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Part 06. Nutrition

PART ¥µ. 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)

    ; Ç¥3-3

# ¡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