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63 Cards in this Set

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Primary vs. Secondary vs. Tertiary Prevention
Primary: actions to reduce adverse outcomes by reducing risk exposure

Secondary: prevention of adverse outcomes in asymptomatic patients who already have a disease (ie: screening growth, development, vitals, hearing, vision, etc.

Tertiary: actions to maintain function, limit disability or progression of disease in symptomatic patients with specific disorders
Folic Acid in Pregnancy
0.4mg (400mcg) or 4mg in women with other children with NTD
Fetal Alcohol Syndrome: char by
1. prenatal and post natal growth deficiency
2. mild to moderate MR
3. Microcephaly
4. Infantile irritability
5. Characteristic facial features
Fetal Alcohol Effects: char by
1. ADHD
2. Fine Motor Impairment
3. Clumsiness
4. subtle delays in motor performance
5. speech disorders
HIV ppx in pregnancy: Mothers and Infants
Mothers: PO Zidovudine 300mg BID or 200mg TID at 14-34wks), then IV Zidovudine (1mg/kg/hr) throughout L&D.

Infants: PO Zidovudine 2mg/kg q6H for the first 6weeks of life
Postpartem Infectious ppx in the Newborn
1. Hemorrhagic Disease of the Newborn
2. Funiculitis or Omphalitis
3. Opthalmia Neonatorum
4. NSVD untreated gonorrhea
5. HBsAg+ Moms
1. HDN: 0.5-1.0mg vitamin K (phylloquinone) IM
2. Omphalitis: triple dye (=broad spec abx effective ag. MRSA)
3. ON: erythromycin or tetracycline ointment
4. Gonorrhea NSVD: Single IM injection CTX
5. HBsAg+: HBIG + Vaccine
IPV Vaccine
IPV promotes some mucosal immunity, not as much as OPV.

IPV is safe in immunocompromised pts or household contacts and when there's an adult household contact who is known to be inadequately vaccinated against polio
OPV Vaccine
OPV off US market dt vaccine-associated poliomyelitis

Vaccine of choice for global eradication, esp. where wild-type poliovirus still exists, and when inadequate sanitation makes mucosal immunity paramount

May be administered to immunocompetent individuals at 3rd and 4th dose before visiting a polio-endemic country, or to control a polio outbreak
IPV dosing schedule
D1, 2 @ 2mo, 4mo
B1, 2 @ 6-18mo, 4-6yo
Hib Vaccine
all Hib vaccines are conjugates of Hib capsular polysaccharide and a carrier protein
Hib dosing schedule
D1, 2, 3 @ 2mo, 4mo, 6mo
B1 @ 12-15mo
MMR, VZV dosing schedule
D1, 2 @ 12mo, 4-6yo (min 4 wks between doses)
can give on same day, but if not, must wait 4wks between MMR and VZV
VZV vaccine in cases of non-immunized person exposure to chickenpox
Recommended for:
non-immunized and susceptible patients within 3 days of exposure to an index case of chicken pox.
Hep B vaccine in cases of HBsAg(+) pregnancy
give initial dose + HBIG within 12 hours of birth
Hep B in previously non-immunized teens
11-15yo: 2 dose series, 4-6 months apart
IVIG and measles vaccine
IVIG interferes with immunogeniticty of measles vaccine
Measles Vaccine and PPD
MMR interferes with tuberculin reactivity. If not performed before or at the time of vaccine, defer PPD for 4-6 weeks.
Vaccines in congenital immunodeficiency?
live-bacteria and live-virus vaccines are contraindicated
Corticosteroids and Vaccine
If received high doses of CS (2mg/kg/D or >20mg/day for weight >10kg) for 14 days or more should not receive live-virus vaccines until steroid Rx dc'd for at least 1 month

When a lower dose or shorter duration of therapy is used, there is no contraindication
the following are NOT contraindications to vaccines
1. Mild acute illness with LG fever or mild diarrheal illness
2. current abx or convalescent phase of illness
3. reaction to previous DTaP dose involving soreness, redness, swelling, temp <105 (40.5)
4. Pregnancy of mother or household contact
5. Breast-feeding
6. Allergies to PCN or any other abx (except anaphylactic to neomycin or streptomycin
7. FHx of adverse event after vaccination
Body Composition in Utero and Term, Puberty
In Utero - H2O is 96% embryonic weight

Term - H20 is 70% body weight, fat is 25%

At Puberty - Skeletal Muscle is 45% of body weight
Caloric Requirement (based on body weight)
Neonatal Period - 120kcal/kg to support metabolic needs and growth

Thereafter:
100kcal/kg for initial 10kg, 50kcal/kg for next 10kg, 20kcal/kg for the next 50kg.
Breastmilk decreases incidence of what diseases?
1. NEC
2. diarrhea
3. LRTI
4. AOM
5. bacteremia +/- meningitis
6. UTI.
7. ? IDDM
8. ? IBD
9. Atopic disease (eczema, asthma)
Nutritional Composition of Breastmilk
6% protein
54% fat
40% carbs

Protein:
80% Whey / 20% Casein

Fat: Polyunsaturated fat, cholesterol

Carb: lactose
Iron in breastmilk
Iron content is lower than cowsmilk, but high bioavailability due to lactoferrin. No supplementation necessary unless iron stores are low
Vitamin D in breastmilk
lower than cowsmilk. supplement all exclusively breastfed babies
Strict Vegans and breastmilk - what are the deficiencies
vitamins B6 and B12 (found only in animal protein sources). Also at risk for riboflavin, vitamin D, and mineral deficiency states.
Absolute Contraindications to Breastfeeding
1. HIV or HTLV
2. Active TB
3. HSV localized to the breast
4. galactosemia
5. maternal use of recreational drugs (amphetamines, marijuana, phencyclidine, opiates other than methadone, chemotherapy, radioactive drugs, ergot alkaloids, iodides, lithium, atropine, cyclosporine, Abx: chloramphenicol and metronidazole?)
6. environmental toxins: DDt, methyl mercury, polychlorinted biphenyls (PCBs)
Relative Contraindications to Breastfeeding
Hep B is no post-exposure ppx given; Hep C if bleeding or cracked nipples
Infants who feed sufficiently should..
1) not lose >10% BW
2) urinate at lease 6x/day
3) pass 3-4 stools within 24hrs
4) regain BW by 10-14 days life
Weaning from the breast at or after 6 mo and before 12mo should not include cows milk because...
increased risk iron-deficiency anemia (poor absorption of iron from cow's milk)
Fluoride Supplementation - When is supplementation required?
B/W ages of 6mo-3yo: only if water supply is severely deficient (contains <0.3ppm) or a ready-to-feed formula without fluoride is used exclusively.

Supp Fluoride is also recc for older children beginning at age 3 if fluoride concentration in drinking water is B/W 0.3-0.6ppm.
What is the amount of fluoride supplementation recommended if fluoride concentration in community drinking water is >0.6ppm?
>0.6ppm (1ppm = 1mg/L)
0mo - 6mo: none
6mo - 3yo: none
3yo - 6yo: none
6yo - 16yo: none
What is the amount of fluoride supplementation recommended if fluoride concentration in community drinking water is <0.3ppm?
<0.3ppm
0mo - 6mo: none
6mo - 3yo: 0.25mg/day
3yo - 6yo: 0.5mg/day
6yo - 16yo: 1.0mg/day
What is the amount of fluoride supplementation recommended if fluoride concentration in community drinking water is 0.3 - 0.6ppm?
0.3 - 0.6ppm
0mo - 6mo: none
6mo - 3yo: none
3yo - 6yo: 0.25 mg/day
6yo - 16yo: 0.5 mg/day
Recommended Amount of fluoride intake at different ages
0mo - 6mo: none
6mo - 3yo: none
3yo - 6yo: 0.25 mg/day
6yo - 16yo: 0.5 mg/day

(so if water contains <0.6ppm, then need to supplement)
Volume - breastmilk or formula intake in the first 3 months of life
20kcal/oz or 67kcal/100mL

150-200ml/kg per day providing 100-135kcal/kg per day
Protein Requirements in Infancy
FT infants require 2-2.5g/kg/d duirng first few months of life
Decreasing to 1.5g/kg/d by age 6 months.

90% of protein ingested by infants is incorporated into tissues, the end products of protein metabolism do contribute to the renal solute load.
Protein content of Modified Cow's Milk Formulas vs. Breastmilk
50% higher in formula than in human milk.
Two classes of protein in human milk/formulas...
Whey = acid soluble, produces small curds.
Casein = acid insoluble and produces large curds
Whey: Casein Ratio in Formula vs human milk...
Formula --> 20:80
Human Milk --> 70:30
Characteristics of Whey-predominant formula-fed infants
Whey - have higher blood levels of threonine, valine, methionine, phenylalanine, leucine, and isoleucine compared with infants fed human milk.
Characteristics of Casein-predominant formula-fed infants
Casein - have higher blood levels of tyrosine, phenylalanine, valine, and methionine compared with infants fed human milk
Taurine
the largest source of nonprotein nitrogen in human milk and important in retinal development is added to all formulas
The higher proportion of whey in human milk is beneficial for infants because...
1 - compared to casein, whey is more easily digested and is associated with more rapid gastric emptying
2 - the whey protein fraction provides lower concentrations of potentially deleterious amino acids that may interfere with brain development
Other benefits of human milk over formula:
human milk has higher levels of CYSTINE (needed to synthesize the antioxidant glutathione) and TAURINE (needed for bile conjugation and brain development) than bovine milk
Benefits of the major human whey protein vs. bovine
Human whey composed of lactoferrin, secretory IgA, and lysozyme (improves host defenses) + alpha-LACTALBUMIN

the predominant whey protein in cow's milk is beta-LACTOGLOBULIN (which may contribute to milk protein allergy and colic)
Nitrogen content of human milk vs. bovine milk
human: ~20% of total nitrogen is in the form of nonprotein nitrogen-containing compounds such as nucleotides, free AA, and urea.

Nucleotides represent 2-5% of the nonprotein nitrogen in human milk and are lacking in bovine milk. (nucleotides are important for GI, immune, and metabolic fxns (enhance development of intestinal villi and immune development by promoting T-lymphocyte maturation)

Formula has <5% non protein nitrogen.
Lipid (fat) in human milk
Lipids represent ~50% of the calories in human milk
Cow's Milk Fomula Lipid Content
contains lipids in the form of vegetable oils (soy, corn, coconut, safflower, and palm) or a mixture of vegetable oil and animal fate, which account for 40-50% of the total energy content. Balance of saturated and polyunsaturated fatty acids of variable chain lengths.

Human milk - enhanced lipid absorption
Cholesterol in formula vs. human milk
formulas prepared with vegetable oils have littelt o no cholesterol compared with breastmilk with have 10-15mg cholesterol per 100mL
How does formula compensate for better lipid absorption of human milk?
To match the overall lipid absorption from human milk, formula has a greater quantity of passively absorbed MCFA than human milk. (so MCFA decreases the content of LCFA in formula compared to human milk.)
What important Fatty Acids are lacking in cow's milk formulas but present in breastmilk?
cow's milk formulas lack omega-3 and omega-6 fatty acids along with their long-chain polyunsaturated derivatives, including arachadonicand (AA) and docosahexanoic acids (DHA), which are present in human milk and may be important for optimal cognitive and visual development, esepcially in preterm infants. (cow's milk formulas are now supplemented)
Consequences of lactose in human milk for the infant...
softer stools, nonpathogenic bacterial fecal flora, improved mineral absorption.
Benefits of lactose...
helps promote calcium absorption from the GIT.
Lactose Content in Breastmilk
40% total calories
Mineral concentrations in formula vs. human milk
mineral content in formula usually exceed human milk with the exception of sodium. Mineral content of formula also contribute to renal solute load. Formula is also supplemented with water and fat-soluble vitamins, as well as iron.
Soy Formulas - benefits
the equivalent to lactose-based formula in supporting linear growth, bone mineralization, and weight gain in TERM infants.
Who should NOT receive soy formulas
not recommended in premies and infants <1800g; (+) association with osteopenia

Should NOT be used to prevent colic or atopic disease or as an alternative formula for infants with documented cow's milk protein-induced enterocolitis
Soy milk vs. cows milk based formula
Soy requires added methionine (bc it is lacking). Carbohydrate source = sucrose or constarch hydrolysates or a combo.
When should iron supplementation begin in exclusively breastfed infants?
by 6mo
Extensively-Hydrolyzed Protein Hydrolysate Formulas - Benefits
- carbohydrate source is not lactose (lactase not required to absorb carb)
- contain varying amts of MCTG (bile salts not needed for absorption)
- contains free AA and peptides of varying lengths
allows for absorption from GIT following degredation by BB enzymes w/o need for pancreatic proteolytic enzymes
Extensively-Hydrolyzed Protein Hydrolysate Formulas - Cons
- may have poor tolerance bc osmolality is high
- result may be net water flux interfering with nutrient and/or water absorption, or diarrhea