Nutrition Assessment of Children with Special Health Care Needs - PowerPoint PPT Presentation

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Nutrition Assessment of Children with Special Health Care Needs

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Supplements/alternative diets/megavitamins. Special diets, i.e. PKU. Dental and nutrition issues ... Renal solute load of diet may alter fluid needs and ... – PowerPoint PPT presentation

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Title: Nutrition Assessment of Children with Special Health Care Needs


1
Nutrition Assessmentof Children with Special
Health Care Needs
2
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

3
Steps to Evaluating Pediatric Nutrition Problems
  • Screening
  • Assessment
  • Intervention
  • Monitor
  • Reassessment

4
Assessment
  • Screening identifies nutritional risk
  • Nutrition Assessment
  • Uses information gathered in screening
  • Adds more in depth, comprehensive data
  • Interprets data
  • Develops care plan
  • Reassess

5
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

6
Interdisciplinary Team
  • Physician
  • Nutritionist
  • Nurse
  • Social worker
  • OT/PT
  • Speech pathologist
  • Behavioral psychologist

7
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)

8
Interpretation
9
Interpretation
  • Goals
  • Expectations
  • References
  • Evidence

10
Interpretation
  • Comparison with references established for
    children without special health care needs

11
Interpretation
  • Evaluate information collected on an
    individualized basis

12
Challenges in Nutrition Assessment of Children
with Special Health Care Needs
  • Goals
  • Expectations
  • References
  • Ability to obtain data

13
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

14
Growth
  • CDC growth charts
  • Specialized growth charts
  • Evaluation of growth rates/velocity

15
CDC Growth Charts (compared to older NCHS
  • Standardized data collection methods
  • Expanded sample
  • Exclusions
  • VLBW infants
  • NHANES III weight data for gt6 year olds

16
Specialty Growth Charts
  • Include
  • Down syndrome
  • Turner syndrome
  • Williams syndrome
  • Spastic quadraplegic CP
  • Prader-willi syndrome
  • others

17
Growth Concerns
  • Underweight
  • Short stature
  • Overweight

18
Weight gain increments from birth to 12
months(g/d)
Roche and Fomon J Pediatr 119355 1991
19
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
20
Weight gain of Breast fed vs bottle fedinfants
8-112 days of age (g/d)
Nelson et al Early Human Development 19223 1989
21
Body Mass Index for Age
  • Body mass index or BMI wt/ht2
  • 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

22
Guidelines to Interpretation of BMI
  • Underweight
  • BMI-for-age lt5th percentile
  • At risk of overweight
  • BMI-for-age ? 85th percentile
  • Overweight
  • BMI-for age ? 95th percentile

23
Interpretation of BMI
  • BMI is useful for
  • screening
  • monitoring
  • BMI is not useful for
  • diagnosis

24
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

25
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

26
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

27
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

28
Dietary Reference Intakes (DRI) (including RDA,
UL, and AI) are the periodically revised
recommendations (or guidelines) of the National
Academy of Sciences
29
Comparison of individual intake data to a
reference or estimate of nutrient needs
  • DRI Dietary Reference Intakes
  • expands and replaces RDAs
  • 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

30
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

31
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

32
Energy
  • Assessing Energy Needs
  • Components, Factors that may alter
  • References (EER, ?other)
  • Equations
  • Correlate Individual Intake with growth

33
Components of Energy Expenditure
  • Basal Metabolic Rate
  • Thermic Effect of Food
  • Thermoregulation
  • Physical Activity
  • Physical activity level
  • Total Energy Expenditure

34
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)

35
Examples of EER by age and weight
36
Energy Partition in Infancy (kcal/kg/d)
37
Factors that alter Energy needs
  • Body composition
  • Body size
  • Gender
  • Growth
  • Genetics
  • Ethnicity
  • Environment
  • Adaptation and accommodation
  • Activity/work
  • Illness/Medical conditions

38
DRIs for Select Nutrients
  • Protein
  • Calcium/Phosphorus
  • Iron
  • Vitamin D

39
DRIs for select Nutrients
40
DRIs 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 lt500 cc infant formula
  • Iron Iron fortified formula (4-12 mg/L),
    Breastfed Infants supplemented 1mg/kg/d by 4-6
    months

41
Diet History and Assessment
42
Medical Information
43
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

44
Drug-Nutrient Interaction
  • Altered absorption
  • Altered synthesis
  • Altered appetite
  • Altered excretion
  • Nutrient antagonists

45
Feeding and Developmental Information
46
Feeding the Infant
  • Feeding Relationship
  • Feeding Development
  • Feeding Difficulties

47
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

48
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

49
Intervention
50
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51
  • Adequate intake vs feeding relationship
  • Concentrating formula vs fluid status
  • impact on tolerance, compliance, errors, cost
  • solution to problem vs exacerbating problem

52
Case Reports
  • Joey
  • Sierra
  • Lucy
  • Adam

53
Joey
  • 7 months old
  • Weight 6 kg (lt 3rd percentile)
  • Length 65 cm (3rd percentile)
  • Birth History 34 weeks Gestation, 1100 grams,
    IUGR
  • History of reflux
  • doesnt like solids
  • ? Risk factors

54
Joey
  • History of IUGR
  • History of GER
  • ? Feeding difficulties

55
Growth
  • Joey (weight, length)
  • 40 Weeks
  • 1.8 kg, 46 cm
  • 4 months
  • 5 kg, 58 cm
  • 5 months
  • 5.6 kg, 62 cm

56
Joey
57
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, doesnt like solids

58
Joey
  • experiencing decrease in rate of weight gain,
    estimated intake appears adequate, hx GER and
    alteration in feeding (solids)

59
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

60
Growth
  • Lucy
  • Birthweight 2.8 kg
  • 2 months 3.2 kg
  • 6-7 g/d estimated weight gain
  • ? Risk factors

61
Lucy
  • Birthweight 2.8 kg
  • 2 months 3.2 kg
  • 6-7 g/d estimated weight gain

62
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 lt67 kcal/kg/d

63
Feeding Information
  • Lucy
  • tires, desaturates, increased work of breathing

64
  • Lucy
  • Inadequate growth. Breastmilk intake appears
    inadequate based on pre/post weights. CHDD.
    Feeding difficulties (tires, length of time)

65
Adam
  • Age 14 months
  • Wt 12.8 kg 90-95th ile
  • Length 78 cm 50th ile
  • Wt/ln gt 95th ile

66
GrowthAdam
  • 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

67
Adam
68
Adam
69
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

70
Feeding Information
  • Adam
  • Behavioral issues (anxiety, hoarding, gorging)

71
Adam
  • Weight/length gt95th percentile. Intake exceeds
    RDA for age. Hx FTT and behavioral issues around
    feeding (anxiety, gorging, hoarding)

72
Adam
73
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.

74
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