Transcript Nutrition Management in Children with Special Health Care

Nutrition Management
in Children with Special
Health Care Needs
(CSHCN)
Jackie Maurer MS, RD
Introduction
Children with Special Health Care Needs (CSHCN)
Definition:
Children with congenital or acquired conditions affecting
physical/cognitive growth and development and who require
more than the usual pediatric health care; also refers to
children who have developmental disabilities, chronic
conditions, or health related problems as well as those who
are at risk for these conditions
(JADA. 1995;95:809)
Introduction
Nutrition Intervention
 Critical aspect

Interdisciplinary

Preventive and
therapeutic
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Family centered
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Community based
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Culturally competent
Objectives
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Understand basic measures of growth &
development
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Acquire fundamental skills in global assessment
techniques

Appreciate general medical nutrition therapy for
lung diseases
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Experience oral supplements that promote
nutrition status
GROWTH & DEVELOPMENT

Weight
– Primary indicator for over/under- nutrition
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Growth chart
– Reflects growth pattern

Technique
– Needs to be consistent
and accurate (ie no shoes,
no diapers)
GROWTH & DEVELOPMENT

Height
– Has slower response to nutrition changes
– May indicate chronic under-nutrition if measurements
continually trend down

Technique:
0-36 months - Recumbent length
2-20 years
- Standing height
GROWTH & DEVELOPMENT

Head Circumference
– Last indicator to be affected by undernutrition
– < 3 yr old
Possible nutritional insult with downtrends, accompanied by
decreases in weight and height
– > 3 yr old
Decreases are generally not nutrition-related
FOR MORE INFO...
See CDC web site, http://www.cdc.gov/growthcharts, to download
charts.
ASSESSMENT SKILLS
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Subjective Global Assessment (SGA)
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Simple technique for assessing nutritional status
Evaluates body fat and muscle stores
Involves visual review of physical body
May be applied by any healthcare worker
Nutrition History
– Interview reveals dietary habits
– Quick tool for assessing one’s ability to meet, fail, or
exceed nutritional needs
SGA METHOD

Fat Stores
– Eye fat pad
– Cheek pad
– Tricep pinch

Muscle Stores
– Temple
– Clavicle
– Shoulder
– Scapula
– Upper joint area
– Interosseus area
REFERENCE:
Detsky, A, et al. Journal of Enteral and Parenteral Nutrition. 11:8,
Jan/Feb, 1987.
http://www.eneph.com/feature_archive/nutrition/v25n4p190.html
DIET HISTORY METHOD
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What is the home life/meal pattern?
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How much is consumed?
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Food allergies or intolerances?
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Who is present at mealtimes?
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Is the child interested in eating?
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Any problems with chewing or
swallowing? Gagging or choking?
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Are there any foods or textures that
the child has difficulty with?
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Does the child eat non-foods ?
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Any weight change perceived?

What religious or cultural backgrounds
are present?
ASTHMA & NUTRITION

Malnutrition of excess
– Cycle of inactivity
– Steroid induced

Potential food allergy triggers

Nutrient Medication Interactions
ASTHMA & NUTRITION

General guidelines
1. No skipping meals (Eat min 3 x day)
2. Maintain a “normal”, balanced diet
and choose sensible portions
3. Lose weight, if needed
4. Avoid excessive salt, fat, sweets
5. Increase dairy or supplements
6. Exercise daily
ASTHMA & EXERCISE

20 minutes total

3 times per week
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Aerobic activity
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Avoid asthma triggers
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May lessen Exercise
Induced Asthma (EIB)
Tips
•Check local pollen, mold, spore
levels.
•Lengthen the time between
breaks while conditioning
occurs.
•Wear scarves over mouth and
nose in winter to keep heat &
moisture in lungs.
•Warm-up to lessen chances of
EIB.
•Do pursed lip breathing when
medication is not readily
available.
ASTHMA & FOOD ALLERGIES
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Food allergies - usually NOT common trigger

Occurs in <5% of asthmatics
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Difficult to diagnose
– Skin tests, Blood test (RAST)
– Food diary, elimination diet
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Symptoms
– hives, itching, eczema, sneezing, coughing, swelling of throat,
nasal stuffiness, vomiting, diarrhea, cramping, collapse and
sometimes death
POTENTIAL FOOD ALLERGENS

Milk and dairy
products
– No link to increased
mucus production or
bronchoconstriction
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Wheat
Soy
Eggs
Peanuts
Tree nuts
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Fish and shellfish
Chocolate
Corn
Tomatoes
Citrus fruits
Other grains
Beef
Chicken
Sulfite-containing
ASTHMA & FOOD AIDS?

Conflicting evidence that foods can
prevent asthma

Of three scientific papers on asthma &
omega-3 fatty acids:
– 1 showed favorable results
– 1 showed no results
– 1 showed negative results w/ worse asthma
BPD: Bronchopulmonary Dysplasia
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Nutrition Concerns
– ?Prenatal undernutrition, premature growth
issues
– Increased caloric intake to maintain normal or
catch-up growth
– Suboptimal intake due to increased effort of
breathing during eating and appetite
suppressing medications
– Delayed development of oral feeding skills
BPD & NUTRITION
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Nutrition Therapy
1. Concentrate infant formula
2. Initiate adjuvant nutrition via enteral
route as indicated
3. Assess feeding skills
4. Occupational therapy/feeding
specialist referral
BPD & FEEDING SKILLS
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Feeding Assessment
– Responses to tactile input
 irritability, frenzy, drowsy, staring, silent cry
– Feeding position
– Oral motor control
 tongue retraction/protrusion, jaw excursion
– Physiologic control
 heart rate
– Sucking, swallowing, breathing
– Caregiver/infant feeding interactions
CYSTIC FIBROSIS & NUTRITION
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Multifactorial risks for malnutrition
– Intake
 Decreased appetite
 Decreased volume consumed
 Physical/mechanical/mental inability to meet
nutritional needs orally
– Output
 Increased energy output to meet cost of breathing
and coughing, higher during pulmonary
exacerbations.
 Malabsorption
CF & NUTRITION
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Basic Nutrition Guidelines
1.
2.
3.
4.
5.
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High calorie diet (moderate fat)
Snacks 2-3 times/day
Salt repletion, especially with sweating
Pancreatic enzymes
Fat soluble vitamins in water miscible form (ADEK)
Oral Supplementation
– Calorically dense
– Sample tasting
Childhood Obesity
Childhood Obesity

DEFINITION: BMI Percentiles (2 to
20 y.o.)
– 85-95th %ile = at risk
– >95th%ile Overweight

Associated risks:
– Hyperlipidemia, glucose intolerance,
hepatic steatosis, cholelithiasis, early
maturation. hypertension, sleep apnea
CDC.org
Childhood Obesity - Factors

Familial influence
– Fat parent = fat child
– Model: eating & activity
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Physical Inactivity
– TV
– Cuts in PE class

Heredity
– Fatness
– regional fat distribution
– response to overfeeding
Childhood Obesity - Management
CDC.org
Childhood Obesity – Treatment
 Physical
 Diet
Activity
Management
– Controlled weight
gain
 Behavior
Modification
Dietary Management
1.
Focus on energy dense, whole foods
Choose
2.
3.
Over
Limit sugar packed drinks and snacks
Watch portion sizes
Thank You!
Questions?