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Child Health
Nursing
Partnering with
Children & Families
Kristine Ruggiero CPNP,
MSN, RN
Chapter 9
Nutrition pp 318-344
Child Health Nursing: Partnering with Children & Families
By Jane W. Ball and Ruth C. Bindler
© 2006 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Nutrition

Overview:
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Nutritional Needs
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Nutritional assessment
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Physical and behavioral measurement
Common nutritional concerns
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Infancy
Todlerhood
Preschool
School age
Adolescence
Nutritional challenges
Overweight and obese
Collaborative care
Dietary deficiencies (iron, ca, vit d, folic acid, protein-energy)
Feeding and eating disorders

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Pica
Ftt
Nutritional concepts

Nutrition:

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Macronutrients:
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Taking in food and assimilating it metabolically for
use by the body.
Major building blocks
Carbohydrates, proteins and fats
Micronutrients:

Substances needed in small quantities for health
body functioning.
Carbohydrates

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
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Energy source: composed of carbon,
hydrogen, and oxygen.
Saccharides (sugar molecules)
50% of daily calories
Fiber= indigestible carbohydrate
components, ensures healthy movement of
fecal matter thru bowel
While a child’s nutritional status influences health, it is also important to consider
conditions that may affect the child’s nutrition and include this knowledge in your
assessment.
FIGURE 9–16
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Proteins
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Amino acid compounds
9 essential and 12 nonessential amino acids
Catabolism and anabolism
Nitrogen balance
Deficiency disorders
Fats
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Energy source
Cellular processes and blood clotting
Fatty acids
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Saturated
Unsaturated
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Monounsaturated
Polyunsaturated
Glycemic Index


The blood glucose response to 50g of
carbohydrate from any specific food as
compared to the glucose level after ingestion
of white bread
Low glycemic index has been found to have
beneficial effects such as reducing serum
lipids, insulin levels and improving serum
glucose control
How are nutritional needs of the
infant different from the adult?
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Increased energy expenditure
Rate of growth: doubles by 6 months, triples
by 1 year
Organ size and immaturity
Physiological changes
Nutritional Needs: Preterm and
SGA Infants
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Preterm (<37 weeks) and SGA (<2700 g)
infants
Medical problems
Immature body systems
High calorie/kg intake to provide energy for
necessary weight gain; may need up to 140
kcal/kg/day
Nursing strategies for Preterm
and SGA infants

Specialized feeding methods
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Parenteral nutrition
Gavage/ tube feedings
Transition to oral feedings
Assist families w/ teaching feeding methods
Assessment of growth and development
This premature baby cannot yet coordinate suck and swallow. Gavage feeding is being used
until the baby can effectively acquire nutrients.
FIGURE 9–3
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutritional Needs: Term
Newborn
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Infants need minimum of 120 cal/kg/day to
maintain weight and growth
20 cal/oz is the usual calories found in
formula
Feedings/day q3-4 hrs= 6-8 feedings/ day
Question…

How much formula would an infant who
weighs 4.3 kg need at each feeding if they
feed every 4 hours?
Answer…
Let’s break it down

1. Infant weight in kg is multiplied by 120 calories/
number of feedings per day
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2. Calories needed/day= 4.3 x 120
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Calories needed/day= 516 calories/ day
3. calories needed per feeding= 516/6
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Baby weight= 4.3 kg
Calories needed per feeding= 86
4. ounces per feeding= calories needed per
feed/number of calories per ounce of formula
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86/20= 4.3 ounces/ feeding
Breast and Formula Feedings

Breast milk: advantages include:
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Excellent nutrition
Promotion of GI function
Fostering immune defense
lower incidence of OM’s, Type 2 Diabetes, and
obesity
Psychological benefits
Economic advantage
Breast Feeding
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Nursing role:
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Includes education, and encouragement to foster
breastfeeding
Help mothers to have positive experience w/
Breastfeeding
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Encouragement
Lactation consultant/ group support
Contraindications to
breastfeeding
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Chemotherapy
Active untreated maternal TB
Maternal HIV/AIDS
Maternal primary herpes in the breast
Certain medications (chloramphenicol)
Use of alcohol and recreational drug abuse
Breastfeeding offers many physical and emotional benefits for the infant. This
new mother is learning to breastfeed her baby. How can nurses encourage mothers to have
positive breastfeeding experiences?
FIGURE 9–4
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Formula Feeding Infants
(newborn- 6 months)

Types of formulas
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Ready to feed, powder, and concentrate (p 323,
Table 9-7)
Specialized formulas for specific needs (PKU,
allergies)
Nursing strategies
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Education
Partent-infant relationship
Prevention of early childhood caries
Introducing solid foods

When is an infant ready to begin solid foods?
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4-6 months of age
Introduction of foods b/f or after this period
increases risk of food allergies
Readiness for solid foods
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Extrusion reflex, swallowing
Sitting skills
Interest
The baby who has developed the ability to grasp with thumb and forefinger should receive some
foods that can be held in the hand.
FIGURE 9–5
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Infants age 6-12 months
Developmental Readiness
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Initial introduction of foods
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Appropriate first foods: rice cereal
Weaning occurs at 12 months
Longer bottle feeding increases
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Dental caries
Otitis media
allergies
General nutrient requirements
of an infant
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Introduction of whole milk at 1 year, and lowfat milk at 2 years
Fluoride supplements at 6 months if not in
water
Iron enriched cereals should be started first
New foods added gradually
Introduce veggies b/f fruits
No honey b/f 1 year…infant botulism
Early childhood caries. This child has had major tooth decay related to
sleeping as an infant and toddler while sucking bottles of juice and milk. Courtesy of Dr.
Lezley Mcllveen, Department of Dentistry, Children’s National Medical Center,
Washington, DC.
FIGURE 9–6
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Feeding 9-12 months
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Finger foods
Peeled fruit
Cheese and soft cooked vegetables
Delay introduction of peanuts/ peanut butter
until 1 year of age (unless h/o allergies in
family, then 3 years of age)
No yolks until 8-10 months of age, or whole
eggs until 1 year of age
Carbs and fats needed for energy and growth
Introduction of a cup (b/t 8-9 months)
Nutritional needs of the
toddler
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Remember developmental level
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Goal is to gain control of bodily functions
Physiologic anorexia
Nutritional needs
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Restrict fat to less than 30% of calories
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Low fat milk (2%)
Adequate protein
Toddlers should sit at a table or in a high chair to eat, to minimize chance of choking
and to foster positive eating patterns.
FIGURE 9–7
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutritional needs of the
preschooler
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Food jags (eating only a few foods for a few
days of weeks)
Socialization (associative play)
Help with food preparations
Dental care
Meal and snack patterns
Nutritional requirements
FIGURE 9–8
Preschoolers learn food habits by eating with others. Engaging them in food preparation
enhances knowledge of food and promotes intake at meals.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutritional needs of the
school-age child
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Appropriate food choices
School involvement
Growth spurts
Dental care
Nutritional needs of the
adolescent
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Growth rate
Calorie needs
Mineral and vitamin needs
Food choices
Nutritional assessment
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Family history
Developmental history
Medical history
Physical examination of growth parameters
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Height
Weight
Head circumference
Assessment of Growth
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Measure using appropriate tools
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Growth charts
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Gender specific
Pre-term or specific medical conditions
The nurse accurately measures the child and then places height and weight on appropriate
growth grids for the child’s age and gender.
FIGURE 9–10
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Growth chart with first few entries in same channel and then a change indicated. The growth for
the child indicated on this chart remained steady and in the same channel (75th percentile) for some months.
Then the weight measurement decreased to another channel. What kind of dietary assessment will you
complete with the parents? What could be the possible causes?
FIGURE 9–11
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutritional assessment includes
physical assessment and lab findings
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H&H
Blood Chemistry
Lipid Profile
Renal and Liver function tests
Nutrition Assessment
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Dietary intake
24 hour food recall
3 day food history
Genogram to recognize nutrtional risk (heart
disease and hypertension)
Overweight and Obesity
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Public health epidemic in US
Increasing incidence
Factors influencing obesity include:
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Genetics
Psychological
Environmental (excessive TV, lack of exercise, %
of calories from fat)
Obesity by the numbers
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Childhood obesity has reached epidemic levels in
developed countries.
Twenty five percent of children in the US are
overweight and 11% are obese. About 70% of obese
adolescents grow up to become obese adults
US children at risk for being overweight= 25%
Overweight + obese children in US= 15%
Increase in obesity since 1960= 300%
Overweight and Family History
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When a child has one obese parent, chances
of the child being overweight are increased
by 220%. In families where both parents are
overweight, the incidence of obesity in
children increases by 320%.
Finally, the child who has obese parents, and
is overweight as an adolescent has an 80%
risk of being an obese adult
Definitions of Obesity and
Overweight
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The Center for Disease Control and
Prevention defined overweight as at or above
the 95th percentile of BMI for age and "at risk
for overweight" as between 85th to 95th
percentile of BMI for age.
Treatment of obesity
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Medical treatment and referrals
Nutrition and behavioral counseling
Treat family

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Focus on family environment
Nonjudgmental support
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Focus on concern for health, not appearance
Treatment of obesity
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Discourage food as a reward
Encourage healthy eating patterns
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Family meals around table
Plan for small changes one at a time
Decrease sedentary behavior
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Decrease tv time to 2 hrs/day
Specific Dietary Deficiencies
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Calcium
Iron
Vitamin D:
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Rickets
Folic acid:

Prevention of neural tube defects and cleft
defects
PICA
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Ingestion of nonfood substances or atypical
ingestion of foods
Pregnant women and young children
Commonly ingested substances
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Lead paint
Soil contaminated by lead based gas fumes
Strong association w/ anemia
Treatment
What is failure to thrive?
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Organic vs Non-organic FTT:
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Nonorganic, NOFTT; also called psychosocial failure to
thrive
 is defined as decelerated or arrested physical growth
(height and weight measurements fall below the fifth
percentile, or a downward change in growth across
two major growth percentiles) associated with poor
developmental and emotional functioning. Usually
occurs in a child younger than 2 y.o
w/ no
known medical condition
Organic failure to thrive
 occurs when there is an underlying medical cause.
Infants with failure to thrive may not look severely malnourished, but they fall well below the
expected weight and height norms for their age. This infant, who appears to be about 4 months old, is
actually 8 months old. He has been hospitalized for feeding disorder of infancy.
FIGURE 9–14
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
FTT Treatment
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
Based on individual child
Management:
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Assessment and case findings
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Infant/ child family hx
Paren (caregiver)- child interactions
Adult and feeding behaviors
Nursing Diagnoses
Planning and implementation
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Monitor intake and growth patterns
Teach nutrition and feeding strategies
Observe feeding and parent-child interactions
Any ???s
Special thanks to Lorraine Murphy for helping
write and give this lecture