Table Of ContentPEDIATRIC NUTRITION
Incorporating National and International Recommendations
(IAP, NNF, GOI’s DOWCD, BPNI, FOGSI, ICMR, AAP,
IPA, NFI, IBFAN,WABA,ACASH, UNICEF,WHO, etc.)
Second Edition
Excerpts from Book Reviews:
“......a very comprehensive and up-to-date book on child
nutrition, especially relevant to the readers of the Indian
subcontinent......Special feature of the book is incorporation of
the national and international recommendations......will serve
the pediatricians, both from academic and practising
background, for a long time to come.”
–Indian Pediatrics
New Delhi, India
“......an outstanding well-illustrated spotlight on the best in the
pediatric nutrition globally with supportive references at the end
of each and every chapter....strongly recommended for the
target audience.”
–Tropical and Subtropical Pediatrics
Kuala Lumpur, Malaysia
PEDIATRIC NUTRITION
Incorporating National and International Recommendations
(IAP, NNF, GOI’s DOWCD, BPNI, FOGSI, ICMR, AAP,
IPA, NFI, IBFAN, WABA, ACASH, UNICEF, WHO, etc.)
Second Edition
Edited by
Suraj Gupte
MD, FIAP
Professor and Head
Postgraduate Department of Pediatrics
Narayana Medical College and Hospitals
Nellore-524002, South India
E-mail: [email protected], [email protected]
[email protected]
Honorary Director Section Editor
Pediatric Education Network Pediatrics Today (New Delhi, India)
Editor-in-Chief Editorial Adviser
Asian Journal of Pediatric Practice (New Delhi, India)
Recent Advances in Pediatrics (International Series)
The Short Textbook of Pediatrics Editorial Advisory Board Member/Reviewer
Pediatric Emergencies
Indian Journal of Pediatrics (New Delhi, India)
Neonatal Emergencies
Synopsis: A Current Survey of World Literature in Pediatrics
Pediatric Gastroenterology,
(Detroit, USA), Indian Journal of Pediatric Gastroenterology,
Hepatology and Nutrition
Hepatology and Nutrition (Jaipur, India),
Influenza: Complete Spectrum ...etc
Maternal and Child Nutrition (Preston, UK),
Journal of Infectious Diseases (Turkey)
Author
Examiner
Instructive Case Studies in Pediatrics National Board of Examinations (NBE) for DNB,
Differential Diagnosis in Pediatrics New Delhi, All India Institute of Medical Sciences (AIIMS),
Pediatric Drug Directory New Delhi, Postgraduate Institute of Medical Education and
Influenza, Perspectives in Influenza Research (PGIMER), Chandigarh,
Speaking of Child Care etc. Sher-i-Kashmir Institute of Medical Sciences (SKIMS) and
E-mail: [email protected] several universities
[email protected],[email protected]
Pediatric Faculty Selection Expert
Co-editor
All India Institute of Medical Sciences, New Delhi
Asian Journal of Maternity and Child Health Punjab Public Service Commission,
(Manila, Philippines) Jammu and Kashmir Public Service Commission,
Union Public Service Commission
PEEPEE
PUBLISHERS AND DISTRIBUTORS (P) LTD.
Pediatric Nutrition
Published by
Pawaninder P. Vij
Peepee Publishers and Distributors (P) Ltd.
Head Office:160, Shakti Vihar, Pitam Pura, Delhi-110 034 (India)
Correspondence Address:
7/31, First Floor,Ansari Road, Daryaganj, Post Box-7243
New Delhi-110 002 (India)
Ph: 65195868, 9811156083, 23246245
e-mail:[email protected]
e-mail:[email protected]
e-mail:[email protected]
www.peepeepub.com
© 2012 by Manu Gupte, Novy Gupte
All rights reserved
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic, mechanical, photocopy, recording, translated, or any information storage and
retrieval system, without permission in writing from the editor and the publisher.
This book has been published in good faith that the material provided by authors/
contributors is original. Every effort is made to ensure accuracy of material, but publisher
and printer will not be held responsible for any inadvertent errors. In case of any dispute,
all legal matters to be settled under Delhi jurisdiction only.
First Edition:2006
Second Edition: 2012
ISBN: 978-81-8445-108-5
To
All healthcare providers contributing
towards the excellence in child nutrition in particular and
maternal nutrition in general, especially in the
Indian subcontinent
Foreword
Malnutrition in childhood continues to dominate the health scenario in India and other developing countries especially in
the South-East Asia. Over the last few decades, its prevalence has come down but rather slowly and to an unsatisfactory
level only. Now, we see less frequently frank cases of advanced protein-energy malnutrition (PEM) like kwashiorkor,
marasmus or marasmic-kwashiorkor and are successful in saving many infants and children who otherwise would have
succumbed to severe acute malnutrition (SAM). Similar is the situation with regard to LBW babies, who may survive but
with many unfavorable problems.
Most of these survivors however suffer from “nutritional stunting” with multiple handicaps including cognitive
subnormality.
Talking about the academic literature in pediatric nutrition, undoubtedly we have innumerable monographs, booklets
and educational material concerning child nutrition and malnutrition. However, these are usually limited to particular
area(s) in child nutrition or have become obsolete with passage of time. Undoubtedly, there is a crying need for a
community-oriented comprehensive and yet concise book that provides detailed essential information, inputs and
practical guidelines for academicians, medical students and teachers, nutritionists and healthcare providers with a
spotlight on improvement in overall nutrition, health and quality of life rather than sheer survival.
Dr. Suraj Gupte, a renowned pediatric educationist, researcher and author of national and international standing
known for his worthy contribution to child nutrition did Herculean academic venture in publishing the much needed
“Textbook of Pediatric Nutrition” in 2006. Inspired by works of the eminent authorities like Profs. D.B. Jelliffe, C.A.
Gopalan and Dr. Shanti Ghosh plus by his own crave for perfection, the treatise met with high academic standards.
Now, its well executed second edition, rechristened Pediatric Nutrition provides a versatile platform for as many as
55 experts from India, United Kingdom, United States, Jamaica, etc. The comprehensive and state-of-the-art updates
in 47 well-written chapters on nearly all aspects of child nutrition and nutrition deficiency states, are indeed very
thought-provoking and timely.
A remarkable feature of the new edition is incorporation of excellent new chapter on 2006-07 WHO growth charts
plus growth tables that are now required to be consulted and followed globally for assessment of nutritional status both
at clinical level and for research studies, have been included, in addition.
The changing concepts in the management of SAM are explicitly dealt with emphasis on medical nutritional therapy.
An independent chapter provides a superb description of ready-to-use therapeutic food (RUTF) that has revolutionized
the nutritional therapy of SAM in Africa and is now making inroads in India and other countries of the South-East Asian
Region (SEAR).
A commendable plus point of the book is a special accent on the relevance of descriptions to the Indian subcontinent
rather than hifi theoretical discussions.
In short, the new edition of the book may aptly be described as a true reader-friendly compendium of changing and
new concepts in child nutrition, undernutrition and overnutrition (that again is a sort of malnutrition) globally, providing
recommendations from national and international organizations that are proactive in the field.
I sincerely feel that the second edition of Dr. Suraj Gupte’s Pediatric Nutrition is set to offer enormous benefit to the
professionals interested in maternal and child nutrition. This reader friendly textbook is strongly recommended to the
pediatric residents, pediatric teachers, practitioners and healthcare providers in the field of maternal and child health,
nutritionists, researchers, policy makers, etc.
Dr. Uday Bodhankar
Secretary General
CommonwealthAssociation for Health and Disability, United Kingdom
International Council Member,ASPR, Japan
Management Council Member MUHS
Ramdaspeth, Nagpur-440012 Maharashtra, India
Ph:(H) 0091 - 712 - 2459090 / 2422505
Fax: 0091 - 712 - 2428145
E-mail: [email protected] [email protected]
Preface to the Second Edition
We are pleased to offer the second revised and updated edition of the “Pediatric Nutrition”.This has become possible
consequent upon the warm reception accorded to the first edition that was released at the 44th National Conference of the
IndianAcademy of Pediatrics (PEDICON 2006) held at the Hotel Ashok, New Delhi, India, consistent demand, changing
recommendations in the field and the enthusiasm of the publishers.
On the suggestion from various quarters that the book is not addressed just to those involved in academics but is
broad-based with appeal to all sections involved in nutrition of the child, including, clinicians and nutritionists, the prefix
“Textbook” has been dropped. Secondly, in order that the book caters to the needs of the average readers, its size has
been reduced without significantly affecting the core contents.
Over and above various revisions, new additions include “Severe Acute Malnutrition (SAM)”,
“MedicalTherapeutic Foods”, “New (2006 and 2007) WHO Growth Standards and Charts”, etc. These shall keep
the readers abreast of the latest developments.
Hopefully, the revised, updated and improved new edition shall receive yet warmer reception from the readers in and
outside India. Of course, feedback aimed at further improvement in the contents shall be most welcome to enable us
work for a yet better next edition.
Suraj Gupte
MD, FIAP
Preface to the First Edition
Over three decades back, the noted American Journal of Clinical Nutrition, had posed this question to the experts in the
field of child health and nutrition: Why does the Third World continue to have so much of child malnutrition?
The best response came from the doyen of international nutrition, Prof Derick B Jellife, pointing out “…. factors
ranging from unequal distribution of food at international, national, community and family levels through poverty, ignorance,
superstitions, erroneous beliefs, lack of knowledge of those involved in delivery of healthcare to wrong priorities and
lopsided mindset of the policy-makers”.
Interestingly, even today, this observation of Prof Jellife seemingly holds good. Nevertheless, over the years, the
scenario with regard to prevalence of child malnutrition has undergone a perceptible change. As for example, it has in
totality shown a significant reduction in Africa and Latin America. In the Indian subcontinent, gross reduction in prevalence
of severe forms and some reduction in that of mild-moderate forms have occurred, though at a slow pace. Except iron
deficiency anemia (IDA), incidence of micronutrient and vitamin deficiencies has been cut down to a large extent. The
resultant fall in morbidity, mortality and improved child survival has been documented by such agencies as National
Nutrition Monitoring Bureau and National Family Health Surveys I and II. Unfortunately, a large proportion of the
survivors suffer from mild-moderate malnutrition that eventually ends up in “stunting” (nutritional dwarfing or short
stature). These substandard survivors are likely to suffer from poor cognitive development and learning skills besides
other handicaps, thereby expanding the pool of poor quality citizens in the long run.
The most important cause for this substandard survival, as duly emphasized time and again by the eminent nutritionist,
Professor C. Gopalan, and the leading pediatric educationist and expert, Dr. Shanti Ghosh, revolves round bad infant and
child-feeding and child-rearing practices. There has got to be an aggressive attack on this front if we are to have children
who should not only survive but also grow into physically strong and mentally alert adults contributing to the welfare of
the society and the nation.
Healthcare providers (of all grades) in general and pediatricians in particular, well sensitized and trained in infant and
child nutrition, can contribute in a big way to attain this goal. Equally important is the actual involvement of the community
in the endeavors. Enhanced emphasis on child nutrition not only in the teaching curriculum, both at undergraduate and
postgraduate level in medical colleges/institutes but also in schools and colleges and in community activities too is
needed.
With this background, need for an up-to-date, comprehensive and well-written textbook in child nutrition relevant to
the settings in the Indian subcontinent has been widely felt.
This state-of-the-art and comprehensive pioneering textbook of pediatric nutrition from Indian subcontinent sets out to
fill this felt gap. Its objective is not only to provide updated knowledge in the field but also to sensitize the healthcare
providers, administrators and policy-makers to the nutritional needs of the community and, thereby, assist in attaining
good nutritional status of our child population.
The reader-friendly book is the outcome of coordinated expertise, dedicated efforts, hard work and thoughtfulness of
as many as 85 distinguished contributors constituting a multidisciplinary author team drawn from India and other countries.
All the 69 chapters are written in a simple, straightforward and easy-to-understand style. Each chapter is to-the-point,
keeping in mind the settings in the Indian subcontinent.
The treatise indeed is a dependable source to find by and large complete and authoritative guidance on various aspects
of child nutrition. The contents, presentation and structure blend to provide a thoroughly readable, enjoyable, problem-
oriented and evidence-based textbook of child nutrition.
I wish to express my thanks to the distinguished contributors, drawn from India and several other countries, for the
rich quality of its contents and for reposing confidence in my editorship.
My wife, Shamma, daughter, Novy, a final year MBBS student, Government Medical College, Jammu, and son,
Manu, an 8th semester BE student, MBS College of Engineering and Technology, Jammu, helped me in their own ways
in working through the project successfully.
Finally, thanks are due to Mr. Pawaninder P. Vij, Director, Peepee Publishers and Distributors (P) Ltd. for commissioning
this project, for handling its publication efficiently and for the skillful publishing qualities of the book.
Suraj Gupte
Acknowledgements
Grateful acknowledgements are due to:
• My wife, Shamma, who graciously assisted me so much in taking this important project to its logical conclusion
despite her own preoccupations.
• My daughter, Dr. Novy, and son, Er Manu, for undertaking the tough responsibility of Executive Editors of the
project.
• Dr. P. Narayana, Chairman, Dr. B. A. Ramakrishna, Principal, Dr. S. Vijay Kumar, Coordinator, and Dr. M. Veera
Prasad, Medical Superintendent, Narayana Medical College and Hospitals for providing moral support and
motivation for completing the project.
• The distinguished contributors, drawn from various countries globally for responding to our queries while the
scripts were under process.
• The peer-reviewers who enhanced the excellence of the book though their objective comments, suggestions and
recommendations.
• The reviewers/Journals, both from India and abroad, for appreciating the project and warmly recommending
the book to the readers.
• Dr. Uday Bodhankar, a friend and philosopher, for his graciousness in penning “Foreword” and warmly
recommending the treatise.
• The Publishers, Peepee Publishers and Distributors, New Delhi, for the skillful production qualities of the book.
Suraj Gupte
MD, FIAP
Contributors
Stephen Abil Sandeep B Bavdekar
Assistant Professor Professor
Department of Infant and Child Nutrition Department of Pediatrics
Institute of Child and Adolescent Health Seth GS Medical College and KEM Hospital
London, United Kingdom Parel, Mumbai, India
Ch 13: Feeding of the Low Birthweight Infants Ch 38: Immunonutrition
Pankaj Abrol Lalit Bharedia
Senior Professor and Head Consultant Pediatric Gastroenterologist
Department of Pediatrics II Department of Pediatrics and Neonatology
Pt. BD Sharma Postgraduate Institute of Medical Sciences Fortis Escorts Hospital
Rohtak, Haryana, India Jaipur, Rajasthan, India
Ch 20: Vitamin B Complex Deficiencies Ch 42: Nutrition in Liver Disease
B Adhisivam B Vishnu Bhat
Assistant Professor Professor
Department of Pediatrics Department of Pediatrics
Jawaharlal Postgraduate Institute of Medical Jawaharlal Postgraduate Institute of Medical Sciences
Sciences and Research (JIPMER) and Research (JIPMER)
Pondicherry, Union Territory, India Pondicherry, Union Territory, India
Ch 16: Malnutrition and Infection Ch 15: Immunology of Malnutrition
Ch 26: Zinc in Child Nutrition Ch 16: Malnutrition and Infection
Ch 26: Zinc in Child Nutrition
Samta Agrawal (Malik) Ch 47: Parenteral Nutrition
Practising Pediatrician
Malik Nursing Home, Chhindwara Uday Bodhankar
Maharashtra, India Consultant Pediatrician and Neonatologist
Ch 11: Complementary Feeding Ramdaspeth, Nagpur, Maharashtra, India
Ch 34: The Child with Failure to Thrive
Sugandha Arya
Pediatrician Millie Boettcher
Department of Pediatrics Division of Pediatric Gastroenterology and Nutrition
Vardhman Mahavir Medical College and Safdarjung Hospital Alfred 1. DuPont Hospital for Children
New Delhi, India Wilmington, United States
Ch 8: Breastfeeding: The Supreme Gift Ch 44: Nutrition in Inflammatory Bowel Disease
Akash A Bang Harish Chellani
Pediatric Intensivist Associate Professor
Associate Professor in Pediatrics Department of Pediatrics
Mahatma Gandhi Institute of Medical Sciences (MGIMS) Vardhman Mahavir Medical College and
Sevagram, Maharashtra, India Safdarjung Hospital
Ch 1: Nutritional Requirements New Delhi, India
Ch 8: Breastfeeding: The Supreme Gift
Louise A Baur
Consultant Javed Chowdhary
Department of Pediatrics Professor and Head
The Chinese University of Hong Kong and Department of Pediatrics
Prince of Wales Hospital Government Medical College
Hong Kong, China Srinagar, Jammu and Kashmir, India
Ch 36: The Child with Obesity Ch 12: Low Birthweight Infants: Overview
