DEVELOPMENT
Nutrition / Feeding
WHO recommends exclusive Breastfeeding in first 6/12 of life
Ø Inadequate BF (due to poor supply, difficulty latching, pain/discomfort)
can lead to malnutrition
Ø Overfeeding occurs more often with bottle-fed babies
Benefits of Breastfeeding?
1) Antibody (IgA) to protect newborn against infection
2) Reduced risk of sudden infant death syndrome
3) Reduce Breast and ovarian cancer risk
When and How much should babies be fed?
Ø 150mL/kg/day which is initially split between feeds every 2-3 hrs ® then to 4 hrs ® feeding on demand
o Pre-term or underweight babies require more
Ø In first week of life:
o 60mL/kg/day on day 1
o 90mL/kg/day on day 2
o 120mL/kg/day on day 3
o 150mL/kg/day after day 4
Ø WEANING -transition from milk to normal food
o Begins around 6/12 old
o Purees (e.g. pureed fruits, baby rice) ® normal diet
(supplemented with milks and snacks by 1 yo)
What weight is normal?
Fe deficiency in cow’s milk. Why?
Ø Breast-fed babbies normally lose ≤ 10% of weight by day 5® regained by day 10 Ø High casein and Calcium in cow’s milk
o Formula fed babies normally lose ≤ 5% of weight by day 5 interacts with digestive enzymes and
Ø XS Weight loss mainly due to dehydration, underfeeding cause poor absorption
Ø Wt gained (weight doubles in first 2 years)
o 30g /day (until 3 months)
o 20g /day (until 6 months) Neurological development
o 10g/day (until 12 months) Ø Rapid myelination in first 2 years
o 2kg/year (from 2 years to puberty) – rebound adiposity (↑BMI) from aged 5-7yo Ø Increased brane pruning until
adolescence – rewiring and plasticity ®
brain stop growing at 25 yo
Growth Charts
What Factors that affect growth?
1. Genetics (e.g. tall parents = tall children)
2. Environment /SES
3. Nutrition (breastfed vs non-breastfed)
4. Biological causes (e.g. LGA due to GDM or maternal obesity) ® high risk of Met Syn
5. General health (e.g. infections, feeding issue, chronic diseases.e.g CKD, CLD long-term meds, developmental delays)
How often monitor growth?
Ø Infant (0-1) = > 5 wt recordings
Ø Child (1-2) = > 3 wt recordings
Ø Child (≥2) = annual
Ø < 2nd percentile ® GP review
Ø < 0.4th percentile ® paeds review
Why no single measurements?
Need serial measurements over time to
evaluate growth pattern
CORRECTING FOR PREMATURITY:
Ø single measurements ONLY give
information about overall size • Check child’s birthday and today’s date
Ø Review in 2-4 weeks E.g. plot 3 years and 7 mths
• Correct for prematurity (until 2nd B’day)
What to do if overweight > 85th
? • Corrected age = actual - # of weeks
Ø Healthy lifestyle discussion – promote premature
family support, dietary control and Children go through 3 phases of growth: *Nb: Infant born at 32 wks and now 4 mths old,
involve dietician would actually be corrected for 2 mths
Ø Refer to GP, paeds and dietician
• First 2 years ® rapid growth driven by nutritional factors +
insulin
Ø Beware of bullying, IGT, T2DM, CVD PATIENT DISCUSSION ABOUT PREMATURITY
and arthritis • From 2 years to puberty ® thyroxine and growth hormone Ø INCORRECT to compare pre-term baby to
• During puberty ® rapid growth spurt by sex hormones + term child at 50th percentile
What to do if wt/ht/BMI falls below 3rd ? growth hormones Ø Maintaining growth in same proportion
across length, weight and BMI is normal
Ø NOT uncommon for healthy babies to even if lowest percentile
have initial dip in wt percentiles in early RED FLAGS Ø Feeding practises
months of life 1) Horizontal / vertical trend line Ø Parental height
Ø Check feeding habits 2) DO not wean BM (as higher concentration of calories) than food Ø Social history
Ø Beware WHO charts based on healthy
mothers exclusively BF > 4/12
, WHO charts
Advantages of using WHO charts:
• WHO growth charts recommended to monitor growth of all
infants regardless of:
o Feeding type
o SES
o Ethnicity
• WHO charts reflect growth of ideal children who were
exclusively or predominantly breastfed for at least 4 months
Main issue: and still breastfeeding at 12 months.
• focuses on ideal growth = unfair to developed nations o Exc. smoking mothers
o incorrect indication of their growth
• weight for age
o breastfeeding as the biological norm
o 80% of infant lose some weight after birth due to increased • CDC charts based on cross-sectional survey of formula-fed
metabolism infants focusing on the size of a group of infants NOT actual
o % birthweight lost more useful measure (> 10% below growth reflected by WHO longitudinal charts
birthweight at 2 weeks ® unrecognized illness)
Tanner staging
<10yo
10-11yo
11-13yo
13-14yo
>14yo
General age 8-14 yo General age 9-15 yo
1) BOOBS – palpable breast budding 1) Testicular enlargement (> 4mL)
2) PUBES – pubic hair 2) penis lengthening and widening
3) GROW - accel. Growth 3) Darkening of scrotum and Increased scrotal vol
a. Peak height velocity = 8-10 yo (later for boys) 4) Pubic hair
b. Peak weight velocity = 12-14yo (later for boys) 5) Growth (accel) + voice deepens
4) FLOW -menarche (usu. 2 years after puberty starts) *BODY FAT increases until 12yo then decreases
*BODY FAT increases linearly with age
DELAYED PUBERTY
Hypergonadotrophic Hypogonadotrophic General Ix
hypogonadism hypogonadism Bloods
Ø FBC + ferretin (anaemia)
Type Peripheral - dysfn gonads Central - dysfn pituitary gland
Ø EUC (CKD)
Ø Anti-TTG/EMA (coeliac)
LH/FSH High Low
Hormone panel
TT/E2 Low Low Ø Early AM FSH/LH
Ø TFT
• Gonad damage (e.g. torsion, • Damage to HT and pit (trauma, RT, Ø GH test + IGF-1 Assay
cancer, infection – mumps) surgery) Ø Serum prolactin
• Congenital absence of gonads • Kallman (anosmia) Genetic testing
• Klinefelter (47XXY) • Endocrine = GH def, hypothyroidism, Ø Klinefelter
• Turner’s (45XO) HyperPrL Ø Turner’s
Cause
• Chronic disease (e.g. CF, IBD) Imaging
• XS exercise/dieting Ø XR wrist/hand – bone age (for CDGD)
• Constitutional delay in growth and Ø Pelvic USS - ovary absence
development (CDGD) – temporary delay Ø MRI brain – pituitary tumour, olfactory
in puberty but reaches adult potential bulbs - Kallman
• Reassurance if CDGD
Rx
• Replacement sex hormones (E2 -girls, TT for boys)
Nutrition / Feeding
WHO recommends exclusive Breastfeeding in first 6/12 of life
Ø Inadequate BF (due to poor supply, difficulty latching, pain/discomfort)
can lead to malnutrition
Ø Overfeeding occurs more often with bottle-fed babies
Benefits of Breastfeeding?
1) Antibody (IgA) to protect newborn against infection
2) Reduced risk of sudden infant death syndrome
3) Reduce Breast and ovarian cancer risk
When and How much should babies be fed?
Ø 150mL/kg/day which is initially split between feeds every 2-3 hrs ® then to 4 hrs ® feeding on demand
o Pre-term or underweight babies require more
Ø In first week of life:
o 60mL/kg/day on day 1
o 90mL/kg/day on day 2
o 120mL/kg/day on day 3
o 150mL/kg/day after day 4
Ø WEANING -transition from milk to normal food
o Begins around 6/12 old
o Purees (e.g. pureed fruits, baby rice) ® normal diet
(supplemented with milks and snacks by 1 yo)
What weight is normal?
Fe deficiency in cow’s milk. Why?
Ø Breast-fed babbies normally lose ≤ 10% of weight by day 5® regained by day 10 Ø High casein and Calcium in cow’s milk
o Formula fed babies normally lose ≤ 5% of weight by day 5 interacts with digestive enzymes and
Ø XS Weight loss mainly due to dehydration, underfeeding cause poor absorption
Ø Wt gained (weight doubles in first 2 years)
o 30g /day (until 3 months)
o 20g /day (until 6 months) Neurological development
o 10g/day (until 12 months) Ø Rapid myelination in first 2 years
o 2kg/year (from 2 years to puberty) – rebound adiposity (↑BMI) from aged 5-7yo Ø Increased brane pruning until
adolescence – rewiring and plasticity ®
brain stop growing at 25 yo
Growth Charts
What Factors that affect growth?
1. Genetics (e.g. tall parents = tall children)
2. Environment /SES
3. Nutrition (breastfed vs non-breastfed)
4. Biological causes (e.g. LGA due to GDM or maternal obesity) ® high risk of Met Syn
5. General health (e.g. infections, feeding issue, chronic diseases.e.g CKD, CLD long-term meds, developmental delays)
How often monitor growth?
Ø Infant (0-1) = > 5 wt recordings
Ø Child (1-2) = > 3 wt recordings
Ø Child (≥2) = annual
Ø < 2nd percentile ® GP review
Ø < 0.4th percentile ® paeds review
Why no single measurements?
Need serial measurements over time to
evaluate growth pattern
CORRECTING FOR PREMATURITY:
Ø single measurements ONLY give
information about overall size • Check child’s birthday and today’s date
Ø Review in 2-4 weeks E.g. plot 3 years and 7 mths
• Correct for prematurity (until 2nd B’day)
What to do if overweight > 85th
? • Corrected age = actual - # of weeks
Ø Healthy lifestyle discussion – promote premature
family support, dietary control and Children go through 3 phases of growth: *Nb: Infant born at 32 wks and now 4 mths old,
involve dietician would actually be corrected for 2 mths
Ø Refer to GP, paeds and dietician
• First 2 years ® rapid growth driven by nutritional factors +
insulin
Ø Beware of bullying, IGT, T2DM, CVD PATIENT DISCUSSION ABOUT PREMATURITY
and arthritis • From 2 years to puberty ® thyroxine and growth hormone Ø INCORRECT to compare pre-term baby to
• During puberty ® rapid growth spurt by sex hormones + term child at 50th percentile
What to do if wt/ht/BMI falls below 3rd ? growth hormones Ø Maintaining growth in same proportion
across length, weight and BMI is normal
Ø NOT uncommon for healthy babies to even if lowest percentile
have initial dip in wt percentiles in early RED FLAGS Ø Feeding practises
months of life 1) Horizontal / vertical trend line Ø Parental height
Ø Check feeding habits 2) DO not wean BM (as higher concentration of calories) than food Ø Social history
Ø Beware WHO charts based on healthy
mothers exclusively BF > 4/12
, WHO charts
Advantages of using WHO charts:
• WHO growth charts recommended to monitor growth of all
infants regardless of:
o Feeding type
o SES
o Ethnicity
• WHO charts reflect growth of ideal children who were
exclusively or predominantly breastfed for at least 4 months
Main issue: and still breastfeeding at 12 months.
• focuses on ideal growth = unfair to developed nations o Exc. smoking mothers
o incorrect indication of their growth
• weight for age
o breastfeeding as the biological norm
o 80% of infant lose some weight after birth due to increased • CDC charts based on cross-sectional survey of formula-fed
metabolism infants focusing on the size of a group of infants NOT actual
o % birthweight lost more useful measure (> 10% below growth reflected by WHO longitudinal charts
birthweight at 2 weeks ® unrecognized illness)
Tanner staging
<10yo
10-11yo
11-13yo
13-14yo
>14yo
General age 8-14 yo General age 9-15 yo
1) BOOBS – palpable breast budding 1) Testicular enlargement (> 4mL)
2) PUBES – pubic hair 2) penis lengthening and widening
3) GROW - accel. Growth 3) Darkening of scrotum and Increased scrotal vol
a. Peak height velocity = 8-10 yo (later for boys) 4) Pubic hair
b. Peak weight velocity = 12-14yo (later for boys) 5) Growth (accel) + voice deepens
4) FLOW -menarche (usu. 2 years after puberty starts) *BODY FAT increases until 12yo then decreases
*BODY FAT increases linearly with age
DELAYED PUBERTY
Hypergonadotrophic Hypogonadotrophic General Ix
hypogonadism hypogonadism Bloods
Ø FBC + ferretin (anaemia)
Type Peripheral - dysfn gonads Central - dysfn pituitary gland
Ø EUC (CKD)
Ø Anti-TTG/EMA (coeliac)
LH/FSH High Low
Hormone panel
TT/E2 Low Low Ø Early AM FSH/LH
Ø TFT
• Gonad damage (e.g. torsion, • Damage to HT and pit (trauma, RT, Ø GH test + IGF-1 Assay
cancer, infection – mumps) surgery) Ø Serum prolactin
• Congenital absence of gonads • Kallman (anosmia) Genetic testing
• Klinefelter (47XXY) • Endocrine = GH def, hypothyroidism, Ø Klinefelter
• Turner’s (45XO) HyperPrL Ø Turner’s
Cause
• Chronic disease (e.g. CF, IBD) Imaging
• XS exercise/dieting Ø XR wrist/hand – bone age (for CDGD)
• Constitutional delay in growth and Ø Pelvic USS - ovary absence
development (CDGD) – temporary delay Ø MRI brain – pituitary tumour, olfactory
in puberty but reaches adult potential bulbs - Kallman
• Reassurance if CDGD
Rx
• Replacement sex hormones (E2 -girls, TT for boys)
