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BREASTFEEDING

BY: SITI HAJAR MUHD ROSLI


Def: Feeding a child with human breast milk.
Breast milk is the best diet for babies
normal way of providing young infants with the nutrients they
need for healthy growth and development
initiated within the first hour after birth
Colostrum secreted during initial breast feed has higher content
of protein and immunoglobulins, compared to mature breast milk.

Exclusive breastfeeding is recommended up to 6 months of age
continued breastfeeding along with appropriate complementary
foods up to two years of age or beyond
Should be on demand

POSITION OF THE MOTHER
any position comfortable to her and the baby
Sitting or lying down
Her back should be well supported
Should not be leaning on her baby
POSITION OF THE BABY
whole body must be well supported
Head and body are in line without any twist in the
neck
Body should turn towards the mother with the
babys abdomen touching the mothers abdomen
Nose at the level of nipple
CRADLE HOLD
CROSS CRADLE
HOLD
FOOTBALL HOLD
SIDE-LYING HOLD
SADDLE HOLD
SIGNS OF GOOD ATTACHMENT
Babys mouth is wide open, proper latching on
Most of the nipple and areola in the mouth, only
upper areola visible, not lower one
Babys chin touches the breast
Babys lower lip is everted
EFFECTIVE SUCKLING
Baby suckles slowly
Pauses in between to swallow
Babys cheek are full, not
hollow or retracting during
sucking
ADVANTAGES
1. Safe , clean, hygienic, cheap and available to infant at correct
temperature
2. Fully meets the nutritional requirements of infant-1
st
few
months of life
3. Contain antimicrobial factors-protect against diarrhoeal disease,
necrotising enterocolitis and respiratory infection-1
st
few months
of life
4. Easily digested and utilized-both term and preterm
5. Promotes bonding between mother and infant
6. Sucking-development of jaw and teeth
7. Protect from tendency of obesity
8. Biochemical: prevention of neonatal hypocalcemia and
hypomagnesaemia
8. Contraceptives
9. Boosts mothers immune system









DISADVANTAGES
1. Unknown intake
2. Transmission of infection
3. Breast milk jaundice
4. Transmission of drugs
5. Nutrient inadequacies-beyond 6months without
introduction of appropriate solids
6. Vitamin K deficiency: insufficient to preveny
hemolytic disease of newborn
7. Potential transmission of environmental
contaminants(eg: nicotine, alcohol, caffeine)
8. Not sufficient for very preterm infants
1. Insufficient calories and protein for optimal growth
2. Insufficient sodium to compensate for high renal sodium
losses
3. Deficient in vitamins, calcium, phosphate: predispose to
anemia and osteopenia of prematurity



Special considerations
Contraindications of breastfeeding:
HIV, HTLV (Human Tcell lymphoma virus type I
and II)
Active Tuberculosis
Herpes lesions on mothers breasts
Infants with IEM: galactosemia,
phenylketonuria
Mother on certain medications:
Anticancer therapy, radioactive isotopes.
Necrotising enterocolitis
acute bowel necrosis seen in preterm infants receiving enteral
feedings started too early or advanced too rapidly
d/t bowel ischaemia causing loss of mucosal integrity
Enteral feedings leading to gas producing bacterial
proliferation invading damaged intestinal mucosa
Triad: feeding intolerance, abdominal distension, grossly
bloody stools/ change in stool character
Clinical signs: resp distress, apnea, bradycardia, lethargy,
vomiting, hypotension, acidosis
How to avoid?? Minimal enteral feed (MEF) is recommended
on day 1-3 of life (5-25mls/kg/day)
Enhances gut DNA synthesis, promoting gut intestinal growth.

Vitamins and minerals
supplement
Mainly consider for premature infants, in prevention of
anemia of prematurity
Multivits: (syrup Appeton) and hematinics
Given at day 14 of life when on feeding of 150mls/kg/day
Rx: Syrup Appeton 1cc OD, syrup folate 1cc OD, continue for
3-4 months post discharge.
FAC (Ferric Ammonium Citrate): for infants < 2kg start at day
14 of life (2mg/kg/day) D21 3mg/kg/d) day 28 (4mg/kg/d)
If transfused before: start at day 28

Total FAC= _____mg elemental iron X weight / 17.2
Nutrition
in Children

Chatichai
Nutrition and Health
Childhood and adolescence = key
periods for growth and development
Ensure daily energy and nutrients
requirements for health, growth and
development and health in adulthood
Inadequate intake of nutrients
(esp. 0-2 years ) might cause
irreversible changes


Enteral Feeding
The goal of nutrition is to achieve as near to normal
weight gain and growth as possible.
Enteral feeding should be introduced as soon as
possible.
Breast milk is the milk of choice.

Normal caloric requirements in:
Term infants: 110 kcal/kg/day
Preterm infants : 120 140 kcal/kg/day

Babies who have had a more eventful course need
up to 180kcal/kg/day

Route of administering
Orogastric Route (Tube Feeding)
Cup feeding
Breast Feeding
Term Infants
Milk requirements for babies on full enteral feed from
birth:
Day 1 - 60 mls/kg/day
Day 2 90 mls/kg/day
Day 3 120 mls/kg/day
Day 4 6 months - 150 mls/kg/day



Add 15% if the babies is under phototherapy
Prem Infants
Milk requirements for babies on full enteral feed from
birth:
Day 1 - 60 mls/kg/day
Day 2 80 mls/kg/day
Day 3 100 mls/kg/day
Day 4 120 mls/kg/day
Day 5 6 months - 150 mls/kg/day


Add 15% if the babies is under phototherapy
What is the maximum volume?
Target weight gain should be around 15g/kg/day (range 10-
25g/kg/day).
Less weight gain than this suggests a need to increase calories especially
protein calories. More weight gain than 30g/kg/day should raise the
possibility of fluid overload particularly in babies with chronic lung
disease.
Preterm infants
Increase feed accordingly to 180 to 200 mls/kg/day. (This should only be
achieved by Day 10 to Day 14 respectively if baby had tolerated feeds well
from Day 1
If on EBM, when volume reaches 75 mls/kg/day: add HMF.

Term infants
allow feeding on demand.
Total Parenteral Nutrition
Intravenous infusion of all nutrients necessary for
metabolic requirements and growth.

Indication for TPN
Birth weight < 1000 gm
Birth weight 1000-1500 gm and anticipated to be not on
significant feeds for 3 or more days.
Birth weight > 1500 gm and anticipated to be not on significant
feeds for 5 or more days.
Surgical conditions in neonates: necrotizing enterocolitis,
gastroschisis, omphalocoele, tracheo-esophageal fistula,
intestinal atresia, malrotation, short bowel syndrome,
meconium ileus and diaphragmatic hernia.
Components of TPN
Fluids
Carbohydrate
Protein
Lipids
Electrolytes
Vitamins
Trace minerals
Caution
Hyperkalaemia. < 4 mmol/l.
Hypocalcaemia. May result from inadvertent use of excess
phosphate.
Corrects with reduction of phosphate.
Never add bicarbonate, as it precipitates calcium carbonate
Never add extra calcium , as it will precipitate phosphates
Complications
Sepsis
Malposition.
Thrombophlebitis
Extravasation into the soft tissue

Metabolic complications
Hyperglycaemia
Hyperlipidaemia
Cholestasis
Normal output
Daily stool and urine output guidance
Day 0 1 wet nappy and meconium at least once a day
Day 1 2 wet nappies and meconium at least once a day
Day 2 & 3 3 or 4 wet nappies and changing stools at least once a day
Day 4+ 5 or 6 heavy wet nappies and yellow stools at least once daily
A baby who is passing meconium at 3 or 4 days old may not be getting enough milk.
A baby who does not have yellow stools by day 5 may not be getting enough milk.
A baby who is not doing as many wet nappies each day as expected may not be getting
enough milk.
Nutrition
Amino acids (protein)
Amino acids prevents catabolism; prompt introduction via TPN achieves
an
early positive nitrogen balance.
Decreases frequency and severity of neonatal hyperglycaemia by
stimulating
endogenous insulin secretion and stimulates growth by enhancing the
secretion of insulin and insulin-like growth factors.
Protein is usually started at 2g/kg/day of crystalline amino acids and
subsequently advanced, by 3rd to 4th postnatal day, to 3.0 g/kg/day of
protein in term and by 5th day 3.7 to 4.0 g/kg/day in the extremely low
birthweight (ELBW) infants.
Reduction in dosage may be needed in critically ill, significant
hypoxaemia,
suspected or proven infection and high dose steroids.
Adverse effects of excess protein include a rise in urea and ammonia
and
high levels of potentially toxic amino acids such as phenylalanine.
Carbohydates and Lipids
Carbohydrates
Provide energy for the body, especially the brain
and the nervous system.

Lipid
Lipids prevent essential fatty acid deficiency,
provide energy substrates and improve delivery
of fat soluble vitamins.
Iodine
Important for synthesis of thyreoid
gland hormones
Prenatal iodine deficiency impact on
cognitive development (e.g.learning
disabilities)
Less evidence on relationship between
deficit in children and cognitive
development

Folic acid (vitamin B9)
B-group vitamins (B1, B2, B6, B9, B12)
required for the synthesis of various
neurotransmitters
Folic acid deficiency in early
pregnancy risk of neural tube defects
1996 FDA a flour supplementation
programme in the USA reduced the
incidence of malformations by 13%
Fatty acids (omega 3, 6)
Omega 3,6 polyunsaturated fatty acids
(DHA) found in phospholipids in CNS
(brain, retina)
Play a role in cognitive development
Deficiency rare neurological and
visual disorders (esp. in premature
infants)
Iron
Metabolism of neurons, cognitive
functions and behaviour
Iron deficiency:
- impaired brain function:
* poor spatial memory in adolescents
* cognitive performance , attention
- impaired immunocompetence:
* decreased resistance to infections
- anaemia
Zinc
Key role in growth of cells and CNS
development
Modulates the transmission of nerve
signals
Deficiency in prenatal and postnatal
period: malformations of NS
Deficiency in childhood:
- impact on cognitive and motor
functions in vulnerable children

Intestinal flora (immunity)
0-5 years development of intestinal flora
BM important for the development of
immune system (L. bifidus, growth factors,
trans-oligosacharides), protection against
infections, allergies
IF ferments non-digestable carbohydrates
(fiber), results in formation of short-chain
fatty acids (SCFA) which provide colonocytes
with energy
Multiple deficiencies (Fe, Ca, Zn,
Mg, I, vit. B6, vit. C, folic acid)
Delayed growth and development
Rachitis (infants)
Anaemia (6-24 months, puberty)
Delayed menarch in girls (eating
disorders)
Decreased resistance to infections
Fatigue, low mental performance
Emotional disorders
Brain and cognition
Most intensive development of CNS in
prenatal period and up to 3 years
Decreased intake of energy and
essential nutrients in first years
important impact on structural and
functional development of CNS
Relationship between the intake of
some nutrients and cognitive
functions studied in detail
Bone growth
0-2 years very fast growth (esp.in length)
11-13 years (prepuberty) intensive bone
mineralization - half the mass of calcium of
the adult is laid down
9-14 years the period of peak bone
growth adolescents acquire 25% of their
final bone mass
Intense bone turnover in children, who
replace 50 to 100% of their skeleton in
a year, compared to 10% in adults
Bone growth
The construction of bone outweighs its
destruction allows the bones to
increase in length and get stronger
Calcium requirement of children (3-8
years) per unit bodyweight are 2 to 4
times greater than that of adults
Intake of calcium and phosphorus
Ca/P > 1 (cola beverages P>Ca)
Bone growth
Calcium
Phosphorus
Fluoride
Protein
Vitamin D
Vitamin A
Vitamin K
Vitamin C
References
WHO/Nutrition School-age children
and adolescents:
http://www.who.int/nutrition/publicatio
ns/schoolagechildren/en/
WHO/Global Strategy on Diet, Physical
Activity and Health/Childhood
overweight and obesity:
http://www.who.int/dietphysicalactivity
/childhood/en/
Aspects of Nutritional Assesment
Kamleshwari
Aspects of Nutritional Assessment

Dietary evaluation
Growth (weight, height, head circumference)
BMI (body mass index)
Additional corrections for:
-gestational age (premature infants)
-delayed/precocious growth (radiographic bone age)
-sexual maturity (Tanner stage)
Clinical evaluation (medical history, physical
examination and anthropometry)
Laboratory data (e.g., hemoglobin, iron, serum
proteins)
Dietary evaluation
Proper Diet as recommend for each age
should be the main consideration when it
comes to evaluate children with nutritional
disorders/deficiencies.

Growth
Implies a net increase in the size or mass of
tissue and occurs due to multiplication of cells
and an increase in the intracellular substance

Why monitor growth ?
Assessment of a childs growth is the best marker of
their well being- nutrition and good health
The normal pattern of expected growth is
traditionally displayed on a growth chart
Early detection of disease in children
PHASES OF GROWTH
4 PHASES OF HUMAN GROWTH:
Fetal
Infantile
Childhood
Pubertal



Fetal
Fastest period of growth
30% of eventual height
Determined by the size of the mother and by
placental nutrient supply
Insulin like growth factor 2 , Human placental
lactogen and insulin
Infantile phase
Growth during infancy to around 18 months of age is
largely due to adequate nutrition
Good health, normal thyroid function
Accounts for about 15 % of final height
Childhood phase
Growth hormone and IGH-1, thyroid hormone
acting at the epiphysis
40 % of final height
Psychosocial causes important
Pubertal growth spurt
Testosterone and oestradiol cause the back to
lenghten and boost GH secretion
Adds final 15% to height
Measurement
Height
Weight
Head circumference
Height
Most accurate height measuring equipment is the
Harpenden Stadiometer
Remove shoes, position the child with the heels and
back touching the backboard,head straight, eyes and
ears level,gentle upward traction of the mastoid
process,knees straight for children above 2 years

In children below 2 years ,supine length is taken

Weight
Naked infant
Child dressed in underclothes, shoes removed
Electronic scales
Uncooperative toddlers weighed with adult
Head circumference
Maximum occipitofrontal circumference is
taken
Mean of 3 measurements
Measure of head and brain growth
Growth parameters
Neonate normally loses up to 12%of body
weight in the first few days of life but should
regain birth weight by 10 days of life
Subsequent weight gain of 30 grams per day
Birth weight is doubled by 5 months and
tripled by at about 1 year.
Expected weight of a young child in kilograms
age in years plus 4, multiplied by 2.
Height
At birth approx. 50 cm,increasing to 75 cm at
1 year and 100 cm at 4 years
Subsequently annual gain of approx. 5 cm
Head circumference
At birth average 35 cm,40 cm at 3 months,47
cm at 1 year.
Subsequent annual increase is 0.5 cm from 2
to 7 years and 0.3 cm from 8 to 12 years
BMI
Not so much applicable in pediatric practice
unless we are considering obesity.
We rely more on growth charts.



Clinical evaluation
medical history
Feeding history
Genetics-height of parents, other sibling
physical examination
Weight
Height
head circumference
Other specific signs of nutrition deficiencies
Laboratory data (e.g., hemoglobin, iron, serum
proteins)

Mentzer= MCV
RBC count



Nutrition In
Diabetes Type 1
Children
In children particularly, keeping normoglycemia
is vital to unsure
optimum growth and to keep up with high energy
requirement.
avoiding extremes of hyperglycemia and
hypoglycemia.
To coordinate between insulin therapy and diet


The following are among the most recent dietary
consensus recommendations
(although they should be viewed in the context of the
patients culture)
Carbohydrates - Should provide 50-55% of daily energy
intake; no more than 10% of carbohydrates should be
from sucrose or other refined carbohydrates
Fat - Should provide 30-35% of daily energy intake
Protein - Should provide 10-15% of daily energy intake
Current recommendations for children with
diabetes:

three main meals
two to three snacks
the whole family eats the same meals.

The total carbohydrate content of the meals and
snacks should be kept constant.



MAGERWARI MARIMUTHU
NAMES AND SYNONYMS
VITAMIN A : Retinol (Vitamin A) is an alcohol
of high molecular weight; 1g of retinol = 3.3 IU
vitamin A.
Provitamin A: the plant pigments -, - and -
carotenes and cryptoxanthin: activity of
retinol.



CHARACTERISTIC
Fat soluble; heat stable; destroyed by oxidation,
drying; bile necessary for absorption; stored in liver;
protected by vitamin E.
SOURCES
Liver, fish liver oils, whole milk, milk fat products, egg
yolk, fortified margerines.
Carotenoids from plants: green vegetables, yellow
fruits and vegetables.



BIOCHEMICAL ACTION
Component of retinal pigments, rhodopsin and
iodopsin, for vision in dim light; bone tooth
development; formation and maturation of apithelia.
EFFECTS of DEFICIENCY
Nyctalopia, photophobia, xerophthalmia,
conjunctivitis, keratomalacia leading to blindness;
faulty apiphyseal bone formation; defective tooth
enamel; keratinization of mucous membrances and
skin; retarded growth; impaired resistance to
infection.

DIAGNOSIS

Dark adaptation test may help in diagnosing
vitamin A deficiency.
Xerosis conjuctivae can be detected by
biomicroscopic examination of the conjunctiva.
Examination of the scrapings from the eye and
vagina is recommended as a diagnostis of aid.
the plasma carotene concentration falls quickly,
but that of vitamin A decrreases more slowly.

TREATMENT
A daily suppliment of 1,500 g of vitamin A is
sufficient for treating latent vitamin A
deficiency.
Xerophthalmia is treated by giving 1,5000
g/kg orally for 5 days followed by daily
intramuscular injection of 7,500 g of vitamin A
in oil until recovery occurs.
Morbidity and mortality rate from viral infection
such as measles may be lower in nondeficient
children who are given daily doses 1,500 - 3,000
g of vitamin A.
EFFECTES of EXCESS
Anorexia, slow growth, drying and cracking of
skin enlargement of liver and spleen, swelling
and pain of long bones, bone fragility, increased
intraoranial pressure, alopecia and
carotenemia.
NAMES AND SYNONYMS
Vitamin B Complex : thiamine: vitamin B; anti
beriberi vitamin ; aneurin

CHARACTERISTICS
Water and alcohol soluble; fat insoluble; stable
in slightly acid solution; labile to heat, alkali,
sulfites.

SOURCES
Liver, meet, especially pork, milk, whole grain or
anriched cereals, wheat germ, legumes, nuts.
BIOCHEMICAL ACTION
Component of thiamine pyrophosphate
carboxylases, which act in various oxidative
decarboxylations, including that of pyruvic
acid.
EFFECTS OF DEFFICIENCY
Beriberi, fatigue, irritability, anorexia,
constipation, headache, insomnia, tachycardia,
polyneuritis, cardiac failure, edema, elevated
pyruvic, acid in the blood, aphonia.

DIAGNOSIS
Low red blood cell transketolase and high blood
or urinary glyoxylate levels are useful diagnostic
indicators.
Measurement of urinary thiamine excretion or
urinary excretion of its metabolites, thiazole or
pyrimidine, after an oral loading dose or
thiamine may help to identify the deficiency
state.
Clinical response to administration of thiamine
is the best test for thiamine deficiency.

TREATMENT
If a breast-fed infant develops beriberi, both the
mother and child should be treated with
thiamine.
The daily dose for children and adults,
respectively, is 10mg and 50mg.
In the absent of gastrointestinal disturbances,
oral administration is effective.
However, thiamine should be given
intramuscularly or intravenously to children
with cardiac failure.
EFFECTS of EXCESS
None from oral intake

NAMES AND SYNONYMS
Riboflavin: Vitamin B
CHARACTERISTICS
Sparingly soluble in water; sensitive to light and
alkali; stable to heat, oxidation, acid
SOURCES
Milk, cheese, liver and other organs, meet, eggs,
fish, green leafy vegetables, whole or enriched
grains.
BIOCHEMICAL ACTION
Constituent of flavoprotein enzymes important in
hydrogen transfer reactions, amino acid, fatty acid
and carbohydrate metabolism and cellular
respiration. Retinal pigment for light adaptation.



EFFECTS of DEFFICIENCY
Ariboflavinosis, photophobia, blurrec vision,
burning and itching of eyes, corneal
vascularization, poor growth, cheilosis.
DIAGNOSIS
The signs and symptoms are too nonspecific to
make a definitive diagnosis.
Useful diagnostic tests include urinary
excretion of riboflavin below 30g/24 hr and
low levels of erythrocyte glulathionine
reductase, a flavo-protein requiring FAD.

TREAMENT
Oral administration of 3-10 mg of riboflavin
daily.
If no response occurs within a few days,
intramuscular injections of 2 mg of riboflavin in
saline may be given a well-balanced diet,
including, at least temporarily, generous
supplements of other B complex vitamins.
EFFECTS Of EXCESS
Not harmful
NAMES AND SYNONYMS
Niacin: nicotinamide; nicotinic acid; antipellagra
vitamin.
CHARACTERISTICS
Water and alcohol soluble; stable to acid, alkali,
light, heat, oxidation.
SOURCES
Meat, fish, poultry, liver, whole grain and enriched
cereals, green vegetables, peanuts.
BIOCHEMICAL ACTION
Constituent of coenzymes I and II. NAD, NADP
cofactors in a number of dehydrogenase systems .



EFFECTS of DEFICIENCY
Pellagra, multiple B-vitamin deficiency
syndromes, diarrhea, dementia, dermatitis.
DIAGNOSIS
Usually made from the physical signs of
glossitis, gastrointestinal symptoms and a
symmetric dermatitis.
Rapid clinical response to niacin is an important
confirming test.
N-methylnicotinamide, a normal metabolite of
niacin, is almost undetectable in the urine of
niacin-deficient individuals.
TREAMENT
Children usually respond to anti pellagral
therapy.
A liberal and well-balanced diet should be
supplemented with 50-300 mg of niacin daily;
cases or in cases of poor intestinal absorption.
100 mg may be given intravenously .
Large doses of niacin are often followed by a
sensation of heat as well as flushing and
burning of the skin.
These unpleasant effects, which occur within a
haif of niacin ingestion, are not produced by
niacinamide.

Large doses of niacin also may cause cholestatic
jaundice or hepatotoxicity.
EFFECTS of EXCESS
Nicotinic, acid (not the amide) is vasodilator;
skin flushing and itching; hepatopathy.
NAMES AND SYNONYMS
Folacin: group of related compounds containing
pteridine ring, para-amino benzoic acid and
glutamic acid. Pteroylglutamic acid (PGA).
CHARACTERISTICS
Slightly soluble in water; labile to heat, light,
acid.
SOURCES
Unknown


BIOCHEMICAL ACTION
Concerned with formation and metabolism of
one-carbon units; participates in synthesis of
purines, pyrimidines, nucleorpteins and methyl
groups.
EFFECTS of DEFICIENCY
Megaloblastic anemia (infancy, pregnancy)
usually is secondary to malabsorption disease,
glossitis, pharyngeal ulcers, impaired immunity.
NAMES AND SYNONYMS
Cyanocobalamin: vitamin B
CHARACTERISTICS
Slightly soluble in water; stable to heat in
neutral solution; labile in acid or alkaline ones;
destroyed by light. Castle intrinsic factor of the
stomach required for absorption.
SOURCES
Muscle and organ meats, fish, eggs, milk,
cheese.





















BIOCHEMICAL ACTION
Transfer of one-carbon units in purine and labile
methyl group metabolism, essential for maturation
of red blood cells in bone marrow.; metabolism of
nervous tissue; adenosylcobalamin is the
coenzyme for methylmalonyl CoA mutase.
EFFECTAS of DEFECIENCY
Juvenile pernicious anemia, due to defect in
absorption rather to dietary lack; also secondary to
gastrectomy, celiac disease, inflammatory lesions of
small bowel, long-term drug therapy (PAS,
neomycin); methylmalonic aciduria;
homocystinuria.

NAMES AND SYNONYMS
Biotin
CHARACTERISTICS
Crystallized from yeast; soluble in water
SOURCES
Yeast, animal products; synthesized in intestine
BIOCHEMICAL ACTION
Coenzyme carboxylases; involved in CO transfer
EFFECTAS of DEFECIENCY
Dermatitis, seborrhea; inactivated by avidin in raw
egg white



DIAGNOSIS
Suggested by organic aciduria, particularly
propionic and dicarboxylic to biotin
administration is confirmatory.
Inclusion of biotin in parenteral nutrition
infusates will prevent the most common cause
of biotin deficiency in infants.
TREAMENT
Oral administration of 10 mg is sufficient for
treatment of deficiency as well as to confirm
the diagnosis of deficiency.
EFFECTS OF EXCESS
None known

NAMES AND SYNONYMS
Vitamin B active forms; pyridoximine
CHARACTERISTICS
Water soluble; destroyed by ultraviolet light
and by heat
SOURCES
Meat, liver, kidney, whole grains, soybeans,
nuts, fish, poultry, green vegetables.
BIOCHEMICAL ACTION
Constituent coenzymes for decarboxylation,
transamination, transsulfuration, fatty acid
metabolism

EFFECTAS of DEFECIENCY
Irritability, convulsions, hypochromic anemia;
peripheral neuritis in patients receiving
isoniazid; oxaluria
DIAGNOSIS
If more common causes of infantile seizures
(e.g. hypocalcemia, hypoglycemia, infection) are
eliminated, 100 mg of pyridoxine should be
injected.
If the seizure stops, vitamin B deficeincy
should be suspected and a tryptophan loading
test should be performed.



In order children, 100 mg of pyridoxine may be
injected intramuscularly while the EEG is being
recorded; a favorable response of the EEG suggests
pyridoxine deficiency.
TREATMENT
Convulsions due to pyridoxine deficiency should be
treated with 100 mg of the vitamin given
intramuscularly.
One dose should suffice if the diet is adequate.
For pyridoxine dependent children, daily does of 2-
10 mg intramuscularly or 10-100 mg orally may be
necessary.
EFFECTS of AXCESS
Sensory neuropathy
VITAMIN C
NAMES AND SYNONYMS
Vitamin C; ascorbic acid; antiscobutic vitamin
CHARACTERISTICS
Water soluble; easily oxidized, accelerated by
heat, light, alkali oxidative enzymes, traces od
copper or iron.
SOURCES
Citrus fruits, tomatoes, berries, centaloupe,
cabbage, green vegetables. Cooking has
destructive effect.
BIOCHEMICAL ACTION
Integrity and maintenance of intercellular
material; facilitates absorption of iron and
conversion of folic acid to folinic acid;
metabolism of tyrosine and phenylalanine,
activity of succinic dehydrogenase and serum
phosphatase in infants not in adults.
EFFECTAS of DEFECIENCY
Scurvy and poor wound healing.

DIAGNOSIS
Laboratory test for scurvy are unsatisfactory.
Diagnosis is usually based on the characteristic
clinical picture, the radiographic appearance of the
long bones and history of poor vitamin C intake.
TREATMENT
Daily intake of 3-4 oz of orange juice or tomato
juice quickly produces healing in children with
scurvy, but ascorbic acid is preferable.
The daily therapeutic dose is 100-200 mg., orally or
parenterslly.
EFFECTS of EXCESS
Oxaluria

VITAMIN D
NAMES AND SYNONYMS
Vitamin D; group of sterols having similar
physiologic activity, D - calciferel is activated
ergosterol, D is activated 1- dehydrocholestero in
skin. 1 mg = 4010 vitamin 0 mcg.
CHARACTERISTICS
Fat soluble, stable to heat, acid alkali, and
oxidation; bile necessary for absorption.
Prohormone for 25-OH cholecalciferol
SOURCES
Vitamin D-fortified milk and margarine, fish liver
oils, exposure to sunlight or other ultraviolet
sources.

BIOCHEMICAL ACTION
Regulates absorption and deposition of calcium
and phosphorus by affecting permeability of
intestinal membrane; regulates level of serum
alkaline phosphatase, which is believed to be
concerned with calcium phosphate deposition
in bones and teeth.
EFFECTAS of DEFECIENCY
Rickets (high serum phosphatase level appears
before bone deformities); infantile tetany; poor
growth; osteomalacia
DIAGNOSIS
The urinary cyclic AMP level is elevated.
Serum 25-hydroxsycholecalciferol is low.
Include a generalized arminoaciduria, a low bone
citrate level with elevated urinary citrate excretion,
impaired renal acidification, phosphaturia and
occasionally, glucosuria.
Rickets is based on a history of inadequate intake of
vitamin D or inadequate exposure to sunlight and
the characteristic clinical signs of the condition.
It is confirmed chemically and by radiographic
examination.

TREATMENT
Daily administration of 50-150 g of vitamin D
or 0.5 -2 g of 1.25- dihydroxycholecalciferal
produces demonstrable radiographic healing
within 2-4 week, expect in cases of vitamin D
refractory rickets.
EFFECTS OF EXCESS
Wide variation Is tolerance; over 500 g /24 hr
toxic when continued for weeks; prolonged
administration of 45 g /24 hr mat be toxic;
nausea; diarrhea, weight lose, polyuria,
nocturia, calcification of soft tissues, including
heart , renal tubules, blood vessels, bronchi,
stomach.



VITAMIN E
NAMES AND SYNONYMS
Vitamin E: group of related chemical
compounds tocopherols with similar biologic
activities.
CHARACTERISTICS
Fat soluble; unstable to ultraviolet light, alkali;
readily oxidized by oxygen, iron, rancid fats
Antioxident; bile necessary for absorption.
SOURCES
Germ oils of various seeds, green leafy
vegetables, nuts, legumes


BIOCHEMICAL ACTION
Minimizes oxidation of carotene, vitamin A and
linoleic acid; stabilizes membranes.
EFFECTAS of DEFECIENCY
Requirements related to polyunsaturated fat intake;
red blood cell hemolysis in premature infants; loss
of neural integrity.
DIAGNOSIS
Best detected by a serum rati of -tocopherol to
lipid of less than 0.8 mg/g and/or erythrocyl
hemolysis in hydrogen peroxide of more than 10%.
Blood levels within 3 days of vitamin E
administration may no reliably reflect vitamin E
status.
EFFECTS OF EXCESS
unknown
VITAMIN K
NAMES AND SYNONYMS
Vitamin K: group of nophthoquinones with
similar biologic activites K, is phytoquinone.
CHARACTERISTICS
Natural compounds are fat soluble; stable to
heat and reducing agents; lebile to oxidizing
agent, strong acids, alkali , light; bile salts
necessary for intestinal absorption.
SOURCES
Green leafy vegetables, pork, liver. Widely
distributed

BIOCHEMICAL ACTION
Prothrombim formation; coagulation factors II,
VII, IX and X and osteocalcin are vitamin K-
dependent; proteins C, S, Z
EFFECTAS of DEFECIENCY
Hemorrhagic manifestations ; bone metabolism
DIAGNOSIS
Hypoprothrombinemia that is corrected by
vitamin K administration establishes the
diagnosis.
TREATMENT
Oral administration of vitamin K may correct
mild prothrombin deficiency.
For an infant, 1-2 mg every 24 hr usually
suffices.
If prothrombin deficiency is severe and
hemorrhagic manifestations have appeared., 5
mg of vitamin K every 24 hr should given
parenterally.
EFFECTS OF EXCESS
Not established; analogues may produce
hyperbilirubinemia in premature infants.