Pediatric Nutrition and Obesity

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Pediatric Nutrition and Obesity

• Brenda Beckett, PA-C

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Key Nutritional Conceptsin Children

• Nutritional requirements
• Feeding patterns of infants and children
• Vitamin supplements
• Brief assessment of nutritional status
• Common feeding and nutritional concerns

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Influences on Nutrient Requirements

• Rate of growth
• Highest in early infancy
• Body composition
• Needs of the brain
• Composition of new growth
• Fat needs

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Energy

• Kilocalorie(or Calorie)- unit of heat measurement
• Definition-amount of heat necessary to raise the
  temperature of one kilogram of water 1 degree

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Energy needs of children

• Vary by age
• Vary by body size
• Vary by growth rate at a point in time
• Vary by activity
• Periods of rapid growth and development increase
  caloric needs

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Energy (Calorie) Needs

• Newborn
• 120 kcal/kg/day
• 6-12 months
• 90 kcal/kg/day
• Decrease 10 kcal/kg for each succeeding 3 year
  period
• Adolescent
• 40 kcal/kg/day

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Protein

• Consists of amino acids
• Essential nutrient for forming new cells
• Arrangement of amino acids in a protein molecule
  determine its type
• Essential amino acids-needed to form new tissue
  in the body. Must be present in the diet
• Nonessential amino acids can be synthesized, and
  do not need to be supplied in the diet

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Too much and too little

• Proteins cannot be stored effectively
• Not enough protein-muscle tissue may be broken
  down to supply amino acids to the brain and for
  enzyme synthesis
• Inborn errors of metabolism-problems in the
  breakdown of amino acids, at any point in the
  cycle

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Protein Needs

• Newborn
• 2.5 g/kg/day
• 12 months
• 1.5-2 g/kg/day
• Adolescent
• 1-1.5 g/kg/day

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Fat Needs

• Main dietary energy source for infants
• 45-50 of calories
• Required for
• Absorption of fat-soluble vitamins
• Myelination of CNS
• Brain development

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Carbohydrate Needs

• In the form of lactose for infants
• 40 of calorie intake
• Converted to glucose, the principle fuel for the
  brain

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Requirements for 2 year olds

• Similar to adults (transition)
• High fiber, limit sodium, limit fats
• Carbs 55 of total cal (10 simple sugars)
• Protein 15-20 of total cal
• Total Fat less than 30 of total cal
• Sat Fats less than 10
• Chol less than 300mg/day

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Feeding PatternsBreast Milk

• Advantages
• Economical/convenient
• Psychological/emotional bond
• Easier to digest
• Immunologic
• Allergy-protective
• Infection preventive

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Contraindications toBreast Feeding

• Maternal Infection
• TB
• HIV (in developing countries)
• ? Hepatitis C
• Drugs
• Illicit drugs
• Radioactive compounds
• Antineoplastic agents
• Lithium
• Ergots
• Gold salts
• Tetracycline
• Plus many more

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Composition (calories 20kcal/oz)
Product Protein Source CHO Source Fat Source
Breast 40 casein 60 whey lactose Human milk fat
Cows Milk 80 casein 20 whey lactose butterfat
Milk-based formula Nonfat cows milk lactose Coconut, soy oils
Soy-protein formula Soy protein Corn syrup, sucrose Coconut, soy oils
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Infant Formula

• Approx. 20 kcal/oz (human milk 22kcal/oz)
• Protein, fat, carbohydrate similar
• Mineral content in formula slightly higher
• Some differences in electrolyte composition

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Technique of bottle feeding

• Comfortable position for infant
• No bottle propping
• Comfortable temperature for the infant(discourage
  microwave heating)
• Avoid air in the bottle
• Burping, spitting up
• Discard unused portion of bottle

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Infant Feedings

• How much ?
• First 6 weeks
• q1½-3h
• Breast fed 8-12x/24 hours
• Formula fed 6-8x/24 hours
• 2 months
• q3-4h, 3-4 oz.
• 6 months
• q4-6h, 5-7 oz. (this does not include solids)

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How to tell if the infant is ready for solids

• Interested in what parent is eating
• Seems to be hungry between feedings
• Wakes at night to feed, after already sleeping
  through the night
• Sits with support
• Holds head steady and upright
• (double birth weight)

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Im still hungry !!!

• At a routine health maintenance visit, a
  mother asks if she may begin giving her 4 month
  old daughter solid foods. The infant is taking
  about 4-5oz. of formula q3-4h during the day and
  sleeps from 11pm to 6am without awakening for a
  feeding. Her birth weight was 7 lbs., and her
  current weight is 13 lbs. The PE, including
  developmental assessment, is normal for age.

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Intro. To solid foods

• Age 4-6 months
• Iron fortified rice cereal, mix with breast milk
• Veggies / Fruits
• Feed with a spoon
• By 10 months soft finger foods
• By 12-15 months regular diet
• Wide range of normal
• Wait 3-5days between introducing a new food

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Some Foods to avoid in 1st year of life

• Honey
• Eggs
• Seafood
• Peanuts
• Nuts

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Manageable Mealtimes

• Encourage child to stay seated
• Hands-on food, feed self (pincer grasp)
• Introduce spoon (6-8 months)
• Use a cup
• Whole milk for 12-24 months of age
• 2-3 years of age transition to adult diet

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Vitamin Supplements

• Vitamin D
• Low in breast fed babies
• Vitamin B12
• if mom is strict vegetarian
• Iron
• importance of screening
• Fluoride
• Dose dependent on age of child and fluoride
  content of water supply

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Supplemental Fluoride Recommendations

• Concentration of Fluoride in Water lt0.3 ppm

Age Supplemental Fluoride (mg/d)
6 mo to 3 yr 0.25
3-6 yr 0.5
6-12 yr 1.0
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Assessment of Nutritional Status

• Diet History
• Quantity of foods
• Quality of foods
• Variety of foods

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Feeding Concerns

• A 4 month-old infant is brought to the
  office for a routine exam by his mother, who
  complains that her son is constipated. He grunts
  with each bowel movement, and his face turns
  bright red. He has soft BMs every five days.
  The infant is breast-feeding and has not yet
  started other foods.
• On examination, the infants vital signs are
  normal, and the infant is at the 75th percentile
  for height and weight. The remainder of the PE
  is normal.

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Feeding Concerns

• Constipation
• Spitting up
• Toddler feedings
• Deficiencies
• Excesses

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Constipation

• Very uncommon in breast fed infants
• Most infants have 1 or more stools/day, varying
  consistency is normal
• Cause may be insufficient fluid intake
• Add small amount of water to diet
• Pear juice/prune juice

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Diarrhea

• Breast fed infants have looser stools than
  formula fed infants
• Most likely causes of diarrhea in breast fed
  infants
• Infectious
• Food or medication taken by mother
• Mild diarrhea may be due to overfeeding, more
  common in formula fed infants

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Colic

• Severe crying in infants younger than 3 months,
  with paroxysmal abdominal pain
• Symptoms
• Sudden onset, may last hours
• Abdomen is tense
• Legs may be drawn up, hands clenched
• Seems relieved with passing gas
• Occurs often at late afternoon or evening
• Treatment
• Try to prevent attacks by improving feeding
  technique, environmental controls
• Identify possible food sensitivities in the
  mothers diet, food allergies in infant

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Feeding after age 1

• Most have adapted to a schedule of 3 meals a day
• Decreased rate of growth in the 2nd year of
  life-decreased kcal/weight requirements
• Children start to self select diet
• Look at what they are eating over a week, not
  just a day to day basis

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Eating habits

• Important to start early
• Patterns started in the 1st years often continue
• Avoid mealtime stress
• Respect the childs appetite

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Later childhood

• Consider dietary needs and tastes as child gets
  older
• Suggest that parents involve the child in meal
  planning and preparation
• Be aware of adequate caloric intake, especially
  for athletes
• Educate parents on eating disorders and obesity

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So you have a picky eater

• Wont eat at mealtime, will only eat 1 food, will
  only drink.what else?
• Appetite reduced with slower growth
• Eat when hungry
• Look at food over 1 week, not daily
• Disguise nutrient rich food in other foods
• Is snacking an issue?
• Try new foods in small portions
• Involve your child
• Be a positive role model

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Malnutrition

• Worldwide, a leading cause of mortality in
  children
• Caused by either inadequate intake or inadequate
  absorption of food

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Severe Malnutrition

• Marasmus
• Common in areas with insufficient food
• Poor feeding habits
• Failure to gain weight,
• Loss of weight until emaciation results
• Kwashiorkor
• Severe protein deficiency with inadequate caloric
  intake
• Loss of muscle tissue
• Edema
• Liver enlargement with fatty infiltrates
• Secondary immunodeficiency

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Vitamin Deficiencies

• Not encountered very frequently in US
• List of all doses recommended for children, and
  consequences of deficiency and overdose listed in
  any text

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Multivitamins

• Be aware many vitamins and minerals are toxic in
  large amounts
• Choose a multi-vit for KIDS, not adult
• Does not replace good nutrition
• Always supervise
• Not gum or candychoking issue

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Childhood Obesity
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Objectives

• Discuss societal trends contributing to obesity
• Define obesity
• Discuss medical complications of obesity
• Review effective communication techniques for
  talking to patients and their families
• Tools for assessment
• Clinical evaluation of the obese child
• Discuss disease processes associated with obesity
• Discuss treatment goals

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U.S. Statistics

• Prevalence of childhood obesity has been rising
  dramatically
• Over the past 30 years, the obesity rate in the
  U.S. has more than doubled for preschoolers and
  adolescents.
• Over the past 30 years the obesity rate has more
  than tripled for children ages 6-11 years old.
• In the U.S. as many 25-30 children may be
  affected

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Maine Statistics

• 27 of Maine high school students, 30 of Maine
  middle school students are overweight, or at risk
  of becoming overweight
• 36 of Maine kindergarten students are overweight
  or at risk of becoming overweight

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National Trends

• Increase consumption of fast foods
• Increase in portion size (SUPERSIZE)
• Increase consumption of soft drinks
• Increase amount of T.V. / video game viewing
• Decrease in family meal times
• Decrease time in physical education classes

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Portion Comparison over past 20 years

• Bagel 3 inch diam, 140 kcal. Now 6 inch diam,
  350 kcal
• Popcorn 5 cups, 270 kcal. Now 11 cups, 630 kcal
• Soda 6.5 oz, 85 kcal. Now 20 oz, 250 kcal

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Definition Obesity/Overweight

• Preferred terms are at risk for overweight and
  overweight replacing at risk for obesity and
  obesity
• At risk BMI for age between the 85th and 95th
  percentiles
• Obese/Overweight BMI for age is at or greater
  than the 95th percentile

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Factors contributing to obesity

• Change in dietary intake-i.e. types of foods
• Increase caloric intake
• Decrease in physical activity
• Increase in inactivity

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Which one of these factors is found to correlate
directly with childhood obesity?

• Fast food
• Soft drinks
• Infrequent family meal time
• Watching television
• Decreased physical activity

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Effects of obesity on major organ systems

• Musculoskeletal
• Endocrine
• Gastrointestinal
• Respiratory
• Cardiovascular
• Reproductive
• Neurological

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Tips on discussing childhood obesity

• TREAT FAMILIES WITH SENSITIVITY
• A lot of value in society placed on physical
  appearance
• Often the parent(s) or other family members are
  obese as well
• Beliefs that obesity is secondary to laziness
• Family members may be embarrassed
• Treat obesity as a chronic medical problem
• Be a respectful and compassionate health care
  provider

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Create an alliance by asking focused questions

• Instead of asking, Why cant you stop eating?
• Try instead, Do you ever feel out of control
  while you are eating?
• Instead of asking, Why do you eat out at
  restaurants 5 nights a week?
• Try instead, What are some of the barriers you
  are encountering when you try to prepare a meal
  at home?

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Instead of asking

• Why do you take you kids to fast food eateries
  for French fries and soda after school for a
  snack?

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Try instead.
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Understanding the family

• Economic limitations
• Social concerns
• Language issues
• Cultural norms
• Schedule issues

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Family History

• Obesity
• Hypertension
• High Cholesterol/Triglycerides
• Diabetes

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Conditions associated with childhood obesity

• Genetic Syndromes associated with childhood
  obesity (usually also have developmental delay
  and other sequelae)
• Prader-Willi
• Bardet-Biedl
• Turner syndrome
• Endocrine Disorders
• Hypothyroidism
• Cushings
• Psychiatric Disorders
• Eating disorders
• Depression

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Assessment of Childhood Obesity

• Height, Weight plotted
• BMI-Body Mass Index
• Body weight (in kg) divided by the Height (in
  meters squared)
• Measured in units kg/m squared
• Triceps skin fold
• Compare these to norms in age group

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BMI-Body Mass Index

• Anthropometric index of weight and height
• A screening tool, not a diagnostic tool
• In children, BMI changes with age and gender
• BMI is plotted on the appropriate chart for
  gender, and is evaluated using specific cut off
  points compared to values of other children of
  the same gender and age

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BMI

• BMI can be used to track body size through life
• BMI found to correlate with health risks
• CDC recommends use of BMI for age and gender for
  age 2 and older
• Shape of BMI curve shows adiposity rebound
• Decline in BMI until age 4-6, and then increase
• Reflects normal pattern of growth
• Theory that early adiposity rebound may be
  associated with adult obesity

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Steps to plotting the BMI

• Be careful to obtain accurate height and weight
• Select BMI chart for gender and age
• Calculate BMI
• Plot measurement
• Interpret plotted measurement

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Calculating the BMI

• Weight(kg)/ height(cm)/height(cm) x10,000
• Weight(lb)/height(in)/height(in)x703

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Triceps skin fold

• gt85 obesity
• gt95 severe obesity
• Direct measure of subcutaneous fat. Variability
  by experience.

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Genetic/Endocrine causes of obesity rare

• Over 90 of obese children have no known genetic
  or endocrine cause for obesity
• Many have positive family history of obesity

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Complications of Childhood Obesity

• Pseudotumor Cerebri
• Orthopedic Problems
• SCFE
• Blounts Disease
• Sleep Apnea
• Gall Bladder Disease
• Type II Diabetes Mellitus
• Hyperlipidemia
• HTN
• Cardiovascular disease

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Pseudotumor cerebri

• Increased intracranial pressure with papilledema,
  and normal CSF without ventricular enlargement
• Can present with headaches, vomiting, blurred
  vision
• Fundoscopic exam on obese patients
• Diagnosis of exclusion-need to R/O all other
  causes of increased ICP

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SCFE-Slipped Capital Femoral Epiphysis

• Hip motion is limited on abduction and internal
  rotation
• Patient may present with a limp, or complain of
  groin, thigh or knee pain
• Immediately suspect in obese patient with any
  abnormal gait
• Diagnose with x-ray, often bilateral, so compare
  both

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Blounts Disease

• Bowing of tibia and femur resulting from
  overgrowth of medial aspect of the proximal
  tibial metaphysis
• 2/3 of patients with Blounts are obese

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Sleep Apnea

• Intermittent or prolonged obstruction of the
  upper airway during sleep
• Disrupts normal ventilatory pattern in sleep, and
  normal sleeping patterns
• Nighttime awakenings
• Restless sleep
• Difficulty awakening in the morning
• Decreased concentration/poor school performance
• Abnormal sleep patterns reported in many obese
  children

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Sleep apnea (cont.)

• Enlarged tonsils and adenoids
• Increased fat mass
• Increased muscle relaxation during sleep

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Sleep ApneaDiagnosis and Treatment

• Sleep study
• Weight loss
• Tonsillectomy/adenoidectomy
• CPAP

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Gall Bladder Disease

• More common in obese patients
• Among adolescents with cholecystitis, 50 are
  obese
• Symptoms-abdominal pain, tenderness
• Diagnosis-ultrasound

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Hyperlipidemia

• All obese patients, esp. adolescents need
  screening. Can screen younger.
• Elevated LDL, Triglycerides, lowered HDL
• Increases risk for cardiovascular disease
• May improve with weight reduction

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Glucose Intolerance/ DM II

• Glucose intolerance precursor of diabetes
• Acanthosis nigricans increased skin pigmentation
  and thickness of skin between folds
• Obesity contributes to insulin resistance, and
  resulting hyperglycemia

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BMI assessment

• 95ile for age/gender obesity-in depth medical
  assessment (fasting glucose, insulin, liver
  profile, lipid profile)
• 85-95ile for age/gender at risk-evaluate
  carefully
• Pay attention to secondary complications of
  obesity
• Pay attention to family history
• Lab tests/further medical assessment as indicated
• Recent large changes in BMI
• Evaluate and treat
• BMI most reliable indicator. Correlates best with
  complications of childhood obesity

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Evaluation for Treatment

• Child/family needs to be ready for change
• If not ready, and decrease childs self esteem
  will make it difficult later to make improvements
• Ask patient and family
• How concerned are you?
• Do you believe that weight loss is possible?
• What do you think you could change?
• Involves time commitment
• Dietary and activity evaluation
• Revisits

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Treatment-Weight goals

• Develop awareness in patient and family
• Consult with a dietician
• Identify problem behaviors
• High caloric foods
• Eating patterns
• Obstacles
• Modify current behavior
• What small changes can make a difference?
• Continued awareness

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Treatment-Weight Goals (cont.)

• Maintain baseline weight
• Modest changes in appearance
• Initial success
• Gradual decrease in BMI as child grows in height
• Continue prolonged weight maintenance(if no other
  medical symptoms) until BMI is below the 85ile
• If older than 7, and severely obese or has other
  associated medical symptoms, weight loss
  recommended
• Weight loss of 0.5 kg/month
• Goal to achieve a BMI lt85ile

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Treatment-Weight Goals (cont.)

• If weight loss is too rapid, risks of gall
  bladder disease, risk of malnutrition
• Possibility decrease growth velocity
• Possible emotional problems
• Self-esteem issues
• Eating disorders
• Drugs for treatment of weight loss are not
  recommended in children

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Weight loss surgery

• Can be safe and effective for severely obese
  adolescents
• Potential risks and long term complications
• Effect on growth and development unknown
• Need to change lifestyle, diet, exercise

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Advice to parents to help children limit caloric
intake

• Praise you kids!!!
• Avoid using food as a reward
• Be a role model for your kids
• Establish meal and snack times
• Offer healthy choices
• Limit high calorie foods kept at home
• Avoid prepackaged and sugared foods
• Follow the food pyramid recommendations using
  oils and fats sparingly, 3 servings of dairy, 2-3
  servings of proteins, 5-8 portions fruits and
  veggies, 6-10 servings of grains

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Diet(cont.)

• Fad diets (ie. Atkins, South Beach, diet of the
  week)-The positives
• May jump start weight loss
• 2 times the amount of weight loss
• Parents are familiar with these diets
• Fad diets-The negatives
• Hard to follow for child
• Too restrictive
• MAJOR risk of developing serious metabolic side
  effects
• Not recommended by AAP

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Diet(cont.)

• Healthy food, healthy choices
• Portion control
• Allowing room for error

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Treatment Increased Physical Activity

• Track all activity to see where improvements can
  be made
• Vigorous activity
• Activities of daily living
• Track all sedentary activity
• TV
• Computer
• Sitting down time

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TV Viewing/Screen Time

• AAP
• Children lt2 should not be exposed to TV at all
• Children gt2 should be limited to 2 hours max/day
• HMS studied 1200 children
• Every hour of additional TV viewing associated
  with deficits in diet
• Increased trans fats
• Increased fast foods
• Decreased healthy food choices
• Other studies
• Increased TV viewing directly correlated with
  increased rate of obesity

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Advice to Parents To Increase Childs Activity
Level

• Limit screen time
• Incorporate activity into daily life
• Encourage participation in sports
• Encourage and provide opportunity for outdoor
  play
• Establish regular family activities-walks, bike
  rides, playing catch

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Treatment-Medical Goals

• Hypertension-decrease blood pressure, hopefully
  without medication
• Reverse abnormal lipid profile
• Improve DM II

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Treatment -Overall

• Intervene early-the risk of obesity increases as
  age increases
• Back to basics Increase activity level, decrease
  caloric intake
• Family must change
• Provider educates families on medical
  complications of obesity (HTN, abnl Lipid
  profile, DM II)
• Involve all family members
• Small gradual changes
• Encourage NOT criticize

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Why is it important to address the issue of
childhood obesity with your patients?

• Major public health concern, increasing at
  alarming rates
• Early evaluation and treatment may help prevent
  disease progression
• Help prevent associated health problems
• Though genetic and endocrine problems are rare
  causes, need to consider these and evaluate
• Emphasizing healthy eating and exercise promotes
  a healthy lifestyle that can have lasting effects.

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5 2 1 Almost None

• 5 servings fruits and vegetables
• No more than 2 hrs screen time / day
• 1 hour of activity per day
• Limit sugary drinks

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