The Latest Nutrition Recommendations for Your Infant or Child

Good nutrition during the developing years of life has been correlated with improved growth, body height, IQ, educational achievement and hourly wage. Are you familiar with the current guidelines for infants, adolescents and teens?

Age 0-4 months. Breast feeding only, either directly from breast or expressed via pump. Supplement with Vitamin D 400 IU/Day (800 in winter). If mother cannot breast feed, iron-fortified infant formula is recommended. Do not offer juices, water, nonhuman milk or foods.

• If family history of allergy or atopic dermatitis, using breast milk or hypoallergenic hydrolyzed (casein or 100% whey protein) infant formulas instead of cow’s milk formulas may reduce the risk in the child.
• If infant was preterm or small for gestational age (SGA), nutrient-enriched and soy formulas are not recommended.
• Many formulas boast the addition of probiotics and long chain polyunsaturated fatty acids (LCPUFA) to their products, but there is no evidence that these are beneficial to the infant.

Age 4-6 months. Begin to introduce single grain, iron-fortified cereal (1 tbsp cereal mixed with 4tbsp breast milk, gradually increase the amount of cereal over time). Never put cereal in a bottle! Sit child upright and feed to them with a spoon.

Cues that an infant is ready for solid foods include:

• Doubled birth weight
• Ability to sit up without support with control of head and neck
• Infant shows interest in foods parents are eating

Age 6-8 months. Once all cereals have been tried, continue breast milk while gradually adding solids. Begin introducing 1-2 tbsp of both fruits and vegetables, strained, twice daily and increase to 2-3 tbsp. Try baby fruit juice in a cup and offer finely chopped or mashed fruits and cooked vegetables once all strained varieties have been tried. Introduce 1 food each week to determine which foods are poorly tolerated. Start with single ingredient baby foods before introducing mixed ones. Limit 1 serving per day of carrots, beets and spinach (may cause methemoglobinemia) and never feed them honey.

Age 8-12 months. Introduce finger foods in cups and encourage self-feeding (allow baby to get messy).  Begin to add finely chopped meats, one per week. Avoid sweetened beverages and foods that may get stuck in the throat (nuts, raw carrots, round candies, hot dogs, apple pieces, grapes and chips). Introduce no more than 4 ounces of unsweetened 100% fruit juice a day. Be sure to sit child up straight in high chair while eating, and always taste heated foods before serving. Do not restrict fat intake unless directed to do so by pediatrician.

Age 12-24 months. Add whole milk and eggs. Offer small portions. Never force toddler to eat. Continue to offer foods that have been rejected! Bedtime bottles are recommended. Transition to reduced fat (2% or fat-free) unflavored cow’s milk. Continue unsweetened 100% fruit juice and water. Limit sodium, sugar-sweetened beverages, saturated and trans fat intake. Encourage fruits, vegetables and whole grains and always offer water.

Age 2-21 years.  Primary beverage should be fat-free unflavored milk. Encourage healthy eating habits starting at age 11, stressing daily breakfast, limited fast food and eating meals as a family. Continue to limit sodium, sugar-sweetened beverages, saturated and trans fat intake. Encourage fruits, vegetables and whole grains.

• It is important not to overfeed your child. This has been associated with higher fat mass in children, insulin sensitivity (risk of diabetes) and childhood obesity.

References

Nutrition (pediatric and preventive care). In DynaMed [database online]. EBSCO Information Services. http://web.a.ebscohost.com.ezproxy.hsc.usf.edu/dynamed/detail?vid=3&sid=7ebdc599-239e-4629-b0ad-740dd1944370%40sessionmgr4005&hid=4107&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=115435.

Updated May 02, 2014. Accessed May 6, 2014.

SIRS: The End of a Deadly Disease Spectrum

When an infant or child falls very ill, one of the most feared complications is systemic inflammatory response syndrome (SIRS). 

SIRS is a deadly ending to a spectrum of bloodstream infection which begins when a bacteria or virus enters the bloodstream (bacteremia). In most cases, young bodies can successfully fight off the organism before it causes any serious problems. Unfortunately, this is not always the case. Sometimes, the immune system goes a bit too far and decides to put all of its cards on the table. It releases everything it has, including white blood cells, pro-inflammatory molecules and blood-clotting proteins. This most often leads to the loss of fluids in our blood vessels and the collapse of our circulatory system. Inside the body, the organs (heart, lungs, kidneys, brain) lose vital oxygen and nutrients and begin to shut down. Outside the body, doctors notice signs of shock, which include fever and changes in breathing, heart rate, mental status, blood pressure and temperature regulation. If caught very early, doctors can typically keep the patient alive. In many cases, however, nothing the physician does will save the patient from the downward spiral.

The inci­dence of SIRS is highest in infants (5.16 per 1000), occurring in 20% of low birthweight neonates and resulting in death in over 10% of cases. Studies show that 37% of infections leading to SIRS arise from the respiratory tract, while 25% are primary bloodstream infections (BSIs). 

The management of SIRS is performed in a neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU). Doctors will culture the blood and monitor vital organs while ensuring the body is receiving adequate oxygen. A broad spectrum antibiotic (fights many different infections) is started until a culture comes back from the lab showing what specific organism is causing all the trouble. The antibiotic is then switched to one specifically formulated to kill that bug. One of the most frightening scenarios for a physician is when the culture comes back showing a bacteria that is resistant to all the drugs we have available. This is becoming the case with some gram negative bacteria (Klebsiella and E. coli) that release something called endotoxin and are resistant to our last line of antibiotic defense against them, carbapenems.

Scientists and physicians continue to conduct studies in order to discover ways to prevent SIRS from occurring. Though many different types of treatments have been attempted, the most effective of them continues to be early detection with  prompt antibiotic administration and fluid resuscitation.

• Occasionally, other conditions can trigger SIRS (trauma, ARDS, neoplasm, burn injury, pancreatitis)
• In order to reduce your child's risk, always ensure they are up to date on their vaccinations and be sure to keep them away from undercooked meat, especially beef and chicken.

References

Principles and Practice of Pediatric Infectious Diseases. Judith A. Guzman-Cottrill, Beth Cheesebrough, Simon Nadel, and Brahm Goldstein. Part II, Section A, 11: The Systemic Inflammatory Response Syndrome (SIRS), Sepsis, and Septic Shock. Pg 97-104.

Is Ebola Coming To America?

The deadly Ebola virus has again struck the human race and attracted media attention in it's wake, particularly in the United States. For many, simply hearing or reading about Ebola evokes an uncomfortable and fearful feeling, partly due to media attention and movies like Outbreak but mostly because of the mystery that surrounds it. 

Is this virus as threatening to us as we make it out to be?

The Ebola virus likely begins it's life in African caves and mines within the bodies of fruit bats. Epidemics seem to begin when a single farmer or miner comes into contact with the infected animal. After seven days of incubation (virus making millions of copies of itself), the man develops sudden flu-like symptoms (headache, body ache, fever) and severe diarrhea that rapidly progress to cell death (necrosis), multi-organ failure, shock, widespread bleeding and, in many cases, death. Often, hospital staff or family members also become infected through contact with the patient's bodily fluids. 

Every couple of years, Ebola cuts through the middle of Africa like a knife, killing up to 88% of those it infects. It's monitored closely by the Center for Disease Control (CDC) for two important reasons: it easily spreads through the air (aerosol) and kills more than half of those it infects (high mortality rate). This is a harrowing combination for a virus but, despite it's label as a biosafety level 4 pathogen, it's currently not very threatening to the human race. Good sterilization and isolation processes help prevent rapid and deadly spread.

It's the fear of the unknown, though, that keeps scientists wary.

Ebola's lethal potential is recognizable in non-human primates: the virus has caused massive die-offs in gorilla and chimpanzee groups. It seems that the primates produce more infectious aerosol particles than do humans, attributing to the lethality. Luckily, these primate infections rarely spread to humans: only 25 human cases have been acquired from monkeys, with seven ending in death. The typical infection transmitted to humans from primates is more on par with a common cold. If this virus were to acquire the same virulence (or lethality) in humans as in monkeys, the results would be catastrophic. For now, however, it seems that Ebola is a manageable illness with little threat to the Americas.

• There are five known species of Ebola, each named for the regions where they were originally identified.  The first reported cases in 1967 included 550 humans in Zaire and Sudan. The Zaire Ebola virus recurred in Gabon in 1994, causing 317 cases. The Sudan Ebola species returned in 2004, but this time in Uganda, killing 224 (53%) of 425 patients. 

• The inflammatory response caused by the virus often leads to the body losing all it's platelets (used to plug holes), resulting in bleeding through multiple orifices.  It is for this reason it is known as a "hemorrhagic fever"

• A new Ebola vaccine has been developed, but low funding has halted human trials. It may be as long as 20 years before the vaccine is commercially available. 

References

Peters CJ. Chapter 197. Ebola and Marburg Viruses. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York: McGraw-Hill; 2012.http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu/content.aspx?bookid=331&Sectionid=40726956. Accessed March 22, 2014.

The New Electrolarynx For Intubated Patients

The New England Journal of Medicine (NEJM) recently published an exciting article showcasing some breakthrough technology: physicians successfully used a device called an electrolarynx, allowing an intubated patient to communicate with his providers and family members. If you've ever had to witness a loved one in a setting where they were intubated, you know how frustrating it can be for the patient, family and staff.  This new technology will be extremely helpful in intensive are unit (ICU) settings where doctors can change their treatment regimens based on feedback from the patient, improving care tremendously. The patient and device (white arrow) can be seen below.

Read the article here:
http://www.nejm.org/doi/full/10.1056/NEJMc1313379

Deciphering Your Recent Blood Test, Part 1 of 3

On your recent visit to the doctor's office, you had the pleasure of getting stuck with a needle and drained of a few small tubes of your blood. You were left with a painful memory, a small bruise at the site of injection and a printout of the results. You spend a few seconds looking through the words and values before giving up, but wouldn't it be helpful if you really knew what all of those numbers meant? 

The laboratory blood test is one of the most useful diagnostic tools of the modern physician. It allows the provider to peer inside the body like a mechanic checks under the hood. There are many blood tests available, from single tests on proteins to "panels" containing several different measurements. Two commonly ordered panels are the complete blood count (CBC) and the comprehensive metabolic panel (CMP).

CBC

Our blood is made up primarily of red blood cells (RBC) and white blood cells (WBC). The RBCs carry nutrients through the body, while the WBCs protect us either by filling holes (platelets) or by attacking and killing whatever looks suspicious (leukocytes). The colors are red and white because, simply, when you spin the blood around very fast, these cells separate based on weight and reveal red-colored and white colored fluids. The CBC is performed by a machine that lines the blood cells up in a single row and counts how many are present in a set amount (microliter) of blood. 

WBC. An increase in WBC typically suggests that our body is training an army to kill an infection. This can also be elevated in cases of cancer or with the administration of steroid medications. The specific types of WBCs (neutrophils, eosinophils, basophils, monocytes or  lymphocytes) help give insight as to what type of infection may be present (for example, neutrophils are released acutely for bacterial infections). Decreases in WBCs are seen most commonly as a side effect of medications such as chemotherapy, antibiotics and anti-seizure drugs. In other cases, a decrease may suggest that something is killing them (infection, alcohol, autoimmune, radiation) or that there is a problem within the factory that produces them (the bone marrow). 

RBC and Hemoglobin. The primary role of the RBC is to carry oxygen, using hemoglobin, to cells so they can use it to make energy. When RBCs are decreased, it is known as anemia. This can be caused by iron (holds on to oxygen) deficiency, blood loss from chronic diseases, genetic diseases such as sickle cell anemia, significant bleeding or a problem with the factory that produces RBCs (the bone marrow). Increased RBCs can be seen in cases of dehydration, chronic breathing problems (COPD) and some cancers of the bone marrow.

Hematocrit. This is simply the ratio of red to white fluid when the blood is spun around very fast in a centrifuge. Normally, 46% of blood is RBCs. If this number is low, it's an anemia. 

MCV. This is the size of the RBC, much like measuring the square footage of a house. Increased MCV is seen with alcoholism, vitamin deficiency (B12 and/or folate) and a stomach disorder called pernicious anemia. Decreased MCV suggests one of the anemias described above.

MCH and MCHC. These measure the amount of hemoglobin per RBC, helping the physician narrow down the type of anemia present. MCHC is decreased in the anemias described above, and elevated in some genetic diseases.

RDW. This compares the RBCs to one another. If there is a large discrepancy between them, meaning some are very large and others are very small, this number will be high. The most common cause of this is iron deficiency anemia.

Platelets. Platelets are very important because they plug holes and cracks to stop bleeding. Low platelets are dangerous because it increases the risk of bleeding, whether out of a wound or into body cavities like the head or digestive system. High platelets are also dangerous because they cause over-clotting, which can lead to obstruction of blood vessels and thus problems like stroke and heart attack. Platelets are often kept intentionally low with medication (such as aspirin) to reduce the risk of stroke and heart attack. Many rare diseases and some cancers can also cause low platelet counts. 

• Parts 2 and 3 of this section, coming soon, will cover the CMP and other specialty tests.

• Your physician should discuss any abnormal blood test result with you. 

• Visit our resources at thedailydiagnosis.com for more trusted information on blood tests.

References

Chapter 5. Laboratory Diagnosis: Clinical Hematology. In: Gomella LG, Haist SA. eds. Clinician's Pocket Reference: The Scut Monkey, 11e. New York: McGraw-Hill; 2007. 

Klepin HD, Powell BL. Chapter 103. White Cell Disorders. In: Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S. eds. Hazzard's Geriatric Medicine and Gerontology, 6e. New York: McGraw-Hill; 2009. 

Verhovsek M, McFarlane A. Chapter 173. Abnormalities in Red Blood Cells. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York: McGraw-Hill; 2012.