Training in Nutrition

The basic goal of pediatric nutrition is to provide appropriate support for normal growth and development, which is a cornerstone of pediatric care. The science of clinical nutrition focuses on the effects of nutrient deficiencies and excesses during acute and chronic illness and the role of diet and specific nutrients in the development of chronic illnesses, such as obesity, type II diabetes, coronary artery disease, and cancer, that appear to have their clinical onset in adulthood. Didactic lectures and directed readings are basic components of the training program. In addition, experiences in nutritional support can be obtained through service in the wards.

At the end of the training program the trainee will be able to :

• Understand the biochemistry, digestion, absorption, and metabolism of macronutrients and micronutrients
• Understand the physiology of starvation and the metabolic and nutritional consequences of physiological stress, along with age-related changes in nutrient metabolism, absorption, and digestion
• Understand the theoretical basis for the estimates of energy, protein, carbohydrate, fiber, fat, mineral, trace element, and vitamin requirements of healthy pediatric patients, as well as how these requirements vary with age and health status
• Assess nutritional status as the primary step in the recognition and evaluation of pediatric patients whose growth differs from the norm
• Evaluate and treat children with acute and chronic diseases impacted by nutritional deficiencies
• Understand the importance of a detailed diet history and other methods of assessing nutrient intake
• Be familiar with the various techniques available for clinical assessment of nutritional status. This includes careful inspection of the patient for generalized and specific signs of nutrient excess or deficiencies (e.g., cheilosis, xerosis, and dermatitis). Anthropometry should be used to assess growth either cross-sectionally or longitudinally, by measurements of length and stature, weight, head circumference, midarm circumference, and triceps skinfold thickness. The trainee should understand the use of these measurements and the indices derived from them, such as body mass index and weight-for-height, in the classification of undernutrition (protein and energy), and obesity. The trainee should understand the importance of nutritional assessment derived from measuring body composition, nitrogen balance, and energy expenditure as well as the use of hematological and biochemical indices of nutritional status
• Be familiar with the physiology of lactation and support of the breast-feeding mother, the composition of human milk and infant formulas and how these foods support the growth of the developing infant
• Know the specific nutritional requirements of the preterm infant and the development of gastrointestinal function in premature and term infants
• Consider the different stages in the development of gastrointestinal function when planning the methods of nutritional support
• Understand the approach to feeding problems in infants with particular difficulties such as cleft palate, swallowing dysfunction, and gastroesophageal reflux
• Recognize failure to thrive in infancy, understand its causes, and be able to treat such patients
• Understand the requirements for micro- and macronutrients and the means of nutritional support for the following disease states:
  • gastrointestinal, hepatobiliary, and pancreatic diseases characterized by emesis, chronic diarrhea, and maldigestion or malabsorption
  • acute gastroenteritis and oral fluid therapy
  • inflammatory disorders of the gastrointestinal tract
  • inborn errors of metabolism
  • Diabetes mellitus
  • hyperlipidemia or risk for cardiovascular disease
  • obesity or an eating disorder
  • chronic dysfunction of single or multiple organ systems
  • food hypersensitivity
  • acute or chronic infections, such as human immunodeficiency virus or tuberculosis
• Understand the role of nutrition in the prevention of chronic illnesses (including those that may occur later in life), including the relationship between undernutrition and susceptibility to infectious illnesses, the role of nutrition in support of optimal oral health, and the role of diet in lowering the risk of illnesses such as cancer and heart disease
• Understand the nutritional aspects and risks of vegetarian diets, food fads, and other dietary patterns not practiced by most children and adolescents
• Be familiar with enteral nutrition support and understand when this therapy is indicated. Such situations include: prematurity; cardiac, renal, hepatobiliary, and pulmonary diseases; acute and chronic gastrointestinal disease or dysfunction; and when absorption and digestion are possible through the use of specifically tailored feeding techniques, specific nutrient formulations, or a combination of the two
• Be familiar with available infusion devices and the techniques of placing feeding tubes (e.g., nasogastric, nasojejunal, jejunal, and percutaneous gastrostomy feeding tubes)
• Know the composition of available commercially prepared formulas for infants and children, including standard hospital enteral feeding formulas, elemental formulas, oral supplements, blenderized feedings, and modular components
• Modify enteral feedings to meet the special needs of individual patients and should be cognizant of interactions between drugs and nutrients
• Have knowledge about the indications for parenteral nutrition and the physiology, techniques for administration, and efficacy of parenteral nutrition for pediatric patients with gastrointestinal and other medical problems that preclude or severely limit the use of the intestine for nutrition. Examples of these conditions include prematurity; severe respiratory or cardiac disease; congenital anomalies of the gastrointestinal tract, severe inflammatory disease of the intestinal mucosa; protracted diarrhea, short-bowel syndrome, extensive body-surface burns, malignant disease; and hepatic, cardiac, or renal failure
• Be familiar with parenteral nutrition catheters and the complications arising from their use, as well as the composition and metabolic effects of the solutions used to provide parenteral nutrition
• Monitor such patients in the hospital and home and be able to collaborate with a multidisciplinary team and manage nonsurgical complications of parenteral nutrition.