrhea, renal failure, shock
¨è missing untrient replacement
¨é mod. or severe dehydration
eye sign of vit.A def., severe anemia µî Tx
¨ê severe dehydration½Ã IV fluid
ºÒ°¡½Ã rapid intraosseous or intraperitoneal infusion of
70ml/Kg, ¨ö Ringerlactate solution
¨ë parenteral AB for 5-10 ds
¨ì dehydration ±³Á¤½Ã milk feeding : small, frequent dilute
¨í skim milk, casein hydrolysate, synthetic aa. mixture
¨î impaired glucose tolerance½Ã : 250ug chromium chloride
¨ï mental, physical retardation : permanent
Malnutrition In Children Beyond Infancy
; poor eating habit : 5-6yr. : parental factor
Protenin Excess
** ¨ç dehydration-protein fever : excessive protein intake
¨è morbidity¡è : in premature
¨é hyperammonemia : recovery phase of marasmic pt.
¨ê protein intoxication : +-- liver ds
+-- wt. reducing diet with high protein
45.2 Obesity(=Overnutrition)
# ¡ÊDefinition
; excess accumulation of body fat
# ¡ÚChildhood 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)
# ¡ÊMeasures
for DDx
; relative weight, weight-stature indices, body circumference, skinfoldness
; BMI
-
¡ãuseful 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
; ¡ÊThree
Peak Age
-
in 1yr : *¡ãfrequently
- 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
# ¡Ø97 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
# ¢¾Second 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
¡ÊTable
45-1 Differential Diagnosis of childhood obesity
Complication
¡ÊTable
45-2 Repoted complication of childhood obesity
# Pickwickian synd.
;
obesity·Î ÀÎÇØ
*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
# ¡Êchildhood
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
¡ÚTable
45-4
Vit.A Deficiency
** carotenemia : sclera (not yellow)
¨ç liver ds.
¨è DM
¨é hypothyroidism
¨ê cong. absence of enz. (Provit A¡æcarotenoids)
Etiology
¨ç deficient diet : 2-3¼¼¿¡ ¸¹´Ù.
# ¡ÚInadequate
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
# ¡ÚRole
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
¡æ pyuria £¦ hematuria
IICP
hydrocephalus
Diagnosis
¨ç dark adaptation test : xerosis conjunctiva
¨è standard absorption test for vit A
¨é plasma vit A¡é (slow), carotene¡é (rapid)
Prevention
¨ç infant : 500ug/day
¨è children £¦ adult : 600-1500ug
Treatment
¨ç latent : *1500 ug vit A
¨è xerophthalmia : * 1500 ug/Kg/24hr for 5 dayÈÄ
* 7500 ug 1M daily until recovery
Hypervitaminosis A
# Acute Hypervitaminosis A
; 10¸¸ ugÀÌ»ó ¸ÔÀº °æ¿ì ( ±¸ 30¸¸ IU )
; *N/V, drowsiness, bulging fontanel, diplopia, papilledema,
cranial n.palsy, pseudotumor cerebri
# Chronic Hypervitaminosis A
; anorexia, pruritus, wt.gain (-)
;
*irritability¡è, 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
# ¡Ø96 severe cong. malformation
; acneÄ¡·áÀ§ÇÑ large amount retinoids¸ÔÀº motherÀÇ infant
¨ë cortical hyperostosis¿Í DDx
¥¡) Hx
¥¢) vit A¡è
¥£) hyperca, liver cirrhosis°¡´É
Vit.B Complex Defic.
Thiamine Defic. (Beriberi )
Etiology
¨ç function
coenz. in CHO metabolism
Ach»ý¼º¿¡ °ü¿© : ºÎÁ·½Ã impaired n. conuction
coenz in transketolation £¦ decarboxylation of ¥á-keto acid
¨è 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
# ¡ÚProgression
; 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
¨é late ¥¡) IICP
¥¢) meningismus
¥£) coma
¨ê dry beriberi
plump, pale, flabby, listless dyspneic,
rapid heart rate, enlarged liver
¨ë wet beriberi
undernourish, pale, edema, waxy skin
¨ì cardiac sign : cyanosis, dyspnea - óÀ½
tachycardia, hepatomegaly, consciousness loss, convulsion
ECG +--¥¡) QT prolongation
| ¥¢) inversion of T
+--¥£) low voltage
Diagnosis
¨ç ¡éRBC transketolase
¨è ¡èblood or urine glyoxylate
¨é thiamine oral loading ÈÄ excretion
* ¨ê clinical response to adm. of thiamine : best
Treatment
breast fed½Ã +-- mother : 50 mg
+-- CH : 10 mgÀÌ»ó
Riboflavin Deficiency (Ariboflavinosis)
- Function
¨ç electron transport¿¡ Áß¿ä
¨è light adapation
¨é pyridoxine ¡æ pyridoxal phosphate
Etiology
¨ç inadequate intake
¨è faulty abs. ( biliary atresia, hepatitis )
¨é probenecid, phenothiazine, oral contraceptives
¨ê photoTx½Ã B©üÆÄ±«
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 response½Ã 2mg im 3x daily
Niacin Deficiency ( Pellagra )
Etiology
# Function
; electron transfer & glycolysis¿¡ Áß¿äÇÑ NAD(nicotinamide adenine dinucleotide), NADP(nicotineamide denine dinucleotide phophate)ÀÇ ±¸¼º¼ººÐ
; dietary tryptophan
- partial substitute of niacin
-
*milk, egg : high tryptophan, good
preventive food
Clinical Manifestation
# prodromal Sx
; anorexia, lassitude, weakness, burning sense, numbness, dizziness
# ¡ÚTriad
: 3D
; dermatitis, diarrhea, dementia
; appear after long periods
# cutanous Sx
;
*¡ãcharaceristics
; 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
¨ç glossitis, Gl Sx, symm.dermatitis
¨è rapid clinical response to niacin
Treatment
¨ç 50-300 mg niacin diet daily
¨è large dose½Ã cholestatic J & hepatotoxicity
¨é active phase½Ã sun-exposure avoid
Pyridoxine (B6)
Deficiency
# vit B6
; pyridoxal, pyridoxine, pyridoxamine ¡æ Pyridoxal-5-phosphate
decarboxylation & transamination of a.a.ÀÇ coenz.
Etiology
¨ç human & cow's milk, cereals
¨è Vit B6 dependency syndrome
¥¡) B6 dependent convulsion
¥¢) B6 responsive anemia
¥£) xanthurenic aciduria
¥¤) cystathioninuria
¥¥) homocystinuria
¨é vit B6 ¿ä±¸·® Áõ°¡ÇÏ´Â °æ¿ì
¥¡) INH ¥¢) pregnancy ¥£) penicillamine
¥¤) hydralazine ¥¥) oral prog-estrogen contraceptives
Clinical Manifestation
# ¡Ú4
Clinical Disturbances
; convulsion in infants
; peripheral neuritis
; dermatitis
; anemia
# convulsion from B6 dependency
; birth-6mo µ¿¾È
; 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
# ¡ÚXanthurenic
aciduria
# ¡ÚCystathioninuria
# ¡ÚHomocystinuria
Diagnosis
¨ç infantile seizure½Ã hypoCa, hypoglycemia, inf.¾Æ´Ï¸é
100mg of pyridoxine imÇÏ¿© seizure controlµÊ
¨è Tryptophan loading test
* ¨é erythrocyte glutamic pyruvic transaminase¡é
Prevention
INH »ç¿ë½Ã daily pyridoxine
daily intake IN 0.3-0.5 mg, CH 0.5-1.5 mg, adult 1.5-2.0 mg
Treatment
¨ç 100 mg im at convulsion
¨è dependency½Ã 2-10mg im or 10-100mg p.o. daily
Toxicity
;
*excessive½Ã sensory neuropathy
Biotin
biotin antagonistÀÎ avidinÅõ¿©½Ã ¹ß»ý
brawny dermatitis, somnolence, hallucination
hyperesthesia with organic acids¡è
Vitamin C Deficiency(Scurvy)
# Function
; essential for formation of collagen
¨è transient tyrosinemia ( function in Ez activity )
: LBW, FT with high protein diet¿¡ common Tx : vit. C
¨é defi.½Ã megaloblastic anemiaÀÇ ¿øÀÎ
: folic acid conversion¹æÇØ
Etiology
* vit. C ¿ä±¸·® Áõ°¡ÇÏ´Â °æ¿ì
¥¡) febrile illness ( inf. & diarr. ) ¥¢) iron defi.
¥£) cold exposure ¥¤) protein depletion
¥¥) smoking
Pathology
¨ç collagen & chondroitin sulfate Çü¼º (-)
¨è hemorrhage, loosening of teeth
¨é loose periosteum & subperiosteal hm
¨ê 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¿¡ ºñÇØ sharper angulation
- softend epiphysisÀÇ widening¿¡ ÀÇÇÑ °ÍÀÌ ¾Æ´Ï°í subluxation of sternal plate¶§¹®
; 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
# ¡ÚKnee
Jt
;
*¡ãgreat changes
# early stage : simple atrophy of boneÀ¯»ç
¥¡) 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
¥¨) healing½Ã elevated periosteumÀÌ calcified
¡æ dumbbell or club shape
Diagnosis
¨ç clinical
¨è X-ray finding of long bone
¨é Hx of poor intake of vit C
¨ê Lab. test
¥¡) fasting plasma vit C level > 0.6 mg% ½Ã R/O
¥¢) white cell-PLT layer (buffy layer) of centrifuged blood
ascorbic acid content
¥£) sat. of tissue with vit C
¥¤) nonspecific aminoaciduria
¥¥) tyrosine loading½Ã ¹Ì¼÷¾Æ¿Í À¯»çÇÑ ´ë»ç¹° ¹è¼³
¥¦) PT ¡è¡è
6) DDx
¨ç arthritis or acrodynia
¨è rheumatic fever
¨é suppu. arthritis, osteom.
¨ê pseudoparalysis of syphilis
¨ë poliomyelitis
¨ìH-S purpura, ITP, leukemia, meningitis, nephritis
7) Prevention
formula fed½Ã 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
¨ç vit D©ü ( calciferol ) : irradiated ergosterol dietary or
therapeutic vit D
¨è vit D©ý 7-dehydrocholesterol in skin : provit. stage
¡é UV
cholecalciferol
¡é
25 OH-cholecalciferol in liver
¡é
1, 25 (OH)©ücholecalciferol in kidney
# ¡Ú1, 25
(OH)2 cholecalciferol±â´É
¨ç intestinal absorption of Ca & P¡è
¨è kidney phosphorus reabsorption ¡è
¨é bone dissolution & mineralization ¡è
Predisposition to vit D defic.
¨ç lack of dietary vit D
¨è lack of exposure to UV
¨é rapid growth ( LBWI, adol )
¨ê abs.Àå¾Ö ( celiac ds, steatorrhea, pancreatitis, CF )
¨ë anticonvulsant (Pb, phenytoin)
¨ì glucocorticoid
¨í black children
Pathology
¨ç bone growth¿¡ °ü·Ã factors
¥¡) phosphorus ¥¢) Ca ¥£) fluoride ¥¤) GH
¨è Lab
¥¡) inorganic P ¡é : 1.5-3.5 mg/dl (N: 4.5-6.5)
¥¢) S-Ca : usually n (¡ñPTH)
¥£) S-ALP¡è: 500 IU/dl (n : 200)
* ¨é CaÈí¼ö ¡è°æ¿ì
¥¡) dietary Ca : P = 2 : 1 (P¡è½Ã CaÈí¼ö¡é)
¥¢) acidity of intestinal content
¥£) dietary suger°¡ lactoseÀÎ °æ¿ì
* ¨ê CaÈí¼ö ¡é°æ¿ì
¥¡) EDTA Phytate of cereals
¥¢) dietary iron
¥£) high stearic & palmitic acid
Clinical Manifestation
# osseous changes
; recognized after several months of vitamin D deficiency
;
*4 Mo-2¼¼
»çÀÌ È£¹ß
- osteomalacia mother breast feeding½Ã 2moÀ̳»¿¡µµ ¹ß»ý°¡´É
; Florid Rickets
-
*1¼¼¸»-2¼¼
# ¡ÚEarly
Signs
; craniotabes
-
*disappear before the end of 1yr
; rachitic rosary
; thickening of wrist & ankle
; increased sweating ( esp. head )
Head
: ¨ç craniotabes ( 1¼¼¸»¿¡ ¼Ò½Ç)
¨è large ant.fontanel & delayed closure
¨é caput quadratum
Thorax
: ¨ç rachitic rosary ¨è Harrison groove ¨é 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 ¡é : Potbelly
Diagnosis
¨ç Hx of inadequate intake & Sx
¨è Lab ¥¡) S-Ca : n or ¡é
¥¢) S-P < 4mg/dl
¥£) S-ALP ¡è
* ¥¤) urinary cAMP ¡è
¥¥) serum 25-hydroxyucholecalciferol¡é
* ¨é X-ray
A. active R. : *wrist-best for early Dx
¥¡) distal end : widened, cupping, frayed
¥¢) distal end of U & R¿Í metacarpal bone °¡°Ý¡è
due to not-calcified large rachitic mataphysis
¥£) decreased shaft density, prominent trabeculae
* B. healing R.
¥¡) line of preparatory calcif.ÃâÇ÷
¥¢) shaf°¡ zone of preparatory calcif. À¸·Î growµÇ¾î united
Differential Diagnosis
¨ç craniotabes ¥¡) immediate postnatal period
¥¢) hydrocephalus
¥£) osteogenesis imperfecta
¨è rosary ¥¡) rickets
¥¢) scurvy
¥£) chondrodystrophy
¨é epiphseal lesion ¥¡) cong. epiphy. dysplasia
¥¢) cytomegalic ds
¥£) syphilis
¥¤) rubella
¥¥) copper deficiency
¨ê bow legs : family Hx
¨ë vit. D resistant R.
Complication
¨ç resp. inf. ( bronchitis, bronchopn. )
¨è pul. atelectasis
¨é IDA & anemia due to inf.
Prevention
¨ç UV exposure
¨è oral vit. D 10ug or 400 IU/day
Treatment
¡¤ 2-4 wk Tx½Ã X-ray»ó È£Àü
¨ç oral vit D©ý 50-150 ug daily
1, 25 (OH)©ücholecalciferol : 0.5-2 ug
¨è 15,000ug vit D single does
** ÀåÁ¡ ¥¡) more rapid healing
¥¢) earlier DDx from vit. D resistant R
¥£) less dependent on parent for daily adm. of vit. D
¡æ * no responce : vit D RR
¡æ complete healingÈÄ vit. D 10 ug/daily
Tetany Of Vit D Deficiency
** -age : 4mo-3yr
- S-Ca 7-7.5 mg/dl ¡é½Ã muscular irritability
- clinical
¥¡) latent tetany ( S-Ca < 7-7.5 mg/dl )
: aSx, Chvostek, Trousseau, Erb procedure¿¡ ÀÇÇØ 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. CaCl©üin milk
¥¢) 5-10ml of 10% calcium gluconate
¥£) calcium lactate : 10-12 g/day for 10 days
Hypervitaminosis D
- idiopathic hypercalcemia¿Í Áõ¼¼ ºñ½Á
- large intake for 1-3mo ½Ã
- 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¡é
¥¢) aluminum hydroxide : po
¥£) cortisone
¥¤) sodium versenate
Vitamin E Deficiency
; vit E (¥á-tocopherol) : fat soluble antioxidant
°æ¿ì **¥¡) 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
¥¡) ÃÖ¼Ò ÇÏ·ç ¿ä±¸·® 0.7mg/g of unsat.fat in diet
¥¢) premature½Ã 15-25 IU/24hr Åõ¿©
Vitamin K Deficiency
naphthoquinoneÀ¸·Î oxidative phosphorylation¿¡ °ü¿©
# vit K dependent factor
¥¡) prothrombin (II)
¥¢) proconvertin (VII)
¥£) plasma thromboplastin component (IX)
¥¤) Stuart-Prower factor (X)
natural vit K : vit K©û(2-methyl-3-phytyl-1,4-naphthoquinone)
cow milk > human milk
Clinical Manifestation
Eti.
¥¡) abs. & utilization of fat Àå¾Ö
¥¢) intestinal synthesis Àå¾Ö : prolonged AB
¥£) diarrhea esp. breast fed
¥¤) liver ds
* ¥¥) dicumarol : liver¿¡¼ vit K ÀÌ¿ë Àå¾Ö·Î 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