A Preschool Nutrition Primer for RDs

Pediatric Growth Assessment Part II:Ends of the Spectrum

Nutrition Screening Tool for Every Preschooler

Évaluation de l’alimentation des enfants d’âge préscolaire

Learning Objectives

Understand the complex and influencing factors in childhood overweight and obesity.Know how to assess childhood overweight and obesity and the appropriate nutritional interventions in a primary care setting.Understand the types of Failure to Thrive (FTT) and the risk factors.Know how to assess FTT and the appropriate nutritional interventions in a primary care setting.

Presentation OutlineOverweight and Obesity

Population and individual level influences and actionsRisk factors and potential causesAssessing obesity and healthy weights in childrenRecommended treatment strategiesNutritional assessment and interventionsTake home messages

Failure to Thrive (FTT)DefinitionClassificationsRisk FactorsClinical PresentationTreatment Team and RD RoleFeeding Observation and Diet Instruction/Education

Factors Impacting Child Growth & Preventing Obesity

Teach MD’s to Educate Patients About Diet

Nutrition/ Behavior Counseling Program

Change LocalRestaurantMenus

Policies to ChangeFood Supply

Change Food Supply

NutritionInterventionStudies

Public HealthEducation

SubsidizedFish, Fruit Vegetable Products Use Media

to ChangeFood Norms

upstream downstreammidstream

Environmental and

PolicyApproaches

Educational,High Risk

and ClinicalPreventive Services

Approaches

Treatment

Individually-orientedPopulation-oriented

Upstream Downstream

Population oriented Individual oriented

Action on Obesity:Three Different Paradigms

What Can We Do

Level 1: Strengthening individual knowledge and skills

Level 2: Promoting community educationLevel 3: Educating service providersLevel 4: Fostering coalitionsLevel 5: Changing organizational practiceLevel 6: Influencing policy and

legislation

Obesity

Almost all cases of childhood obesity are caused by:

Calorie Intake > Calorie Need

Calorie needs are individual and are affected by the amount of physical activity a child gets

The Great Obesity Debate

Energy balancePhysical inactivityFood choicesEating behavioursMeals away from homeGeneticsCommunity designAutomobile cultureParenting

Individual foods/drinksTV/computerThe food industryAgriculture policyCost of foodSchool lunchesVending machinesEnvironmentIndividual responsibilityFast food

Medical Conditions Associated with Pediatric Obesity

GeneticMonogenic disorders (melanocortin-4 receptor mutation, leptin deficiency, proopiomelanocortin deficiencySyndromes (prader-willi, bardet-biedl, cohen, alstrom, frohlich)

NeurologicBrain injury, brain tumor, cranial irradiation, hypothalamic obesity

EndocrineHypothyroidism, cushing syndrome, growth hormone deficiency, pseudohypoparathyroidism

PsychologicalDepression, eating disorders

Drug-InducedTricyclic antidepressants, oral contraceptives, antipsychotics, sulfonylureas, glucocorticoids

Medical Co-MorbiditiesMetabolic

Type 2 diabetes, metabolic syndromeOrthopedic

Femoral epiphysis, blount’s diseaseCardiovascular

Dyslipidemia, hypertension, Lt ventricular hypertrophy, athlerosclerosis

PsychologicalDepression, poor quality of life

NeurologicalPseudotumor cerebri

HepaticNon-alcoholic fatty liver disease or steatohepatitis

PulmonarySleep apnea, asthma

RenalProteinuria

Other FactorsObesity is also related to a child’s environment

School environment

Community environment

Family/Parent environment

Family/parent environment is the area most easily changed by clinical counselling, other environments are more effected by a public health approach

Assessing Obesity

Treatments for overweight/obese children are rarely implemented under 2 years of age.

Thorough nutrition assessments are needed to guide and plan interventions as obesity has many contributing factors.

Weight GoalsAchieve a Healthy Weight

<85th %ile Normal weight/height

Maintain BMI %

85th- 95th %ile Overweight Maintain wt to decrease BMI with age/ht

>95th %ile Obese Wt maintenance or gradual wt loss

Adult BMI >30 Obesity Gradual wt loss 1-2 kg/month)

>95th %ile co-morbidity

Obese with co-morbidity

Gradual wt loss 1-2 kg/month)

Current Recommendations (Gold Standard) for Obesity

Little known re: strategies and effectiveness with the preschool population.For school age and adolescents, use multi-component family based programs

Behavioural counsellingIncreased physical activityParent training/modelingDietary/nutrition education

Interdisciplinary and comprehensive programsOngoing follow-up for at least 3 months

Nutritional Assessment

Subjective and objective data

Detailed food frequency and diet recall

Questions about meals/snacks, beverages, cooking methods, restaurant/take-out meals, friends, school theme days etc

Questions about physical activity and screen time

Nutrient analysis and estimated needs

Readiness/barriers to change

Establishing a care plan and goals

Motivational Techniques

Focus on health benefitsSelf-worth should not rely on appearance

Stages of changePre-contemplation, contemplation, preparation, action, maintenanceHelp to understand your client’s perspectiveTarget interview toward client’s concernsAvoids antagonism and keep relationship open

Motivational TechniquesMotivational Interviewing

Non-directive questionsReflective listeningCompare values and current health practicesUse importance or confidence rulers

Non-judgemental approach evoking motivation rather than imposing it.

Encourage goal setting, monitoring behaviours targeted for change, use positive reinforcement.

How Could Nutrition Care be Optimized?

Earlier referral?Increased frequency of visits

Distance may be a factorMulti-disciplinary team approach

Exercise specialist, behaviour expertPositive reinforcement for behaviour goalsCaregiver continuity-consistent RDBehaviour modeling

Parents’ lifestyle? Siblings? Others?

Key Concepts in Nutrition Interventions

Ellyn Satter - Division of ResponsibilityParents

- Food Preparation and purchasing- Meal timing and location

Children- How much to eat- Whether to eat or not

Focus on Healthy Eating

Increase vegetables and fruitAim for 5 servings a day, but start with small steps, if they eat none, try for 1 serving.

Increase fibreWhole grains, whole fruits & veggies, beans/legumes.

Make healthy choices more oftenLow fat dairy, lean meats/protein, limit added fats.

Focus on Healthy EatingLimit sweet drinks

Rethink your drink choicesWatch fruit flavoured drinks, soft drinks, and sports and energy drinks consumption.

Limit energy-dense, but not nutrient-dense snack foods.

Limit meals/snacks eaten away from home.

Focus on Healthy Eating

What is a snack – What is a mealPortions, nutritional quality, healthy choices, variety

Meal and snack schedules/timingEating cues

Eating for hunger/stopping when fullFamily views of food (food for enjoyment vsnourishment)

Family mealsFoods eaten away from home

Grandma, multiple caregivers, daycare, school, restaurants

Physical ActivityAssess level of activity

Stress that activity is a major component of healthy weights

Limiting screen time to 1-2 hours a day and increasing active play/physical activity

Recommend community resources and programs for individuals with low incomes

e.g. sponsored YMCA programs, sports tax credits, free community events

Take Home Message

Factors are complex and rooted in many sectors.

Begins in early childhood: focus on children (via families, schools, community) is critical.

Education along with environmental and policy approaches.

Start with educating yourself and others about healthy weights approach.

Advocate for model programming.

Failure to Thrive(FTT)

No consistent method of identifying/defining. Generally accepted as growth that deviates from the norm; assess progression of growth longitudinally.A single growth measurement does not provide info or deviation of a growth pattern.A symptom rather than a diagnosis ?May be defined as any of the following:

Wt for age < 5th percentile without a constitutional delayWt for ht (or BMI) < 5th percentileDecreased growth velocity with weight dropping > 2 major percentiles over 3-6 months

Classifications of FTTOrganic

Due to an underlying medical condition

↓ oral intake or↓ absorption or

↓ utilization of nutrients

Can be organic and/or non-

organic

Non-OrganicSocial or behavioural dysfunction

↓ oral intake

Risk Factors of FTT

OrganicInability to consume adequate kcal (dysphasia, cerebral palsy)Inability to retain (GERD, malabsorption)↑ kcal need (CHD, BPD)Altered growth potential (premie, IUGR, chromosomal anomalies)

Risk Factors of FTT

Non-OrganicPsychosocial issues

PovertyDisordered feeding environmentDysfunctional parent-child interactionNeglectSick/difficult child Parental stress (depression, drug abuse, isolation)

Lack of Knowledge/MisinformationIntellectual impairment↓ breast milk production, errors in formula preparation↑ juice consumptionMisperceptions about normal infant/child dietUnusual health/cultural beliefs

Clinical Presentation

Wt loss or decreased growth velocityMay be classified as organic or non-organic, or not classified yetOften a history of poor feeding/food aversionAnemia (in up to 50% of FTT cases)

Treatment Team

PediatricianDietitianSocial WorkerRegistered NurseChild Psychologist/Psychiatrist or BehaviouristCommunity Agencies (e.g. Health Unit (HBHC program), Children’s Treatment Centre, CAS)

Role of the Dietitian:Nutrition Assessment

Get accurate anthropometricsGrowth history from birth (call Family Doctor)Lab values (CBC, ferritin, sweat Chloride)Detailed diet history from birthOutputs-urine and stoolsEmesisSleep patternsSocial history (caregivers, home environment)Estimate kcal intake & requirements for catch-up growthObserve feeding

Feeding Observation(Caregiver and Child)

Look for:Eye contactPhysical contactAttentiveness to child’s cuesUse of distractionsRole modeling/eating with childCaregiver’s tolerance level/expectationsCaregiver’s reaction to child not eatingReactions in a stressed environment-caregiver and childDivision of Responsibility (Ellyn Satter)

Diet Instruction/Education

InfantsHypercaloric EBM/formula (24-30+ kcal/oz) ±high calorie foods/boosters

Toddlers/older childrenHypercaloric milk/beverage + high kcal foods/boosters (Pediasure, Instant Breakfast drinks, Resource JFK…)

…May require tube feeding

Considerations for Tube Feeding

Long term versus short term use (G-Tube/NG-Tube).Overall diet (for a long period of time), and whether child may be able to meet nutritional requirements by mouth.Formula type and concentration.Qualify for formula coverage from the government.Support and ability from family to carry out.Support for family (professional assistance and training for pump machines…if necessary).Consultation and discussion with multi-disciplinary team.

Nutrition Care Planand Education

Review normal diet for age (+ boosters)Avoid grazingLimit juice (less than 8 oz/day)Limit milk consumption (2 cups/day for preschoolers)Assist with feeding techniques

e.g. utensils, approach, remove distractions, feeding team support if necessary (OT, Speech Path, RD)

Assist with establishing a schedule e.g. 3 meals/day + 2-3 snacks, > 2 hrs apart

Division of responsibilityParent = what, when, where

Child = how much, whether to eat or not

Calorie Boosters

Hospital For Sick Children. Guidelines for Energy Boosting, 1994. Sudbury & District Health Unit. Adding Extra Nutrition for Toddlers and Preschoolers.

Acknowledgements

Presentation adapted from: Childhood Obesity (primary, secondary and tertiary intervention) and A Clinical Outpatient Nutrition Perspective (Janice Piper, RD, Alice Gerhardt, RD, Jill Schweyer, RD, and Laura West, RD); Failure to Thrive (Jody Coles, RD), April 2008, Northern Ontario Dietetic Internship Pediatric Video series; and, NutriSTEP Validation RD Training (Lee Rysdale, RD), April 2005. Presentations available from: Lee Rysdale at lrysdale@opha.on.ca. Content revisions by Jane Lac, RD. Consultant. Janelac.work@gmail.com.