Nutrition Management Nutrition Management in Children with in Children with

Special Special Health Care Needs Health Care Needs

(CSHCN)(CSHCN)Jackie Maurer MS, RDJackie Maurer MS, RD

IntroductionIntroduction

Children with Special Health Care Needs (CSHCN)

Definition:Children with congenital or acquired conditions affecting physical/cognitive growth and development and who require more than the usual pediatric health care; also refers to children who have developmental disabilities, chronic conditions, or health related problems as well as those who are at risk for these conditions

(JADA. 1995;95:809)

IntroductionIntroduction

Nutrition InterventionNutrition Intervention Critical aspectCritical aspect

InterdisciplinaryInterdisciplinary

Preventive and Preventive and therapeutictherapeutic

Family centeredFamily centered

Community basedCommunity based

Culturally competentCulturally competent

ObjectivesObjectives

Understand basic measures of growth & Understand basic measures of growth & developmentdevelopment

Acquire fundamental skills in global Acquire fundamental skills in global assessment techniquesassessment techniques

Appreciate general medical nutrition Appreciate general medical nutrition therapy for lung diseasestherapy for lung diseases

Experience oral supplements that promote Experience oral supplements that promote nutrition statusnutrition status

GROWTH & DEVELOPMENTGROWTH & DEVELOPMENT

WeightWeight– Primary indicator for Primary indicator for

over-/under- nutritionover-/under- nutrition Growth chartGrowth chart

– Reflects growth Reflects growth patternpattern

TechniqueTechnique– Needs to be consistent Needs to be consistent

and accurate (ie no and accurate (ie no shoes, no diapers)shoes, no diapers)

GROWTH & DEVELOPMENTGROWTH & DEVELOPMENT

HeightHeight– Has slower response to nutrition changesHas slower response to nutrition changes– May indicate chronic under-nutrition if May indicate chronic under-nutrition if

measurements continually trend downmeasurements continually trend down

Technique:Technique: 0-36 months - 0-36 months - Recumbent length Recumbent length

2-20 years - 2-20 years - Standing heightStanding height

GROWTH & DEVELOPMENTGROWTH & DEVELOPMENT

Head CircumferenceHead Circumference– Last indicator to be affected by undernutritionLast indicator to be affected by undernutrition– < 3 yr old< 3 yr old

Possible nutritional insult with downtrends, Possible nutritional insult with downtrends, accompanied by decreases in weight and heightaccompanied by decreases in weight and height

– > 3 yr old> 3 yr oldDecreases are generally not nutrition-relatedDecreases are generally not nutrition-related

See CDC web site, http://www.cdc.gov/growthcharts, to See CDC web site, http://www.cdc.gov/growthcharts, to download charts.download charts.

FOR MORE INFO...

ASSESSMENT SKILLSASSESSMENT SKILLS Subjective Global Assessment (SGA)Subjective Global Assessment (SGA)

– Simple technique for assessing nutritional Simple technique for assessing nutritional statusstatus

– Evaluates body fat and muscle storesEvaluates body fat and muscle stores– Involves visual review of physical body Involves visual review of physical body – May be applied by any healthcare workerMay be applied by any healthcare worker

Nutrition HistoryNutrition History– Interview reveals dietary habitsInterview reveals dietary habits– Quick tool for assessing one’s ability to meet, Quick tool for assessing one’s ability to meet,

fail, or exceed nutritional needsfail, or exceed nutritional needs

SGA METHODSGA METHOD

Fat StoresFat Stores– Eye fat padEye fat pad– Cheek padCheek pad– Tricep pinchTricep pinch

Muscle StoresMuscle Stores– TempleTemple– ClavicleClavicle– ShoulderShoulder– ScapulaScapula– Upper joint areaUpper joint area– Interosseus areaInterosseus area

Detsky, A, et al. Journal of Enteral and Parenteral Detsky, A, et al. Journal of Enteral and Parenteral Nutrition. 11:8, Jan/Feb, 1987.Nutrition. 11:8, Jan/Feb, 1987.

REFERENCE:

http://www.eneph.com/feature_archive/nutrition/v25n4p190.html

DIET HISTORY METHODDIET HISTORY METHOD What is the home life/meal pattern? What is the home life/meal pattern?

How much is consumed? How much is consumed?

Food allergies or intolerances?Food allergies or intolerances?

Who is present at mealtimes?Who is present at mealtimes?

Is the child interested in eating?Is the child interested in eating?

Any problems with chewing or Any problems with chewing or swallowing? Gagging or choking?swallowing? Gagging or choking?

Are there any foods or textures that Are there any foods or textures that the child has difficulty with?the child has difficulty with?

Does the child eat non-foods ?Does the child eat non-foods ?

Any weight change perceived?Any weight change perceived?

What religious or cultural What religious or cultural backgrounds are present?backgrounds are present?

ASTHMA & NUTRITIONASTHMA & NUTRITION

Malnutrition of excessMalnutrition of excess

– Cycle of inactivityCycle of inactivity

– Steroid induced Steroid induced

Potential food allergy triggersPotential food allergy triggers

Nutrient Medication InteractionsNutrient Medication Interactions

ASTHMA & NUTRITIONASTHMA & NUTRITION General guidelinesGeneral guidelines

1. No skipping meals (Eat min 3 x day)1. No skipping meals (Eat min 3 x day)

2. Maintain a “normal”, balanced diet 2. Maintain a “normal”, balanced diet

and choose sensible portions and choose sensible portions

3. Lose weight, if needed3. Lose weight, if needed

4. Avoid excessive salt, fat, sweets4. Avoid excessive salt, fat, sweets

5. Increase dairy or supplements 5. Increase dairy or supplements

6. Exercise daily6. Exercise daily

ASTHMA & EXERCISEASTHMA & EXERCISE

20 minutes total20 minutes total

3 times per week3 times per week

Aerobic activityAerobic activity

Avoid asthma Avoid asthma triggers triggers

May lessen May lessen Exercise Induced Exercise Induced Asthma (EIB)Asthma (EIB)

Tips•Check local pollen, mold, spore levels.

•Lengthen the time between breaks while conditioning occurs.

•Wear scarves over mouth and nose in winter to keep heat & moisture in lungs.

•Warm-up to lessen chances of EIB.

•Do pursed lip breathing when medication is not readily available.

ASTHMA & FOOD ALLERGIESASTHMA & FOOD ALLERGIES Food allergies - usually NOT common Food allergies - usually NOT common

triggertrigger

Occurs in <5% of asthmaticsOccurs in <5% of asthmatics

Difficult to diagnoseDifficult to diagnose

– Skin tests, Blood test (RAST)Skin tests, Blood test (RAST)

– Food diary, elimination dietFood diary, elimination diet

SymptomsSymptoms– hives, itching, eczema, sneezing, coughing, swelling of hives, itching, eczema, sneezing, coughing, swelling of

throat, nasal stuffiness, vomiting, diarrhea, cramping, throat, nasal stuffiness, vomiting, diarrhea, cramping, collapse and sometimes deathcollapse and sometimes death

Milk and dairy Milk and dairy products products – No link to increased No link to increased

mucus production or mucus production or bronchoconstrictionbronchoconstriction

WheatWheat SoySoy EggsEggs Peanuts Peanuts Tree nutsTree nuts

POTENTIAL FOOD ALLERGENSPOTENTIAL FOOD ALLERGENS Fish and shellfish Fish and shellfish

ChocolateChocolate CornCorn TomatoesTomatoes Citrus fruitsCitrus fruits Other grainsOther grains BeefBeef ChickenChicken Sulfite-containingSulfite-containing

ASTHMA & FOOD AIDS?ASTHMA & FOOD AIDS?

Conflicting evidence that foods can Conflicting evidence that foods can prevent asthmaprevent asthma

Of three scientific papers on asthma & Of three scientific papers on asthma & omega-3 fatty acids:omega-3 fatty acids:

– 1 showed favorable results1 showed favorable results

– 1 showed no results1 showed no results

– 1 showed negative results w/ worse 1 showed negative results w/ worse asthmaasthma

BPD: Bronchopulmonary BPD: Bronchopulmonary DysplasiaDysplasia

Nutrition ConcernsNutrition Concerns

– ?Prenatal undernutrition, premature growth ?Prenatal undernutrition, premature growth issuesissues

– Increased caloric intake to maintain normal Increased caloric intake to maintain normal or catch-up growthor catch-up growth

– Suboptimal intake due to increased effort of Suboptimal intake due to increased effort of breathing during eating and appetite breathing during eating and appetite suppressing medicationssuppressing medications

– Delayed development of oral feeding skillsDelayed development of oral feeding skills

BPD & NUTRITIONBPD & NUTRITION

Nutrition TherapyNutrition Therapy

1. 1. Concentrate infant formulaConcentrate infant formula

2. Initiate adjuvant nutrition via 2. Initiate adjuvant nutrition via enteral enteral route as indicatedroute as indicated

3. Assess feeding skills3. Assess feeding skills

4. Occupational therapy/feeding 4. Occupational therapy/feeding specialist referralspecialist referral

BPD & FEEDING SKILLSBPD & FEEDING SKILLS Feeding AssessmentFeeding Assessment

– Responses to tactile inputResponses to tactile input irritability, frenzy, drowsy, staring, silent cryirritability, frenzy, drowsy, staring, silent cry

– Feeding positionFeeding position– Oral motor controlOral motor control

tongue retraction/protrusion, jaw excursiontongue retraction/protrusion, jaw excursion

– Physiologic controlPhysiologic control heart rateheart rate

– Sucking, swallowing, breathingSucking, swallowing, breathing– Caregiver/infant feeding interactionsCaregiver/infant feeding interactions

CYSTIC FIBROSIS & CYSTIC FIBROSIS & NUTRITIONNUTRITION

Multifactorial risks for malnutritionMultifactorial risks for malnutrition– IntakeIntake

Decreased appetiteDecreased appetite Decreased volume consumedDecreased volume consumed Physical/mechanical/mental inability to meet Physical/mechanical/mental inability to meet

nutritional needs orallynutritional needs orally

– OutputOutput Increased energy output to meet cost of Increased energy output to meet cost of

breathing and coughing, higher during breathing and coughing, higher during pulmonary exacerbations. pulmonary exacerbations.

MalabsorptionMalabsorption

CF & NUTRITIONCF & NUTRITION Basic Nutrition GuidelinesBasic Nutrition Guidelines

1. High calorie diet (moderate fat)1. High calorie diet (moderate fat)

2. Snacks 2-3 times/day2. Snacks 2-3 times/day

3. Salt repletion, especially with sweating3. Salt repletion, especially with sweating

4. Pancreatic enzymes4. Pancreatic enzymes

5.5. Fat soluble vitamins in water miscible form Fat soluble vitamins in water miscible form (ADEK)(ADEK)

Oral SupplementationOral Supplementation– Calorically dense Calorically dense – Sample tastingSample tasting

Childhood ObesityChildhood Obesity

Childhood ObesityChildhood Obesity

DEFINITIONDEFINITION: BMI Percentiles (2 : BMI Percentiles (2 to 20 y.o.)to 20 y.o.)– 85-9585-95thth %ile = %ile = at riskat risk– >95>95thth%ile Overweight%ile Overweight

Associated risks:Associated risks:– Hyperlipidemia, glucose Hyperlipidemia, glucose

intolerance, hepatic steatosis, intolerance, hepatic steatosis, cholelithiasis, early maturation. cholelithiasis, early maturation. hypertension, sleep apneahypertension, sleep apnea

CDC.org

Childhood Obesity - FactorsChildhood Obesity - Factors

Familial influenceFamilial influence– Fat parent = fat childFat parent = fat child– Model: eating & activityModel: eating & activity

Physical InactivityPhysical Inactivity– TVTV– Cuts in PE classCuts in PE class

HeredityHeredity– FatnessFatness– regional fat distribution regional fat distribution – response to overfeeding response to overfeeding

Childhood Obesity - Childhood Obesity - ManagementManagement

CDC.org

Childhood Obesity – Childhood Obesity – TreatmentTreatment

Physical ActivityPhysical Activity

Diet ManagementDiet Management

– Controlled weight Controlled weight gaingain

Behavior Behavior ModificationModification

Dietary ManagementDietary Management

1.1. Focus on energy dense, whole Focus on energy dense, whole foodsfoods

2.2. Limit sugar packed drinks and Limit sugar packed drinks and snackssnacks

3.3. Watch portion sizesWatch portion sizes

Choose Over

Thank You!Thank You!Questions?Questions?