Nutrition Assessment of Children with Special Health Care Needs

Common Nutrition Problems & Concerns

• Growth • Diet/nutrient intake • Feeding problems • Medication/nutrient interactions • Supplements/alternative diets/megavitamins • Special diets, i.e. PKU • Dental and nutrition issues • Bowel management

Steps to Evaluating Pediatric Nutrition Problems

• Screening • Assessment • Intervention • Monitor • Reassessment

Assessment

• Screening identifies nutritional risk • Nutrition Assessment – Uses information gathered in screening – Adds more in depth, comprehensive data – Interprets data – Develops care plan – Reassess

Goals of Nutrition Assessment

• To collect information necessary to document adequacy of nutritional status or identify deficits • To develop a nutritional care plan that is realistic and within family context • To establish an appropriate plan for monitoring and/or reassessment

Interdisciplinary Team

• Physician • Nutritionist • Nurse • Social worker • OT/PT • Speech pathologist • Behavioral psychologist

Information Collected

• Growth • Dietary • Medical history • Diagnosis • Feeding and developmental information • Psychosocial and environmental information • Clinical information and appearance (hair, skin, nails, eyes) • Other (anthropometrics, laboratory)

Interpretation

Interpretation

• • • •

Goals Expectations References Evidence

Interpretation

• Comparison with references established for children without special health care needs

Interpretation

• Evaluate information collected on an individualized basis

Challenges in Nutrition Assessment of Children with Special Health Care Needs

• Goals • Expectations • References • Ability to obtain data

Challenges

Nutrient needs influenced by: genetics, activity, body composition, medical conditions and medications Alterations in growth and measures of growth genetics, body composition, physical limitations

Growth

• CDC growth charts • Specialized growth charts • Evaluation of growth rates/velocity

CDC Growth Charts (compared to older NCHS

• Standardized data collection methods • Expanded sample • Exclusions – VLBW infants – NHANES III weight data for >6 year olds

Specialty Growth Charts

Include: • Down syndrome • Turner syndrome • Williams syndrome • Spastic quadraplegic CP • Prader-willi syndrome • others

Growth Concerns

• Underweight • Short stature • Overweight

Weight gain increments from birth to 12 months (g/d) 1-3 months 4-6 months 8-10 months Male

22-39 13-20 9-15

Female

19-34 12-18 Roche and Fomon J Pediatr 119:355 1991 9-14

Rates of gain for breastfed and formula fed infants during early months of life generally have been found to be similar although some reports have demonstrated greater gains by breastfed infants and others have shown greater gains by formula fed infants

Weight gain of Breast fed vs bottle fed infants: 8-112 days of age (g/d) Breast fed Bottle fed Male

29.8 + 5.8

32.2 + 5.6

Female

26.2 + 5.6

27.5 + 4.9

Nelson et al Early Human Development 19:223 1989

Body Mass Index for Age

• Body mass index or BMI: wt/ht 2 • Provides a guideline based on weight, height & age to assess overweight or underweight • Provides a reference for adolescents that was not previously available • Tracks childhood overweight into adulthood

Guidelines to Interpretation of BMI

• Underweight – BMI -for-age <5th percentile • At risk of overweight – BMI-for-age  85th percentile • Overweight – BMI-for age  95th percentile

Interpretation of BMI

• BMI is useful for – screening – monitoring • BMI is not useful for – diagnosis

Advantages of Using BMI for Age for Children & Adolescents

• BMI for age can be used for adolescents beyond puberty • BMI in children and adolescents compares well to laboratory measures of body fat • Childhood BMI is related to adult health risks

Who might be misclassified?

• BMI does not distinguish fat from muscle – Highly muscular children may have a ‘high’ BMI & be classified as overweight – Children with a high percentage of body fat & low muscle mass may have a ‘healthy’ BMI – Some CSHCN may have reduced muscle mass or atypical body composition

Other Anthropometrics

• Upper arm circumference, triceps skinfolds • Arm muscle area, arm fat area • Sitting height, crown-rump length • Arm span • Segmental lengths (arm, leg) All have limitations for CSHCN, but can be additional information for individual child

Dietary Information

• Family Food Usage • 24 hour recall • Diet history • 3-7 day food record or diary • Food frequency • Other Information – Food preparation, history, feeding observation, feeding problems, likes/dislikes, feeding environment

Dietary Reference Intakes (DRI) (including RDA, UL, and AI) are the periodically revised recommendations (or guidelines) of the National Academy of Sciences

Comparison of individual intake data to a reference or estimate of nutrient needs

• DRI: Dietary Reference Intakes – expands and replaces RDA’s – reference values that are quantitative estimates of nutrient intakes for planning and assessing diets for healthy people • AI: Adequate Intake • UL: Tolerable Upper Intake Level • EER: Estimated Energy Requirement

Approaches to Estimating Nutrient Requirements

• Direct experimental evidence (ie protein and amino acids) • extrapolation from experimental evidence relating to human subjects of other age groups or animal models – ie thiamin--related to energy intake .3-.5 mg/1000 kcal • Breast milk as gold standard (average [] X usual intake) • Metabolic balance studies (ie protein, minerals) • Clinical Observation (eg: manufacturing errors B6, Cl) • Factorial approach • Population studies

Water

• Replace losses and for growth • Increased with increased losses (fever, diarrhea, work of breathing) • Renal solute load of diet may alter fluid needs and available water • Estimated fluid needs (cc/kg/d)* – Newborn: 80-100 – 6 months: 130-155 – 1 year: 120-130 – 2 years: 115-125 * LA Barnes 1992 Nelson Textbook of Pediatrics

Energy

• Assessing Energy Needs – Components, Factors that may alter – References (EER, ?other) – Equations – Correlate Individual Intake with growth

Components of Energy Expenditure

• Basal Metabolic Rate • Thermic Effect of Food • Thermoregulation • Physical Activity • Physical activity level • Total Energy Expenditure

EER

• 0-3 months (89 x wt -100) + 175 • 4-6 months (89 x wt -100) + 56 • 7-12 months (89 x wt -100) + 22 • 13-35 months (89 x wt -100) + 20 • Equations for older children factor in weight, height and physical activity level (PAL)

Examples of EER by age and weight

Age weight total per kg 0-3 months 4-6 months 7-12 months 9 10 11 13-35 months 12 14 2 3 4 6 7 8 253 342 431 490 579 668 723 812 901 988 1166 80 81 81 82 83 126 114 108 81 82 83

Energy Partition in Infancy (kcal/kg/d)

Newborn Losses Activity 5 10 Thermic effect of feed Growth 10 40 Resting Metabolic rate Total 50 115 6 months 5 25 10 12 55 107

Factors that alter Energy needs

• Body composition • Body size • Gender • Growth • Genetics • Ethnicity • Environment • Adaptation and accommodation • Activity/work • Illness/Medical conditions

DRI’s for Select Nutrients

• Protein • Calcium/Phosphorus • Iron • Vitamin D

DRI’s for select Nutrients

Protein Ca/Ph (mg) Iron (mg) A (ug/d) D (ug/d) 0-6 months 1.5 g/kg/d 210/100 .27

600 25 7-12 months 1.5 g/kg/d 270/275 11 600 25 1-3 years 1.1 g/kg/d 500/460 7 600 50

DRI’s for infants

• Macronutrients based on average intake of breast milk • Protein less than earlier RDA • AAP Recommendations – Vitamin D: 200 IU supplement for breastfed infants and infants taking <500 cc infant formula – Iron: Iron fortified formula (4-12 mg/L), Breastfed Infants supplemented 1mg/kg/d by 4-6 months

Diet History and Assessment

Medical Information

Medical Conditions that may alter nutrient needs • Congenital Heart Disease • Cystic Fibrosis • Liver disorders • Short gut syndrome or other conditions of malabsorbtion • Respiratory disorders • Neuromuscular • Renal • Prematurity • Others

Drug-Nutrient Interaction • Altered absorption • Altered synthesis • Altered appetite • Altered excretion • Nutrient antagonists

Feeding and Developmental Information

Feeding the Infant • Feeding Relationship • Feeding Development • Feeding Difficulties

Assessment of Feeding

• dysphagia/aspiration risk • positioning • food texture • therapeutic feeding techniques used • duration of meals/snacks • amount of food/fluids • tube feeding used • feeding interactions – child and caregiver • signs of pleasure, aversion

Dental Factors

• Extended use of nursing bottles; contents of bottles • Pattern of meals and snacks • Types of snacks, including food reinforcers • Daily dental care and thoroughness • Caries, delayed tooth eruption, pain, malocclusion - impact on diet intake

Intervention

Weighing Risks and Benefits

• Adequate intake vs feeding relationship • Concentrating formula vs fluid status • impact on tolerance, compliance, errors, cost • solution to problem vs exacerbating problem

• Joey • Sierra • Lucy • Adam Case Reports

Joey

• 7 months old • Weight 6 kg (< 3rd percentile) • Length 65 cm (3rd percentile) • Birth History: 34 weeks Gestation, 1100 grams, IUGR • History of reflux • “doesn’t like solids” • ? Risk factors

Joey

• History of IUGR • History of GER • ? Feeding difficulties

Growth

• Joey (weight, length) • 40 Weeks – 1.8 kg, 46 cm • 4 months – 5 kg, 58 cm • 5 months – 5.6 kg, 62 cm

Joey

Joey

• • •

Takes 36 oz Standard Infant Formula Takes “ A little cereal and pears”

•

Estimated 180 cc/kg/d, 120 kcal/kg/d, 2.7 g/kg/d Protein History of reflux, “doesn’t like solids”

Joey

– experiencing decrease in rate of weight gain, estimated intake appears adequate, hx GER and alteration in feeding (solids)

Lucy • 2 months of age • Congenital Heart Disease, on diuretics, will need surgery • Weight: 3.2 kg • Birthweight: 2.8 kg • Feeds 8-12 times per day • Mom reports “ tires at feeding” and is concerned her milk supply is dwindling • Pre/post feeding weight indicates 20 cc intake

Growth

• Lucy – Birthweight: 2.8 kg – 2 months: 3.2 kg – 6-7 g/d estimated weight gain • ? Risk factors

Lucy

• Birthweight: 2.8 kg • 2 months: 3.2 kg – 6-7 g/d estimated weight gain

Lucy

• Exclusively breastfed • feeds 8-12 times per day • “tires with feeding” • concern that supply is dwindling • pre/post weights indicate 20cc/feed – estimate 50-80 cc/kg/d and <67 kcal/kg/d

Feeding Information

• Lucy – tires, desaturates, increased work of breathing

• Lucy – Inadequate growth. Breastmilk intake appears inadequate based on pre/post weights. CHDD. Feeding difficulties (tires, length of time)

Adam • Age: 14 months • Wt: 12.8 kg • Length: 78 cm • Wt/ln 90-95th %ile 50th %ile > 95th %ile

Growth

Adam • Birthweight 4 kg, Birthlength 50.8 cm • Birth to 3 months: Significant FTT • 12 months – 12.6 kg, 76 cm • 14 months – 12.8 kg, 78 cm

Adam

Adam

Adam

• Foster parent establishing set meal times and working with behavioral issues around eating (anxiety around food access, gorging, hoarding) • 3 meals, 2 snacks, appropriate food choices • estimated energy intake from 3-day food record: 126 kcal/kg/d

Feeding Information

• Adam – Behavioral issues (anxiety, hoarding, gorging)

Adam

– Weight/length >95th percentile. Intake exceeds RDA for age. Hx FTT and behavioral issues around feeding (anxiety, gorging, hoarding)

Adam

Adam

– Much of growth/intake issues occurred prior to his 14 month evaluation. Although he continued to have behavioral issues related to feeding, his current foster placement was addressing these issues. His intake was decreasing and his growth was stable.