Download Pediatric Nutrition

Pediatric Nutrition
and Obesity
Brenda Beckett, PA-C
Key Nutritional Concepts
in Children
Nutritional requirements
 Feeding patterns of infants and children
 Vitamin supplements
 Brief assessment of nutritional status
 Common feeding and nutritional
concerns

Influences on Nutrient
Requirements

Rate of growth
– Highest in early infancy

Body composition
– Needs of the brain

Composition of new growth
– Fat needs
Energy
Kilocalorie(or Calorie)- unit of heat
measurement
 Definition-amount of heat necessary to
raise the temperature of one kilogram
of water 1 degree

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

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
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Adolescent
– 40 kcal/kg/day
Protein
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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
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

Protein Needs

Newborn
– 2.5 g/kg/day

12 months
– 1.5-2 g/kg/day
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Adolescent
– 1-1.5 g/kg/day
Fat Needs

Main dietary energy source for infants
– 45-50% of calories

Required for :
– Absorption of fat-soluble vitamins
– Myelination of CNS
– Brain development
Carbohydrate Needs

In the form of lactose for infants
– 40 % of calorie intake

Converted to glucose, the principle fuel
for the brain
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
Feeding Patterns
Breast Milk

Advantages
– Economical/convenient
– Psychological/emotional bond
– Easier to digest
– Immunologic
• Allergy-protective
• Infection preventive
Contraindications to
Breast Feeding
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Maternal Infection
– TB
– HIV (in developing countries)
– ? Hepatitis C
Drugs
– Illicit drugs
– Radioactive compounds
– Antineoplastic agents
– Lithium
– Ergots
– Gold salts
– Tetracycline
– Plus many more …
Composition (calories: 20kcal/oz)
Product
Protein Source
CHO
Source
Fat Source
Breast
40% casein
60% whey
lactose
Human milk fat
Cow’s Milk
80% casein
20% whey
lactose
butterfat
Milk-based
formula
Nonfat cow’s milk
lactose
Coconut, soy oils
Soy-protein
formula
Soy protein
Corn
syrup,
sucrose
Coconut, soy oils
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

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

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)
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)

I’m 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.
Intro. To solid foods

Age 4-6 months
– Iron fortified rice cereal, mix with breast milk
– Veggies / Fruits
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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
Some Foods to avoid in 1st year
of life
Honey
 Eggs
 Seafood
 Peanuts
 Nuts

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

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
Supplemental Fluoride
Recommendations

Concentration of Fluoride in Water <0.3 ppm
Age
6 mo to 3 yr
Supplemental
Fluoride (mg/d)
0.25
3-6 yr
0.5
6-12 yr
1.0
Assessment of Nutritional Status

Diet History
– Quantity of foods
– Quality of foods
– Variety of foods
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 BM’s every
five days. The infant is breast-feeding and
has not yet started other foods.
On examination, the infant’s vital signs are
normal, and the infant is at the 75th percentile
for height and weight. The remainder of the
PE is normal.
Feeding Concerns
Constipation
 Spitting up
 Toddler feedings
 Deficiencies
 Excesses

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
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
Colic

Severe crying in infants younger than 3
months, with paroxysmal abdominal pain
 Symptoms
–
–
–
–
–
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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 mother’s
diet, food allergies in infant
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

Eating habits
Important to start early
 Patterns started in the 1st years often
continue
 Avoid mealtime stress
 Respect the child’s appetite

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…
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Won’t 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
Malnutrition
Worldwide, a leading cause of mortality
in children
 Caused by either inadequate intake or
inadequate absorption of food

Severe Malnutrition
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Marasmus
–
–
–
–
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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
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

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 candy—choking issue
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Childhood Obesity
Objectives
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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
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
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

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

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

Factors contributing to obesity
Change in dietary intake-i.e. types of
foods
 Increase caloric intake
 Decrease in physical activity
 Increase in inactivity

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

Effects of obesity on major organ
systems
Musculoskeletal
 Endocrine
 Gastrointestinal
 Respiratory
 Cardiovascular
 Reproductive
 Neurological
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Tips on discussing childhood
obesity
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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
Create an alliance by asking
focused questions
Instead of asking, “Why can’t 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?”
Try instead….
Understanding the family
Economic limitations
 Social concerns
 Language issues
 Cultural norms
 Schedule issues

Family History
Obesity
 Hypertension
 High Cholesterol/Triglycerides
 Diabetes

Conditions associated with
childhood obesity
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Genetic Syndromes associated with
childhood obesity (usually also have
developmental delay and other sequelae)
– Prader-Willi
– Bardet-Biedl
– Turner syndrome

Endocrine Disorders
– Hypothyroidism
– Cushing’s

Psychiatric Disorders
– Eating disorders
– Depression
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

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
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
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
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[Weight(kg)/ height(cm)/height(cm)]
x10,000
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[Weight(lb)/height(in)/height(in)]x703
Triceps skin fold
>85% obesity
 >95% severe obesity
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Direct measure of subcutaneous fat.
Variability by experience.
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
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Pseudotumor Cerebri
Orthopedic Problems
– SCFE
– Blount’s Disease
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Sleep Apnea
Gall Bladder Disease
Type II Diabetes Mellitus
Hyperlipidemia
HTN
Cardiovascular disease
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

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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Blount’s Disease
Bowing of tibia and femur resulting from
overgrowth of medial aspect of the
proximal tibial metaphysis
 2/3 of patient’s with Blount’s are obese
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Sleep Apnea
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Intermittent or prolonged obstruction of the
upper airway during sleep
 Disrupts normal ventilatory pattern in sleep,
and normal sleeping patterns
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Nighttime awakenings
Restless sleep
Difficulty awakening in the morning
Decreased concentration/poor school
performance
Abnormal sleep patterns reported in many
obese children
Sleep apnea (cont.)
Enlarged tonsils and adenoids
 Increased fat mass
 Increased muscle relaxation during
sleep

Sleep Apnea
Diagnosis 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

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

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

BMI assessment

95%ile for age/gender: obesity-in depth medical
assessment (fasting glucose, insulin, liver profile, lipid
profile)
 85-95%ile 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
Evaluation for Treatment

Child/family needs to be ready for change
 If not ready, and decrease child’s 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
Treatment-Weight goals
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Develop awareness in patient and family
 Consult with a dietician
 Identify problem behaviors
– High caloric foods
– Eating patterns
– Obstacles
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Modify current behavior
– What small changes can make a difference?
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Continued awareness
Treatment-Weight Goals (cont.)
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Maintain baseline weight
– Modest changes in appearance
– Initial success
– Gradual decrease in BMI as child grows in
height
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Continue prolonged weight maintenance(if
no other medical symptoms) until BMI is
below the 85%ile
 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 <85%ile
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
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Drugs for treatment of weight loss are
not recommended in children
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
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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
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
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Not recommended by AAP
Diet(cont.)
Healthy food, healthy choices
 Portion control
 Allowing room for error
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Treatment –Increased Physical
Activity
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Track all activity to see where
improvements can be made
– Vigorous activity
– Activities of daily living
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Track all sedentary activity
– TV
– Computer
– Sitting down time
TV Viewing/Screen Time
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AAP
– Children <2 should not be exposed to TV at all
– Children >2 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
Advice to Parents To Increase
Child’s 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
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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
Why is it important to address the
issue of childhood obesity with
your patients?
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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.
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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