Diets in Fever and Anemia: Dr.

Ramolete November 7, 2013

Immunity, Infection, Fever  Sepsis: basal + 13% for each 1˚C above normal.
 Recommendations for healthy young adults Normal temp: 37.8
o Do not become obese. **if you have a fever of 38.8, sepsis= basal +13%
o Be physically active on a daily basis. **if 39.8, basal + 26%
o Enjoy a wide variety of food. **If 41%, basal + 39%
o Consume a variety of fruits, vegetables, and grain products daily. Energy Requirements
o Choose a diet low in saturated fats and cholesterol.  Simple trauma: basal + 20%
o Exercise moderation in salt and sugar consumption.  Multiple injuries: basal + 40%
o Drink alcoholic beverages in moderation, if at all and don’t smoke.  Burns:basal + 50-100%
o Moderate your protein intake. o Depends on degree of burn
o Maintain an adequate intake of calcium. o Rule of 9
o Do not take unnecessary dietary supplements in excessive  Growth and anabolism:
amounts. o Basal + 50 to 100%
o 100% for growth in infancy and adolescence.
 Implementation Guidelines **Mean age for adolescence:
o Cook at home as frequent as possible. Philippines: 10-12 yrs old
o Shop fresh foods, unprocessed foods, fish, poultry, and dairy USA: 9-10 yrs old
products. o 50% for the years in between. (2-12 years of age)
o Always read the labels.
o Understand the difference between grams of fat and percentage
of calories from fats. Immunity, Infection, and Fever
o Steam, broil or bake foods. DO NOT FRY!  Nutritional deficiency  Decreased resistance to infection infection
o Slowly wean yourself from adding salt. aggravates existing malnutrition
o Maintain calcium intake.  Nutrient needs are increased during infection by the following
o AVOID fads and “magic bullets”. mechanisms:
1. Stress reaction induces a catabolic response, which increase
MUST KNOW!! losses of nitrogen, magnesium, potassium, phosphate, and zinc.
Estimation of Energy Requirement 2. In severe infection or fever, increased metabolic rate raises
 MEMORIZE: BMR=[55-(2x age in years) x wt in kg] energy needs.
 The smaller the child, the higher the BMR 3. In anorexia there id a decreased in food intake.
 Maintenance: basal+ 20% 4. Nutrition losses may be increased due to increased perspiration,
o Includes specific dynamic action and amount of energy needed for vomiting, and diarrhea.
equilibrium in the resting but awake state with minimal muscular 5. Malabsorption in enteric infection interferes with nutrient
movement. utilization.
 MEMORIZE: a. Smaller, younger child – more caloric intake
 Activity: basal + 0-25% b. Older – lesser caloric intake
o 0% for comatose state.
o 25% for hospitalized child who ambulates 2-3x a day. Nutritional Considerations
o 50% for active non-hospitalized child. 1. Catabolic effect on CHON metabolism
o Net loss of CHON is from 0.6 to 1,2g/kg body weight/day
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Diets in Fever and Anemia: Dr.Ramolete November 7, 2013

o Energy needs in acute infection is increased to 10-30 kcal/kg/day o Roast chicken

for adults o Baked potato
o 100-150 kcal/kg/day for children. o Buttered toast
o In fever, an increased in metabolic rate amounting to 13% for o Vanilla ice cream
every ‘C rise in the body temperature. o Milk
o An increased in restlessness – greatly increased caloric needs.  Bedtime
2. Decreased nitrogen stores of adipose tissue. o Chocolate malted milk
3. Increased catabolism of CHON especially in typhoid fever, malaria. o Cream cheese sandwich on white bread.
4. Accelerated loss of body water because of increased perspiration and
excretion of body water. Mechanism Contributing to Micronutrient Malnutrition
5. Increased excretion of sodium and chloride.  Insufficient intake of nutrient in relation to requirement.
 Impaired intestinal nutrient absorption (such as in lactose, protein, or milk
Diet in Fever intolerance)
1. Energy requirement is:  Diminished whole body retention of nutrient (diarrhea, infectious process)
o Increased as much as 50% if temperature is high.  Impaired cellular nutrient utilization (enzyme lack)
o Restlessness also increase caloric requirement.  Enhanced intrinsic destruction of nutrient (infection, inflammation,
o Initially patient digest 600-1200 kcal daily but should be increased ongoing process that prevents absorption)
as rapidly as possible (glucose, corn syrup, cane sugar)
2. CHON: 100g* is prescribed if with fever. Scenarios and Contexts for Developing Micronutrient- Malnutrition
3. CHO: glycogen stores are replenished.  Other Social and Environmental Conditions
4. Fats: fried foods and rich pastries. o Poverty
o May retard digestion, therefore do not give  Eating disorders or abuse
5. Fluids: 2500-5000 ml* daily are necessary.  Emotional disturbances
o Beverages, chicken soup, fruits, juice, water
 Intention deprivation
 Diet o The caregivers eat, the child does not
o Caloric intake of 3500 or more*
 Clinical Illnesses
o CHON intake of 100 gram or more
o GIT diseases
 Iatrogenic factors where there are drug reactions and adverse reactions
Sample Diet
from the nutrients with a concomitant drug intake
 Breakfast
o Orange juice
o Cream of wheat with sugar
IRON DEFICIENCY ANEMIA (IDA)
o Poached egg on buttered white toast, cocoa
 Most widespread and common nutritional disorder in the world.
 Mid morning
 30% of global population with IDA
o Eggnog with cream
 USA: 9%
 Mid afternoon
 Infants: 0.5 grams of iron is needed
o Orange juice
 Adults: 5 grams of iron is needed
o Baked custard
 Thus 0.8 grams of iron should be absorbed everyday during the 1st 15 years
 Luncheon or Supper
of life
o Cream of tomato soup
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Diets in Fever and Anemia: Dr.Ramolete November 7, 2013

 1mg/day is needed to maintain positive iron balance in childhood.  Pallor – seen if hemoglobin falls to 7-8g/dl
 <10% of dietary iron is absorbed.
 Need 8-10 mg of iron is necessary to maintain iron levels. o Normal Hemoglobin in adults: 12-15 g/dl; 12-14g/dl in Pedia
 During infancy – approximately 1mg of iron in bovine milk. o Palmar pallor
 Breast milk makes it difficult to maintain body iron – due to rapid growth in o Pallor – palmar crease, nailbeds, conjunctivae
infancy.  When hemoglobin drops <5g/dl
 Breastfed infants absorbed 2-3 more iron than bovine fed infant. o Irritability, anorexia, lethargy
o Systolic flow murmur (Hemic murmur – secondary to increase in
Etiology: systolic flow)
 Infancy – high concentration of hemoglobin of newborn falls during the 1 st  Decrease hemoglobin – tachycardia, high output cardiac failure
to 3rd month of life.
 Iron is reclaimed and stored for blood formation in the 1 st 6-9 months of **MUST KNOW TABLE!!
life in term infants. IDA Alpha and B Anemia of
o For low birth weight – stores are depleted, thus need for dietary thalassemia chronic disease
stores. Hgb Decreased Decreased Decreased
 In term infants – anemia is due to dietary intake deficiency, which occurs MCV Decreased Decreased Normal to
at 9-24 months. decreased
Causes: RDW Decreased Normal Normal to
 Intake of bovine milk increased
o Low iron content RBC Decreased Normal to Normal to
 Blood loss from milk protein colitis increased decreased
 Occult bleeding from: Serum Decreased Normal Increased
o Peptic ulcer diseases (More Common) ferritin
 H. pylori infection TIBC Increased Normal Decreased
 Amoxicillin Transferrin Decreased Normal Decreased
 Clarithromycin saturation
 Mebendazole FEP Increased Normal Increased
 Metronidazole – taken for 14 days Transferrin Increased Normal Increased
o Meckels diverticulum (More Common) receptor
o Polyp (More Common) Reticulocyte Decreased Normal Normal to
o Hemangioma (More Common) Hgb conc decreased
o Inflammatory bowel disease (More Common)
 Infection from: MCV: Mean Corpuscular Volume
o Hookworms, Trichuristrichiuria, Plasmodium, Helicobacter pylori RDW: Red Cell Distribution Width
 Adolescent TIBC: Total Iron Binding Capacity
o Menstrual loss FEP: Free erythrocyte Protoporphyrin

Clinical Manifestations: Laboratory (IDA)

 Asymptomatic – laboratory screening  Hypochromic microcytic red cells

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Diets in Fever and Anemia: Dr.Ramolete November 7, 2013

o *Ferrous fumarate – 33% of elemental iron (300mg: 100mg

Prevention elemental iron), most expensive
 Breastfeeding o *Ferrous sulfate – 20% of elemental iron by weight (300 mg: 60
 Iron fortified formula mg)
o 12mg of iron/L – 1st year o *Ferrous gluconate – 6% of elemental iron (300mg: 20mg
 Iron fortified cereals 4-6 months. elementalFe)
 Routine screening at 12 months of age (for normal children)  Given between meals with juice
o Or at 4 months if at risk (e.g. preterm, low birth weight)  Cheapest but lowest kind
 Food diversification o Parenteral iron
o Bioavailable iron – red meat (highest in Iron) in order:  Used when malabsorption is present.
beef, pork, poutry,fish  Parenteral iron sucrose and ferric gluconate – lower risk
 Enhancers (Enhance Iron absorption) of serious reactions than dextran.
o Heme – food ** Blood transfusion in IDA is supplemental and rarely needed!!
o Vitamin C enhances iron absorption
o Fermented food, yogurt Dietary Counseling
 Inhibitors  Excessive intake of bovine milk should be limited
o Phytates (legumes, nuts, seeds); calcium (found in milk); tannins  Iron and hormone therapy for excessive menstruation in adolescent girls
in tea; high inositol concentration  Repeat blood count after 4 weeks
o One hour after eating  Iron therapy continue for 8 weeks even after blood values normalize to re-
establish iron stores
Time After Iron Administration and Response  Blood transfusion – rarely needed
 12-24 hours  Iron supplementation
o Replacement of intracellular iron enzymes.  Include liver every week
o Subjective improvement  Liberal use of dried fruits, dark green leafy vegetables
o Decreased irritability, increased appetite  Iron enriched bread and cereals
 36-48 hours  Heme iron in red meat is more available than iron in plant foods
o Initial bone marrow response, Erythroid Hyperplasia  Moderate to severe anemia
 48-72 hours o Regeneration of hemoglobin is improved if CHON is increased to
o Reticulocytosis peaking at 5-7 days 80-100 grams/day
 4-30 days
o Increased in hemoglobin levels
 1-3 months Functional Consequences of Iron Deficiency
o Repletion of stores  Reduced cognitive development as measured by intelligence quotient.
o Do not take test in less than 1 month Lowers IQ by 6-9%.
o Give iron until the next 3 months even if iron level is normal  Reduced attention span
because repletion is 1-3 months*  Poor learning and impaired scholastic performance
 Decreased exercise stamina
Treatment  Reduced muscular force and strength
 3-6 mg of elemental iron in 3 divided doses  Impaired body temperature regulation

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Diets in Fever and Anemia: Dr.Ramolete November 7, 2013
 Immune deficiencies involving
o Macrophage and neutrophil phagocytosis
o T cell proliferation
o Interleukin 2 responses
 Depriving intracellular pathogens of the iron needed for
o Proliferation
o Virulence and
o Protecting the host from more severe consequences of infection
**Do not give iron supplementation immediately; it must be given
2 weeks after because the bacteria will feed upon the iron
MEGALOBLASTIC ANEMIA
 Macrocytic anemia characterized by ineffective erythropoiesis associated
with cell output from the bone marrow
 RBC larger than normal at every developmental stage
 Maturational asynchrony between the nucleus and the cytoplasm of
erythrocyte is present
 Giant metamyelocytes and neutrophil bands are present
 Associated thrombocytopenia and leukopenia
 Due to intake of Goat’s milk because goat’s milk lack folates
A. Folic Acid Deficiency
 Consist of pteroic acid conjugated to glutamic acid
 Biological active folates are derived from folic acid and serve as 1
carbon donor and receptor in many biosynthetic pathways
 Essential for DNA replication and cellular proliferation
 Humans can’t synthesize folic acid – derived from dietary sources
o Green vegetables
o Fruits
o Animal organs – liver, kidneys
 Folates are heat labile and water soluble
 Boiling and heating folate sources – lead to decrease amount of
vitamins
 Megaloblastic anemia will occur after 2-3 months of folate-free diet
 Naturally acting folates are polyglutamated form –is less efficiently
absorbed than monoglutamic (folic acid)
 Folates – not biologically active – should be reduced to tetrahyrofolate
B. Vitamin B12 or Cobalamin Deficiency
Medical Nutrition Prelims
 Animal proteins – major source of vitamin B12
 Vitamin B12 Co-factor
o Methylation of homocystein to methionine
o Conversion of methyl malonyl Co-enzyme A (CoA) to succinyl
CoA
o Necessary for production of tetrahydrofolate – important in
DNA synthesis
 Adults and older children have sufficient Vitamin B12 stores to last for
3-5 years
o If mother with low Vitamin B12 – infants develop Cobalamin
deficiency in 1st 6-18 months
o Folate requirement in pregnancy: 400 mg for 8-12 weeks
Dietary Considerations
 Since there is Achlorhydria – rate of digestion is retarded, thus fat content
should be kept to moderate levels
 Restrict fried foods that delay gastric emptying
 Soft diet is preferred until glossitis disappears
 High CHON, high caloric beverages 2-3x a day
o Milk, non fat dry milk
 Folic acid therapy
 Source: liver and dark green leafy vegetables
o Lean beef, eggs, peanut butter, whole grain – in moderate
amounts
 Proper cooking technique
o Avoid minerals being destroyed in cooking
ZINC DEFICIENCY
 Zinc is virtually absent in fruits, vegetables, and tubers
 Zinc in animals – not tightly bound
 Zinc content in legumes and whole grains is tightly bound to phytic acid
and not easily available for intestinal absorption
 Zinc deficiency is postulated to be widespread and responsible for some of
the linear growth retardation in developing countries
 Associated with impaired immune function
 Recent epidemiologic studies indicate that child deaths from respiratory
and GIT infections can be reduced by giving adequate zinc nutrition
 In Acute Gastroeneteritis
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Diets in Fever and Anemia: Dr.Ramolete November 7, 2013

o Give 20 mg of zinc for 14 days

 In Pneumonia
o No standard recommendations
o Some pulmonologists give zinc for 3 to 6 months, however, it has
not yet been adopted by the society
 Other diseases: dengue, malaria, typhoid, sepsis
o On clinical trials
o No standard recommendations

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