CHAPTER 7 CHILDHOOD AND NUTRITION 1.

Nutritional Status of Children in The United States - Nearly half of all children in USA consume less than 70% of the RDA for iron and zinc - The calcium, vitamin B6 and folate content of many childrens diet is also inadequate. - Survey has revealed no symptoms or signs of frank dietary deficiency in the majority of children, with exception of iron. 1.1 Poverty and The Undernourished - Socioeconomic status is an important determinant of nutritional adequacy in children, with children from families living below the poverty line more likely to be undernourished. - Poverty is associated with impaired growth in children, and the impact can be severe articularty in minority groups at high nutritional risk. Studies of lowincome populations have found a significant umber of children underweight or stunted. Homelessness - Homelessness appears to increase nutritional risk beyond that of poverty alone. - A study from New York City in 1991 found that homeless children had higher rates of growth stunting when compared to domiciled children at comparable poverty levels. Even after controlling the other potential influences on growth, homeless children tended to have lower height for age with preservation of normal weight for height a pattern consistent with exposure to mild to moderate undernutrition. - Greater stunting was found in children form single-parent families and those with large numbers of children. 2. Growth and Development During Childhood - Individuals maximum potential size is genetically determined, but nutrition during the growth years has major influence on whether this potential is achieved. 2.1 Height and Weight - Rapid growth in the first 12 months of life triples the birthweight and increases the infants height by nearly 50%. - The growth rate sloes markedly during the second year, with the average height increasing only 12 13 cm and the average weight increasing about 25%. - Childhood is a period of slow and steady growth between the explosive growth of infancy and the acceleration of the pubertal growth spurt. preschool years ( age 2 5 ) : average weight gain 5 6 lb per year Height increases 2,5 3 inches per year. Doubling of birth length at about age 4. school years ( age 5 10 ) : average weight gain 7 lb per year Height increases 2,5 3 inches per year. Gender Differences - Appear at around age 6, with males being slightly taller and heavier than females. - Females begin pubertal growth earlier than males, so by age 9 females are as tall as males and generally heavier.

Ethnic Differences In USA, Black infants have smaller birthweights than White infants, but from age 2 through adolescence Black children are taller than White children at the same age. Asian children are shorter and lighter than their White and Black counterparts. Growth Charts - Growth is predictable characteristic of normal children, and the rate of growth is sensitive to changes in nutrition growth patterns during childhood can be used to evaluate nutritional status. - The National Center for Health Statistics (NCHS) has constructed standard growth charts using data from cross-sectional national surveys of large numbers of children in US. - The charts are used to separate normal form abnormal growth patterns and to draw attention to unusual body size useful information on growth rates can be obtained by examining serial measurements. - Three basic growth chart ( height for age, weight for age, weight for stature ) : Height for age : good indicator of chronic nutritional stature ( steady linear growth is a good measure of the long-term adequacy of a childs diet ) Weight for height : better indicator of recent nutrient intake than of longterm changes ( factor slowing or increasing growth affect weight earlier than stature ) - Healthy children expected to maintain growth channels when serial measurements over time are recorded. Normal variation in the size of individual children will be apparent in the percentile growth channel that each individual follows. - No clear-cut guidelines to interpret shifts on growth charts : short term changes are less likely to be significant if they occur between the 25th and 75th percentiles. A distinct falloff in linear growth should raises suspicion that a growth disturbance, possibly related to undernutrition, may be present. A child whose weight increases from 50th to 90th percentile over a short time is at risk of becoming obese. - Weight for height is a standard criterion for determining obesity, but in some children, this may not predict the level of body fat measurement of a triceps skinfold is the single most accessible and useful measurement thickness above the 85th percentile is generally indicative of excess body fat. - Wasting : a child who has very low weight for height indicate recently being markedly undernourished slowdown in weight gain - Stunted : a childe whose weight and height are both low for age, but whose weight is appropriate for height long-term undernutrition during childhood hypocaloric dwarfism : stunting due to chronic inadequate intake of a generally well-balanced diet OR maybe genetically short, have insufficient growth hormone, suffer form a number of other disease unrelated to nutrition - Characteristic of childhood growth : catch-up growth : the ability to return to the predetermined growth channel after falling out of it because of undernutrition of disease unless the undernutrition has been prolonged or occurred very early in life 2.2 Body Composition - Percentage of body fat is greatest at age 9 12 months ( 25% of body mass )

12 months - 8 years children become leaner half of all new tissue formed is skeletal muscle at age 8 years fat percentage is 13 % of body mass and then begins to increase again ( the prepubertal fat spurt )

2.3 Organ Systems - Many organ system develop in general pattern similar to that for height and weight. - Different pattern : neural tissue rapid during infancy and nearly complete before adolescence 75 80% complete by age 2 95% of its adult weight by age 10 - Different pattern : genital tissues do not begin rapid development until adolescence - Different pattern : lymphoid tissue ( tonsils, thymus, spleen ) develop rapidly through preadolescence, begin to involute during adolescence The Digestive System - Develop rapidly in early childhood - Salivary glands : fully functional by age 2 years - Stomach capacity increase throughout childhood fro 250 300 cc at 1 year old 500 cc at 2 years 900 cc at 10 years - Small intestine : 3 m at birth doubles in length by the beginning of adolescence - Pancreatic and intestinal enzyme systems : partially developed at birth adultlike function early in childhood pepsin, trypsin, amylase secretion : fully developed by 2 years old Lipase secretion : slowly, but complete at 3 4 years old - Liver : continues to develop the ability to storage glycogen and provide glucose between meals. - Large intestine : regularity in timing and character of defecation is usually established by 2 years old neuromuscular development enables the preschooler to control defecation and become toilet trained - By the end of the preschool period, the digestive system is functionally mature. The Dentition - Third semester of pregnancy : calcification of the primary teeth begins - 5 6 months of age : eruption of primary teeth - 3 years of age : 20 primary teeth have erupted - Establishment of the primary dentition and growth of jaws in early childhood enables preschooler to masticate and swallow an increasing variety of solid foods - Shortly after birth until late teens : calcification of permanent teeth - 6 7 years : eruption of permanent teeth The Urinary System - Matures in early childhood - 2-3 years the developing kidney is fully able to concentrate and dilute urine to maintain water balance - Greater ability to control water exchange dehydration occurs less readily in preschool children than in infants

3. Nutritional Requierements During Childhood 3.1 Recommended Dietary Allowances for Children - Divided into 3 age groups : age 1 3, age 4 6, age 7 10 - Gender difference in size and body composition are minimal before the onset of pubertal growth below age 10, dietary allowances are identical for both sexes. - Calculated to meet the needs of children of average height, weight, and activity can be a wide range of adequate daily intake - Total need for most nutrients increases, but decline per unit body weight because lean body mass is skeletal muscle has lower rate of resting metabolism nutrient - Needs per unit body weight fall as the growth rate decelerates 3.2 Energy Needs - Adequate energy is of prime importance during childhood growth - Determined by REE, level of activity and needs for growth - REE : varies primarily with the amount of lean body mass - Activity levels : vary considerably among children and in individual children form day to day if not constrained by illness or the environment, children are very active energy expenditure of acitivity is typically 1.7 2 x REE - Energy cost of new tissue is about 5 kcal/gram energy for growth is only a small component of the total energy requirement ( 1 2 % ) - RDA : age 1 3 : 102 kcal/kg/day Age 4 6 : 90 kcal/kg/day Age 7 10 : 70 kcal/kg/day - Childs appetite is usually a good measure of appropriate energy intake to meet nutritional demands - Adequacy of intake should be based on satisfactory growth as determined from growth charts and measurement of body fat. 3.3 Protein Needs - Characteristic : protein synthesis and deposition into new tissue - Nitrogen retention: infancy ( first few months ) : 200 mg/kg/day age 4 years : 11 mg/kg/day 1 4 gr/ kg of new tissue - Calculated based on maintenance requirements, changes in body size and composition and growth rates. - There is a slow decrease in protein needs relative to weight during childhood : RDA : age 1 3 : 1.2 g/kg Age 4 6 : 1.1 g/kg Age 7 10 : 1 g/kg - Evaluation on protein intake during childhood should consider the quantity AND the quality of the dietary protein. - Judgments on the adequacy of protein intake in children should be based on satisfactory growth rate as determined from growth charts. 3.4 Fat Requirements - Major source of energy during childhood - Provides 36 38% of total energy in the diet - AAP ( American Academy of Pediatrics ) :

age > 2 years : fat : 30% of total calories; saturated fat less than 10%, 3% of total energy form essential fatty acids, linoleic acid and alpha- linolenic acid, dietary cholesterol less than 300mg / day; nutritional adequacy should be achieved by eating a wide variety of foods; adequate calories and other nutrients must be provided to support growth and development. 3.5 Carbohydrate Requirements - 40 60 % of total calories - Provide a readily available source of energy - Should be provided ample complex carbohydrates from varied selection of whole-grain cereals, legumes, fruit and vegetables. - Children tend to eat slightly more added sugar than adults ( 14% vs. 11% of dietary energy, respectively ) - Families trying to reduce sugar consumption should set moderate goals rigorous elimination of sugar containing foods from a childs diet without adequate energy substitution lead to a hypocaloric intake and poor growth. 3.6 Fiber Requirements - Adequate dietary fiber in a childs diet may lessen constipation and lower chances of becoming obese. But on the other hand, children have small stomachs and food high in fiber are bulky and often low in calories children may be unable to consume adequate calories for normal growth. Increasing fiber intake in the school-age child may produce abdominal pain, bloating and flatulence, also may interfere with the absorption of nutrients such as zinc and magnesium. - AAP recommendation : modest amount of fiber including whole-grain cereals and breads, fruit and vegetables; unbalance diet that emphasizes high-fiber, low calorie foods should be avoided during childhood. 3.7 Vitamin Requirements Fat-Soluble Vitamins - Vitamin A : Central role in cellular growth and differentiation during development particularly in epithelial tissue. Adequate intake is important. RDA : 400 RE at age 2 700 RE at age 10 - Vitamin D : Requires for normal skeletal growth RDA : >6 months age : 10 g ( 400 IU ) - Vitamin E : Requirements increased with increasing body weight during childhood growth. RDA : 6 mg at age 2 7 mg at age 10 - Vitamin K : No specific data requirement. RDA : 1 g/kb body weight Water-Soluble Vitamins - Thiamin, riboflavin and niacin : Important in energy metabolism. Intakes based on energy intake are adequate during childhood. RDA : thiamin = 0,5 mg/1000kcal

Riboflavin = 0,6 mg/1000kcal Niacin = 6,6 NE/ 1000kcal rise proportionally with increasing energy intake during childhood growth Pyridoxine (B6) : Plays central role in protein utilization and synthesis. Required in increasing amounts during childhood growth. RDA : 0,02 mg/ g protein 1 mg at age 2 1,4 mg at age 10 Folate and B12 : Required during synthesis of large amounts of new blood cells in growing vascular system No specific data requirement interpolated from adult RDA RDA based on body weight Vitamin C Central role in collagen synthesis necessary for optimal growth and development of supporting tissues including cartilage, bone and the connective tissue in skin and blood vessels. Little data on requirements in children, 10mg / day protect infants from scurvy, > 6 months of age gradually increased to adult level RDA : 1 3 years : 40 mg 3 10 years : 45 mg

3.8 Mineral Requirements Major Minerals - Calcium and Phosphorus Skeletal growth during childhood requires a strong positive balance of calcium and phosphorus Lack specific data RDA calcium : age 1 10 : 800 mg/ day RDA phosphorus : age 1 10 : 800 mg/ day Ratio phosphorus: calcium = 1 : 1 Milk supplies most of calcium and phosphorus by children in the US, however many Blacks, Asian Americans and Americans Indians can drink little or no milk because of intestinal lactase deficiency other source of calcium : dark green leafy vegetables and sesame seeds, or fermented milk product ( often are better tolerated ). Magnesium RDA : 6 mg/ kg/ day; 80 mg at age 2 170 mg at age 10 Iron Need for synthesize hemoglobin during steady growth of the red cell mass and for myoglobin synthesis in developing skeletal muscle. Target iron storage at 20 years = 300 mg RDA age 2 10 : 10 mg/day Iron deficiency is the most common deficiency in children in US, particularly those under 3 years old, because childrens diets are often of limited intake of iron-rich food such as meat and eeg lower in iron. Zinc Important in protein synthesis and normal growth. Even marginal deficiency during childhood may slow growth. RDA : 10 mg/ day

Severe zinc deficiency during childhood and adolescence cause marked stunting of growth and delayed sexual development. Children of low-income families are at an increased risk for suboptimal zinc nutrition because of low dietary intake of meat, fish and whole grains.

Iodine Few studies relative energy requirements are used to set the iodine allowance for children RDA : 70g at age 2 120 g at age 10 Iodine deficiency has adverse effects on the growth and development. Selenium Little is known about selenium needs during childhood allowances have been extrapolated from adult values on the basis of body weight, with additional amount estimated for growth requirements. RDA : age 1 6 = 20 g Age 7 10 = 30 g

Trace Minerals - Very little known about children requirements for many of the trace minerals. - RDA has estimated ranges of safe and adequate dietary intakes for copper, manganese, fluoride, chromium, and molybdenum in childhood. - Since the toxic levels for many trace minerals, particularly in children, may be only several times usual intakes, the RDA committee has recommended that the upper levels of intake for these trace elements not be routinely exceeded. 3.9 Water and Electrolytes - During infancy, daily turnover of water is rapid ( about 15 20% of total body water is taken in from food and water and excreted each day ). - As children grown this decreases steadily, and by early adolescence water exchange is similar to adult rates ( about 5 %). - Water requirements per kilogram of body weight fall steadily, from 120 -140 ml/day at 1 year to 60 8- ml/kg at age 12. - Control of water balance is less precise in early childhood, when water exchange rates and water requirements per kilogram of body weight are higher the younger child is more prone to dehydration than the older child and adult parents need to pay special attention to the substantial water needs of infants and young children. - Along with the increase in total water requirement, electrolyte needs increasse steadily during childhood growth. 4. Feeding Skills - By age 1most infants have developed a coordinated pincer grasp, and finger-feeding becomes common and easy. - About midway through the second year, children begin to scoop food into a spoon, losing much of the food because they lack wrist control. - Later in the second year, the coordination of the elbow and wrist allows smooth transfer of the spoon ( and its content) to the mouth. - Although most 2- year-olds can move a cup steadily without spilling the content and can handle a spoon, food is generally transferred from the plate to the spoon by fingers. - Around age 4, most children begin cutting their foods. - By age 5, most can handle a knife and fork as well as the spoon.

Rotary chewing movements begin around 12 months, as primary dentition is established. The ability to chew hard, brittle or fibrous food increases as the permanent teeth develop during the school years. Food should be prepared with the aim of supporting the development of self-feeding skills and until the child develop the dexterity and motor skill to manage utensils, food should be served in a way that enables them to learn feeding skills without great anxiety or frustration. Most foods served to 2 3 year olds should be divided onto i=bite-sized pieces and prepared so they can be eaten with the fingers.

5. Preschool Years : Ages Two to Five 5.1 Changing Family Structures Working parents may lack the time, interest, and skills to prepare meals for the family more families are depending on takeout and convenience foods meals that generally are nutritionally imbalanced and high in fat, salt and sugar. 5.2 Eating Habits and Schedules - After their first birthday, children usually develop a reduced appetite because nutritional demands fall as the growth rate decelerates during the second and third years of life normal pattern but make concern for many parents families need to select varied and nutrient-dense foods so that total nutrient intake remains adequate. - The average preschool-age child stops eating iron-fortified infant cereals, drink less milk than during infancy and often refuses vegetables intakes of calcium, riboflavin, iron and vitamin A fall. - In recent study in preschool children, children were offered a wide variety of food in addition to standard meal-time foods although there was considerably day-to-day variability in the type and quantity of food consumed, the children accurately self-selected appropriate caloric intake when all the study days were averaged it appears that normal preschool children can regulate energy intake on their own - despite meal to meal variability and maintain energy balance. 5.3 Food Preferences - By 4 5 age years of age, most children have established a wide range of food preferences and aversions shaped by what type of food the child is offered, how it is offered, and parental and peer attitudes toward foods. - Preschoolers generally prefer carbohydrate rich foods that are easy to chew and swallow, most also like milk, fresh fruit and fruit-flavored beverages, easy-to-chew meats such as ground meats, cheese, and yogurt. Vegetables are typically the least preferred food group. 5.4 Introducing New Food and Encouraging Healthy Eating - Preschool children will usually eat, enjoy, and develop preferences for what is - served to them regularly. - Several ways to introduce new foods and encourage healthy eating in young children : Companionship and support at mealtime are important. Maintain a reasonably consistent eating schedule by providing meals and snack at predictable times. Dont force children to eat. Avoid using rewards. Try the one bite policy when introducing new foods to a preschooler.

It is usually better to offer less than children usually eat, and offer seconds if they ask for them. Role models are important in acceptance of new food. Allow the child to participate in food preparation. At about age 4 5, children should be able to eat raw vegetables such as carrots, broccoli and celery sticks. Preschool children generally prefer raw vegetables to cooked vegetables.

5.5 Snack and Food Jags - Young children have a small stomach capacity and cannot eat large meals scheduling several small meals and snacks throughout the day is a good plan for most children. The important thing is what is eaten. - Studies in 10-year-old children have shown that snack are even more important contributes to overall nutrition; supplying 1/3 of the daily energy and fat intake, 20 % of the daily protein, and over 40% of the daily carbohydrate for many children. - Food jags : patterns of eating in which a very few food items are eaten to the exclusion of all others common in preschoolers 5.6 Prevention of Choking - Choking and death by asphyxiation most often occur in children under 2 years old. - Food most often : hard candy, grapes, nuts, chips and hot dogs. - Potato, corn and tortilla chips; popcorn; raw vegetables, dried fruit such as raisins, dates and apricots are also not appropriate for preschoolers. - Choking is more likely to occur when a child is eating while running o playing a child should be encouraged to sit down when snacking and an adult should always be present when a young child is eating. 6. School Years : Age Five to Ten - School-age children begin to make more of their own food choices. - Sweetened beverages, cookies, cakes and other foods of poor nutritional value are commonly chosen. 6.1 Eating Patterns in Older Children - Many of the feeding problems of the preschooler disappear, appetites and food preferences are more predictable and increasing activity stimulates a steady appetite. - Differences in intake between males and females become apparent about age 6 7 males tend to eat more and consume more protein and micronutrients than females. - In school-age children in the US, fat intake is generally about 35 40 % of total calories while sugar contributes approximately 25% of calories. Breakfast - Eating breakfast rebuilds glycogen stores depleted during the night and provides energy for morning activities. - Skipping breakfast can diminish a childs attention span and morning performance at school, play or sports. - Children should be reminded that breakfast does not have to consist of traditional foods such as cereal and eggs.

7. Influences on Nutrition in Childhood - Parental influences: Mealtime criticism of children by their parents reduces food consumption and reduces intake of certain nutrient, particularly vitamin A and C. - The impact of television on childhood nutrition: In study of children from 6 to 11 years old, the risk of obesity was strongly correlated with the amount of television watched each day. 8. Childhood Diet and Health 8.1 Diet, Behavior and Hyperactivity - Two common disorders of childhood, iron deficiency and lead toxicity, have detrimental effects on childhood behavior. - Many children who skip breakfast are less able to concentrate at school and have shorter attention spans than children who eat breakfast. - Hyperactivity is childhood behavioral disorder characterized by severe and chronic impulsiveness, inattention and restlessness. Nearly all studies have found that diet has little, if any, role in hyperactivity. Sweeteners - There is no convincing evidence that refined sugars or aspartame caus behavioral problems in children. - In a double-blind study at 1994, children reported by their parents to be sugarsensitive were fed large amounts of sucrose, aspartame or a placebo for three weeks and neither sucrose nor aspartame affected the childrens behavior or function. Artificial Flavors and Colors - Double-blind studies of diets eliminating artificial colors and flavors have generally found that the great majority of hyperactive children do not benefit. However, a small minority of children with ADHD may benefit from elimination of artificial colors and flavors from their diet. - Some experts recommend a short-term elimination trial to determine whether the child will respond. If no improvement is seen during the elimination period, the child should resume a normal diet. Caffeine - The stimulant effects of caffeine may be more pronounced in children than in adults. - Chocolate, ice cream and carbonated beverages often contain caffeine and some children become inattentive, restless and have difficulty sleeping and also irregular heartbeats after ingesting these products. - Caffeine consumption should be limited during childhood, particularly in those who appear sensitive to its effects. 8.2 Vitamin and Mineral Supplementation - In 1993 the AAP does not recommend routine supplementation for healthy children. - A vitamin-mineral supplementation may be indicated for children in special situations such as children and adolescents from deprived families, or those who suffer from parental neglect of abuse; those who have anorexia; children who are on dietary regimens to manage their obesity; pregnant teenagers; children and adolescents consuming vegetarian diets without adequate dairy products; or those with chronic diseases. 8.3 Vegetarian Diets

Plant-based diets supplemented with milk or with eggs and milk are generally very similar nutritionally to diets containing meat, and such diets may provide some nutritional benefits including rarity of obesity and tendency lower blood pressure. However, such diets may not provide adequate iron for the growing child the child should be encouraged to eat ample of nuts, seeds and legumes in addition to milk and eggs. Because vegans exclude all animal products from the diet, combination of cereals and legumes are necessary to provide ample protein of high biological value must be properly combined to ensure amino acid intake will be adequate to support growth. Because vegan diets are bulky, young children may not be able to consume an adequate volume of food for their needs energy density is low may result in failure to grow. Generous intake of vegetable oils and fortified soy milk can help provide necessary calories and protein to support growth. Vegan diets lack the milk products and meats that are rich sources of bioavailable calcium, zinc and iron for growing children; and they are also high in phytates to avoid deficiencies it is important to have a generous intake of unrefined cereals, legumes, seeds and dark green leafy vegetables.

8.4 Dental Health - Nutritional disorders during childhood can interfere with the calcification and eruption of the teeth. Ample protein, calcium, phosphate and vitamins C and D are particularly important. - Diet is also important in the prevention of dental caries. Plaque on the tooth surface contains several strains of bacteria able to break down dietary sugar produce lactic acid dissolves the enamel, leads to cavity formation progress the cavity will deepen and allow bacteria to invade the dental pulp, causing infection, swelling and pain. - Cariogenic sugar : sucrose, followed by glucose, maltose, lactose and fructose. Sticky, retentive form of sugars are more cariogenic than sugars in liquid forms. - The frequency of sugar ingestion also influences dental decay bacteria can produce acid for only about 20 minutes 1 hour (saliva eventually washes away the food particles and contains buffers that can neutralize the acid) foods of less cariogenicity should be eating as snacks and sugar intake should be restricted to mealtimes. Fat can coat the teeth, reducing the retention and cariogenicity of sugars in the plaque. Protein increases the buffer capacity of the saliva. - Foods rich in protein and fat eaten after carbohydrates may reduce the risk of caries. - Effective cleaning of the teeth after meals is also important. - Resistance to dental caries increases if the diet contains optimal amounts of fluoride. Fluoride is incorporated into the crystals that form the tooth enamel more resistant to demineralization from acid. - Fluoridation of the water supply provides children with ample of fluoride supplementation is unnecessary. - In areas where the fluoride content of the water is less than 0.3 ppm, supplements are recommended, and the best time to give supplements is at bedtime, after teeth cleaning. 8.5 Dietary Fat and Cholesterol

Atherosclerosis appears to begin early in life and progress in life and progress slowly into adulthood. Elevated cholesterol levels in childhood are thought to play a role in the initiation and development of atherosclerosis, and high total and LDL-cholesterol are correlated with the extent of early atherosclerosis in adolescents. Experts have recommended a strategy that combines 2 complementary approach: 1. Population-wide reduction in fat and cholesterol in the diets of all children 2. An individual approach aimed at identifying and treating children who are at greatest risk of having high blood cholesterol and an increased risk of cardiovascular disease in later life The guidelines for individual screening of children only for children who have a parent whose cholesterol level is greater than 240 mg/dl, or a family history of early ( less than 55 years of age) heart disease. Children who have an elevated LDL-cholesterol AHA Step-One diet 3 months careful adherence to this diet fail to achieve goal AHA Step-Two Diet under qualified supervision because this diet requires stringent reduction of saturated fat and cholesterol intake ( saturated fatty acids : less than 7% of total calories; cholesterol less than 200 mg/dl ) careful planning to ensure adequate intake of all necessary nutrients. There have been concerns about safety of implementing a lower-fat diet during childhood. Reducing fat intake while maintaining normal calories and protein will not lead to deficiencies of iron and calcium or other micronutrients. Another controversy surrounding cholesterol levels in childhood is whether high levels during childhood predict elevated levels in later life. A growing consensus of experts recommends the AHA Step-One Diet for children over 2 years old and adolescents. Many think if this diet could be adopted during childhood and carried into adulthood, it would reduce the incidence of cardiovascular disease and also help prevent a variety of other chronic conditions and disease of later life.

8.6 Food Allergies in Childhood - Early childhood is a common age for food allergies occur in 2 - 15 % of young children and much more likely to develop in those with a family history of allergy. - Environmental factors during infancy and exposure to antigens in early infancy may increase the risk of developing food allergies. - Food allergies occur when dietary proteins are incompletely broken down before absorption, allowing large molecules of protein to enter the body and interact with the immune system. The immune cells identify the food molecule as an antigen and react by producing antibodies, histamine and other defensive compounds, and cause a variety of symptoms including anaphylactic reactions to food. - Food allergies occur more often in early childhood than later in life because the developing intestinal tract and immune system are immature and inexperienced in handling food allergies. - Allergy to single foods is much common than to multiple foods, can be immediate or delayed up to 24 hours. - The preferred way to test for food allergy is an elimination diet. Food that most often provokes allergies are eggs, peanuts, fish and milk in 77% of cases; beef, pork, shellfish, peas, cocoa beans, hazelnuts, mustard in 12,8% of cases; and chicken, rabbit, garlic, soybeans, sunflower, carrots, almonds, peaches, bakers yeast and wheat four in 10,2% of cases.

Children often grow out of food allergies. A study in 1987 found that over of children no longer reacted to the foods they had been allergic to previously.

8.7 Lead Poisoning - In the US, elevated levels of lead in the blood are a major health risk for children. It sis estimated that over 3 million children under 6 years old have blood lead levels high enough to decrease intellectual performance and produce other adverse health effects. - Lead is distributed throughout the environment, and it makes its way into food through contaminated soil and water. Warm and hot tap water in homes with lead pipes is contaminated with lead. Dishes are potential sources. Acidic liquids have a greater tendency to cause leaching of lead. - A primary source of lead exposure, particularly on urban areas, is lead-based paints. Children can ingest lead by eating paint chips (which are often colorful and sweet tasting), or by ingestion of lead-contaminated dust and dirt during normal mouthing and exploratory behavior. - Children absorb more lead and are more sensitive to its effects than adults. Lead is absorbed and distributed much like calcium. Deficiencies in protein, iron or calcium enhance the absorption of lead and may increase its toxic effects in children. - Lead is a biochemical poison that interferes with cellular enzymes and metabolism. It can slow growth, damage hearing, and impair coordination and balance. A child with chronic lead intoxication may be listless and irritable and low levels of lead exposure in childhood can impair neuropsychological development and classroom performance. - The AAP now recommends that all children undergo blood lead screening when they are 9 12 months old and again at 2 years. 8.8 Iron Deficiency - Worldwide, it is estimated that over 2 billion people are anemic because of iron deficiency. - In many developing countries, a mostly cereal diet with little meat, fish and ascorbic acid is low in bioavailable iron. Intestinal parasites are common as a frequent cause of increased blood loss and iron deficiency. Iron deficiency may cause anemia, decreased performance and impaired mental and motor development. - Irondeficiency anemia is rare before 4 to 6 months of age, because the healthy infant has ample iron stores at birth. Iron deficiency develops between 6 months 3 years if increased needs for rapid growth are not met by and adequate dietary supply. - Poverty also increases the risk of childhood anemia. - Children who are deficient in iron have poor appetites, are more likely to develop infections, and grow more slowly than their healthy counterparts. They are often irritable, inattentive and withdrawn. Iron deficiency in childhood also impairs intellectual developments as shown in a study in Indonesia. - In order to prevent iron-deficiency anemia in children, regular sources of iron should be provided (food and supplementation). 9. Undernutrition in Childhood : A Worldwide Perspective - Poverty is a major determinant of undernutrition in children but other economic, social, cultural and educational factors contribute to the problem. - Weaning an infant at an early age without a nutritious replacement for breast milk is perhaps the most important single cause of childhood undernutrition.

Infections are a major contributor to morbidity and mortality in the malnourished child. Diarrhea aggravates undernutrition by causing malabsorption of energy, protein and micronutrients, and increasing water and electrolytes looses. The consequences of undernutrition include growth retardation, decrased resistance to infection and disease, impaired learning ability, and increased mortality. Undernutirtion is a contributing cause in 1/3 of all child deaths worldwide.

9.1 Protein-Energy Malnutrition Mild PEM - The mildest and most common form of PEM is growth failure alone. - Growth impairment, most often seen in the post-weaning period from 9 months 3 years of age, is common in children from developing countries. - Mild PEM in children increases the risk of infections, particularly diarrheal illnesses and measles, and increase mortality. Anemia is very often found in children with mild PEM and growth failure. - Growth retardation in early childhood is associated with functional impairment and diminished work capacity in adult life. Severe PEM - Kwashiorkor occurs when a child consumes a diet with adequate energy but with a very low protein : energy ratio. - Children with kwashiorkor will not grow, and they develop anorexia, diarrhea, and characteristic hair and skin changes. Electrolyte and protein losses cause fluid retention edema is a hallmark of kwashiorkor. Subcutaneous fat may be preserved and, with edema, may mask the wasting of underlying tissue. Severe muscle wasting often result in the childs being unable to stand or walk. - Marasmus is a form of severe PEM caused by starvation-inadequate intake of energy, protein and other nutrients results in a shrunken, wasted child. Body weight is less than 60% of expected weight for age. - Marasmic children are often severely anemic, suffer from chronic infections, and have a high mortality. - More often than either syndrome alone, severely malnourished children develop characteristics of both kwashiorkor and marasmus. The term marasmic kwashiorkor is used for children who are less than 60% of expected weight and have edema and other signs of kwashiorkor. - Associated deficiencies of vitamins and minerals contribute to the clinical picture of the child with severe PEM. - Treatment for severe PEM consists of providing adequate amounts of both calories and protein and treating intercurrent infections. - Although the mortality rate is high, then response of children who do recover is rapid. 9.2 Micronutrient Deficiencies - Micronutrient deficiencies are often associated with protein-energy malnutrition and can have significant adverse effects on growth, learning ability, and the immune system. - Studies have shown micronutrient deficiencies, particularly of vitamin A and iron, play major roles in childhood stunting in certain developing countries. Moreover, micronutrient deficiencies were associated with widespread retardation of cognitive, motor and psychosocial development in children. Vitamin A Deficiency - Xeropthalmia : damage to the eyes from lack of vitamin A

Deficiency also impairs immunity. Even mild deficiency of vitamin A is associated with an increased susceptibility to infection and increased mortality. Young children with vitamin A deficiency often die of overwhelming infections-many from severe measles. Preschool-age children (1-6 years old) are most susceptible to vitamin A deficiency. Diets that are mainly vegetarian, with staple such as rice or cassava, and that lack dark green vegetables and yellow fruits, will be deficient in vitamin A. Most cases in children are found in the rice-dependent areas of south and east Asia and in east Africa, where cassava is a major portion of the diet. In many countries where vitamin A deficiency is endemic, public health programs have begun to promptly treat early xeropthalmia and control vitamin A deficiency. Strategies for preventing deficiency involve modification of diets to include more sources of vitamin A, food fortification ( such as sugar in Central America and monosodium glutamate in southeast Asia), and distribution of high doses of the vitamin to young children every three to six months.

Iodine Deficiency - Dietary deficiency of iodine occurs mainly in areas where the soil and water, and therefore the food produced on it, are low in iodine. Deficiency disorders are also found when there is adequate iodine in the diet, but the food supply contains substances that inhibit iodine absorption and metabolism (goitrogens), include cassava, soybeans and cabbages. - Two most common syndromes are goiter and cretinism. - Iodine-deficiency disorders are most common in young children and pregnant women, when iodine requirements are high. The effects of iodine deficiency are particularly severe for the fetus and growing child. Iodine deficiency associated with neurological damage, impaired mental function and retarded physical development. - The most widely used and effective means of controlling iodine deficiency are fortification of salt with iodine and widespread oral or injected administration of iodinated oil.