1. Pediatric Nutrition and Obesity Brenda Beckett, PA-C

2. 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

3. Influences on Nutrient Requirements Rate of growth –Highest in early infancy Body composition –Needs of the brain Composition of new growth –Fat needs

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

5. 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

6. 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

7. 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

8. 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

9. Protein Needs Newborn –2.5 g/kg/day 12 months –1.5-2 g/kg/day Adolescent –1-1.5 g/kg/day

10. Fat Needs Main dietary energy source for infants –45-50% of calories Required for : –Absorption of fat-soluble vitamins –Myelination of CNS –Brain development

11. Carbohydrate Needs In the form of lactose for infants –40 % of calorie intake Converted to glucose, the principle fuel for the brain

12. 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

13. Feeding Patterns Breast Milk Advantages –Economical/convenient –Psychological/emotional bond –Easier to digest –Immunologic Allergy-protective Infection preventive

14. Contraindications to Breast 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 …

15. Composition (calories: 20kcal/oz) ProductProtein SourceCHO Source Fat Source Breast40% casein 60% whey lactoseHuman milk fat Cow’s Milk80% casein 20% whey lactosebutterfat Milk-based formula Nonfat cow’s milklactoseCoconut, soy oils Soy-protein formula Soy proteinCorn syrup, sucrose Coconut, soy oils

16. 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

17. 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

18. 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)

19. 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)

20. 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.

21. 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

22. Some Foods to avoid in 1 st year of life Honey Eggs Seafood Peanuts Nuts

23. 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

24. 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

25. Supplemental Fluoride Recommendations Concentration of Fluoride in Water <0.3 ppm AgeSupplemental Fluoride (mg/d) 6 mo to 3 yr0.25 3-6 yr0.5 6-12 yr1.0

26. Assessment of Nutritional Status Diet History –Quantity of foods –Quality of foods –Variety of foods

27. 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 75 th percentile for height and weight. The remainder of the PE is normal.

28. Feeding Concerns Constipation Spitting up Toddler feedings Deficiencies Excesses

29. 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

30. 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

31. 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 mother’s diet, food allergies in infant

32. Feeding after age 1 Most have adapted to a schedule of 3 meals a day Decreased rate of growth in the 2 nd 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

33. Eating habits Important to start early Patterns started in the 1 st years often continue Avoid mealtime stress Respect the child’s appetite

34. 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

35. So you have a picky eater… 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

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

37. 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

38. 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

39. 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

40. Childhood Obesity

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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 85 th and 95 th percentiles Obese/Overweight BMI for age is at or greater than the 95 th percentile

47. Factors contributing to obesity Change in dietary intake-i.e. types of foods Increase caloric intake Decrease in physical activity Increase in inactivity

48. 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

49. Effects of obesity on major organ systems Musculoskeletal Endocrine Gastrointestinal Respiratory Cardiovascular Reproductive Neurological

50. 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

51. 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?”

52. Instead of asking… “Why do you take you kids to fast food eateries for French fries and soda after school for a snack?”

53. Try instead….

54. Understanding the family Economic limitations Social concerns Language issues Cultural norms Schedule issues

55. Family History Obesity Hypertension High Cholesterol/Triglycerides Diabetes

56. 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 –Cushing’s Psychiatric Disorders –Eating disorders –Depression

57. 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

58. 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

59. 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

60. 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

61. Calculating the BMI [Weight(kg)/ height(cm)/height(cm)] x10,000 [Weight(lb)/height(in)/height(in)]x703

62. Triceps skin fold >85% obesity >95% severe obesity Direct measure of subcutaneous fat. Variability by experience.

63. 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

64. Complications of Childhood Obesity Pseudotumor Cerebri Orthopedic Problems –SCFE –Blount’s Disease Sleep Apnea Gall Bladder Disease Type II Diabetes Mellitus Hyperlipidemia HTN Cardiovascular disease

65. 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

66. 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

67. 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

68. 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

69. Sleep apnea (cont.) Enlarged tonsils and adenoids Increased fat mass Increased muscle relaxation during sleep

70. Sleep Apnea Diagnosis and Treatment Sleep study Weight loss Tonsillectomy/adenoidectomy CPAP

71. Gall Bladder Disease More common in obese patients Among adolescents with cholecystitis, 50% are obese Symptoms-abdominal pain, tenderness Diagnosis-ultrasound

72. 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

73. 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

74. 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

75. 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

76. 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

77. 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 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

78. 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

79. 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

80. 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

81. 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

82. Diet(cont.) Healthy food, healthy choices Portion control Allowing room for error

83. 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

84. TV Viewing/Screen Time 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

85. 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

86. Treatment-Medical Goals Hypertension-decrease blood pressure, hopefully without medication Reverse abnormal lipid profile Improve DM II

87. 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

88. 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.

89. 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