1. Nutrition Assessment of 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. 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 >6 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 119:355 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 fed infants: 8-112 days of age (g/d) Nelson et al Early Human Development 19:223 1989

21. 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

22. 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

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 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

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. DRI’s for Select Nutrients Protein Calcium/Phosphorus Iron Vitamin D

39. DRI’s for select Nutrients

40. 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

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

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 (< 3rd percentile) Length 65 cm (3rd percentile) Birth History: 34 weeks Gestation, 1100 grams, IUGR History of reflux “doesn’t 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. 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”

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

61. 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 <67 kcal/kg/d

63. Lucy –tires, desaturates, increased work of breathing Feeding Information

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 > 95th %ile

66. 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

67. Adam

69. 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 >95th percentile. Intake exceeds RDA for age. Hx FTT and behavioral issues around feeding (anxiety, gorging, hoarding)

72. Adam

73. –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.