Child Health Nursing Partnering with Children & Families Chapter 9 Nutrition pp 318-344 Kristine Ruggiero CPNP, MSN, RN Child Health Nursing: Partnering

Child HealthNursing

Partnering withChildren & Families

Chapter 9Nutrition pp 318-344

Kristine Ruggiero CPNP, MSN, RN

Child Health Nursing: Partnering with Children & FamiliesBy Jane W. Ball and Ruth C. Bindler

© 2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Nutrition Overview:

Nutritional Needs Infancy Todlerhood Preschool School age Adolescence Nutritional challenges

Nutritional assessment Physical and behavioral measurement

Common nutritional concerns Overweight and obese Collaborative care Dietary deficiencies (iron, ca, vit d, folic acid, protein-energy)

Feeding and eating disorders Pica Ftt

Nutritional concepts

Nutrition: Taking in food and assimilating it metabolically for

use by the body. Macronutrients:

Major building blocks Carbohydrates, proteins and fats

Micronutrients: Substances needed in small quantities for health

body functioning.

Carbohydrates

Energy source: composed of carbon, hydrogen, and oxygen.

Saccharides (sugar molecules) 50% of daily calories Fiber= indigestible carbohydrate

components, ensures healthy movement of fecal matter thru bowel

FIGURE 9–16 While a child’s nutritional status influences health, it is also important to consider conditions that may affect the child’s nutrition and include this knowledge in your assessment.

Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

Proteins

Amino acid compounds 9 essential and 12 nonessential amino acids Catabolism and anabolism Nitrogen balance Deficiency disorders

Fats

Energy source Cellular processes and blood clotting Fatty acids

Saturated Unsaturated

Monounsaturated Polyunsaturated

Glycemic Index

The blood glucose response to 50g of carbohydrate from any specific food as compared to the glucose level after ingestion of white bread

Low glycemic index has been found to have beneficial effects such as reducing serum lipids, insulin levels and improving serum glucose control

How are nutritional needs of the infant different from the adult?

Increased energy expenditure Rate of growth: doubles by 6 months, triples

by 1 year Organ size and immaturity Physiological changes

Nutritional Needs: Preterm and SGA Infants

Preterm (<37 weeks) and SGA (<2700 g) infants

Medical problems Immature body systems High calorie/kg intake to provide energy for

necessary weight gain; may need up to 140 kcal/kg/day

Nursing strategies for Preterm and SGA infants

Specialized feeding methods Parenteral nutrition Gavage/ tube feedings Transition to oral feedings

Assist families w/ teaching feeding methods Assessment of growth and development

FIGURE 9–3 This premature baby cannot yet coordinate suck and swallow. Gavage feeding is being used until the baby can effectively acquire nutrients.




Nutritional Needs: Term Newborn

Infants need minimum of 120 cal/kg/day to maintain weight and growth

20 cal/oz is the usual calories found in formula

Feedings/day q3-4 hrs= 6-8 feedings/ day

Question…

How much formula would an infant who weighs 4.3 kg need at each feeding if they feed every 4 hours?

Answer…Let’s break it down

1. Infant weight in kg is multiplied by 120 calories/ number of feedings per day Baby weight= 4.3 kg

2. Calories needed/day= 4.3 x 120 Calories needed/day= 516 calories/ day

3. calories needed per feeding= 516/6 Calories needed per feeding= 86

4. ounces per feeding= calories needed per feed/number of calories per ounce of formula 86/20= 4.3 ounces/ feeding

Breast and Formula Feedings Breast milk: advantages include:

Excellent nutrition Promotion of GI function Fostering immune defense lower incidence of OM’s, Type 2 Diabetes, and

obesity Psychological benefits Economic advantage

Breast Feeding

Nursing role: Includes education, and encouragement to foster

breastfeeding Help mothers to have positive experience w/

Breastfeeding Encouragement Lactation consultant/ group support

Contraindications to breastfeeding

Chemotherapy Active untreated maternal TB Maternal HIV/AIDS Maternal primary herpes in the breast Certain medications (chloramphenicol) Use of alcohol and recreational drug abuse

FIGURE 9–4 Breastfeeding offers many physical and emotional benefits for the infant. This new mother is learning to breastfeed her baby. How can nurses encourage mothers to have positive breastfeeding experiences?




Formula Feeding Infants (newborn- 6 months)

Types of formulas Ready to feed, powder, and concentrate (p 323,

Table 9-7) Specialized formulas for specific needs (PKU,

allergies) Nursing strategies

Education Partent-infant relationship Prevention of early childhood caries

Introducing solid foods

When is an infant ready to begin solid foods? 4-6 months of age Introduction of foods b/f or after this period

increases risk of food allergies Readiness for solid foods

Extrusion reflex, swallowing Sitting skills Interest

FIGURE 9–5 The baby who has developed the ability to grasp with thumb and forefinger should receive some foods that can be held in the hand.




Infants age 6-12 monthsDevelopmental Readiness

Initial introduction of foods Appropriate first foods: rice cereal

Weaning occurs at 12 months Longer bottle feeding increases

Dental caries Otitis media allergies

General nutrient requirements of an infant

Introduction of whole milk at 1 year, and low-fat milk at 2 years

Fluoride supplements at 6 months if not in water

Iron enriched cereals should be started first New foods added gradually Introduce veggies b/f fruits No honey b/f 1 year…infant botulism

FIGURE 9–6 Early childhood caries. This child has had major tooth decay related to sleeping as an infant and toddler while sucking bottles of juice and milk. Courtesy of Dr. Lezley Mcllveen, Department of Dentistry, Children’s National Medical Center, Washington, DC.




Feeding 9-12 months Finger foods Peeled fruit Cheese and soft cooked vegetables Delay introduction of peanuts/ peanut butter

until 1 year of age (unless h/o allergies in family, then 3 years of age)

No yolks until 8-10 months of age, or whole eggs until 1 year of age

Carbs and fats needed for energy and growth Introduction of a cup (b/t 8-9 months)

Nutritional needs of the toddler

Remember developmental level Goal is to gain control of bodily functions

Physiologic anorexia Nutritional needs

Restrict fat to less than 30% of calories Low fat milk (2%)

Adequate protein

FIGURE 9–7 Toddlers should sit at a table or in a high chair to eat, to minimize chance of choking and to foster positive eating patterns.




Nutritional needs of the preschooler

Food jags (eating only a few foods for a few days of weeks)

Socialization (associative play) Help with food preparations Dental care Meal and snack patterns Nutritional requirements

FIGURE 9–8 Preschoolers learn food habits by eating with others. Engaging them in food preparation enhances knowledge of food and promotes intake at meals.




Nutritional needs of the school-age child

Appropriate food choices School involvement Growth spurts Dental care

Nutritional needs of the adolescent

Growth rate Calorie needs Mineral and vitamin needs Food choices

Nutritional assessment

Family history Developmental history Medical history Physical examination of growth parameters

Height Weight Head circumference

Assessment of Growth

Measure using appropriate tools Growth charts

Gender specific Pre-term or specific medical conditions

FIGURE 9–10 The nurse accurately measures the child and then places height and weight on appropriate growth grids for the child’s age and gender.




FIGURE 9–11 Growth chart with first few entries in same channel and then a change indicated. The growth for the child indicated on this chart remained steady and in the same channel (75th percentile) for some months. Then the weight measurement decreased to another channel. What kind of dietary assessment will you complete with the parents? What could be the possible causes?




Nutritional assessment includes

physical assessment and lab findings

H&H Blood Chemistry Lipid Profile Renal and Liver function tests

Nutrition Assessment

Dietary intake 24 hour food recall 3 day food history Genogram to recognize nutrtional risk (heart

disease and hypertension)

Overweight and Obesity

Public health epidemic in US Increasing incidence Factors influencing obesity include:

Genetics Psychological Environmental (excessive TV, lack of exercise, %

of calories from fat)

Obesity by the numbers

Childhood obesity has reached epidemic levels in developed countries.

Twenty five percent of children in the US are overweight and 11% are obese. About 70% of obese adolescents grow up to become obese adults

US children at risk for being overweight= 25% Overweight + obese children in US= 15% Increase in obesity since 1960= 300%

Overweight and Family History

When a child has one obese parent, chances of the child being overweight are increased by 220%. In families where both parents are overweight, the incidence of obesity in children increases by 320%.

Finally, the child who has obese parents, and is overweight as an adolescent has an 80% risk of being an obese adult

Definitions of Obesity and Overweight

The Center for Disease Control and Prevention defined overweight as at or above the 95th percentile of BMI for age and "at risk for overweight" as between 85th to 95th percentile of BMI for age.

Treatment of obesity

Medical treatment and referrals Nutrition and behavioral counseling Treat family

Focus on family environment Nonjudgmental support

Focus on concern for health, not appearance

Treatment of obesity

Discourage food as a reward Encourage healthy eating patterns

Family meals around table Plan for small changes one at a time Decrease sedentary behavior

Decrease tv time to 2 hrs/day

Specific Dietary Deficiencies

Calcium Iron Vitamin D:

Rickets Folic acid:

Prevention of neural tube defects and cleft defects

PICA

Ingestion of nonfood substances or atypical ingestion of foods

Pregnant women and young children Commonly ingested substances

Lead paint Soil contaminated by lead based gas fumes

Strong association w/ anemia Treatment

What is failure to thrive? Organic vs Non-organic FTT:

Nonorganic, NOFTT; also called psychosocial failure to thrive is defined as decelerated or arrested physical growth

(height and weight measurements fall below the fifth percentile, or a downward change in growth across two major growth percentiles) associated with poor developmental and emotional functioning. Usually occurs in a child younger than 2 y.o w/ no known medical condition

Organic failure to thrive occurs when there is an underlying medical cause.

FIGURE 9–14 Infants with failure to thrive may not look severely malnourished, but they fall well below the expected weight and height norms for their age. This infant, who appears to be about 4 months old, is actually 8 months old. He has been hospitalized for feeding disorder of infancy.




FTT Treatment Based on individual child Management:

Assessment and case findings Infant/ child family hx Paren (caregiver)- child interactions Adult and feeding behaviors

Nursing Diagnoses Planning and implementation

Monitor intake and growth patterns Teach nutrition and feeding strategies Observe feeding and parent-child interactions

Any ???s

Special thanks to Lorraine Murphy for helping write and give this lecture

Documents

Child Health Nursing Partnering with Children & Families Chapter 9 Nutrition pp 318-344 Kristine Ruggiero CPNP, MSN, RN Child Health Nursing: Partnering