Nutrition Assessment of Children with Special Health Care Needs

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Nutrition Assessmentof Children with Special
Health Care Needs
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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

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Steps to Evaluating Pediatric Nutrition Problems

• Screening
• Assessment
• Intervention
• Monitor
• Reassessment

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Assessment

• Screening identifies nutritional risk
• Nutrition Assessment
• Uses information gathered in screening
• Adds more in depth, comprehensive data
• Interprets data
• Develops care plan
• Reassess

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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

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Interdisciplinary Team

• Physician
• Nutritionist
• Nurse
• Social worker
• OT/PT
• Speech pathologist
• Behavioral psychologist

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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)

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Interpretation
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Interpretation

• Goals
• Expectations
• References
• Evidence

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Interpretation

• Comparison with references established for
  children without special health care needs

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Interpretation

• Evaluate information collected on an
  individualized basis

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Challenges in Nutrition Assessment of Children
with Special Health Care Needs

• Goals
• Expectations
• References
• Ability to obtain data

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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

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Growth

• CDC growth charts
• Specialized growth charts
• Evaluation of growth rates/velocity

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CDC Growth Charts (compared to older NCHS

• Standardized data collection methods
• Expanded sample
• Exclusions
• VLBW infants
• NHANES III weight data for gt6 year olds

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Specialty Growth Charts

• Include
• Down syndrome
• Turner syndrome
• Williams syndrome
• Spastic quadraplegic CP
• Prader-willi syndrome
• others

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Growth Concerns

• Underweight
• Short stature
• Overweight

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Weight gain increments from birth to 12
months(g/d)
Roche and Fomon J Pediatr 119355 1991
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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
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Weight gain of Breast fed vs bottle fedinfants
8-112 days of age (g/d)
Nelson et al Early Human Development 19223 1989
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Body Mass Index for Age

• Body mass index or BMI wt/ht2
• 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

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Guidelines to Interpretation of BMI

• Underweight
• BMI-for-age lt5th percentile
• At risk of overweight
• BMI-for-age ? 85th percentile
• Overweight
• BMI-for age ? 95th percentile

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Interpretation of BMI

• BMI is useful for
• screening
• monitoring
• BMI is not useful for
• diagnosis

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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

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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

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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

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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

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Dietary Reference Intakes (DRI) (including RDA,
UL, and AI) are the periodically revised
recommendations (or guidelines) of the National
Academy of Sciences
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Comparison of individual intake data to a
reference or estimate of nutrient needs

• DRI Dietary Reference Intakes
• expands and replaces RDAs
• 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

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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

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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

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Energy

• Assessing Energy Needs
• Components, Factors that may alter
• References (EER, ?other)
• Equations
• Correlate Individual Intake with growth

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Components of Energy Expenditure

• Basal Metabolic Rate
• Thermic Effect of Food
• Thermoregulation
• Physical Activity
• Physical activity level
• Total Energy Expenditure

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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)

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Examples of EER by age and weight
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Energy Partition in Infancy (kcal/kg/d)
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Factors that alter Energy needs

• Body composition
• Body size
• Gender
• Growth
• Genetics

• Ethnicity
• Environment
• Adaptation and accommodation
• Activity/work
• Illness/Medical conditions

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DRIs for Select Nutrients

• Protein
• Calcium/Phosphorus
• Iron
• Vitamin D

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DRIs for select Nutrients
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DRIs 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 lt500 cc infant formula
• Iron Iron fortified formula (4-12 mg/L),
  Breastfed Infants supplemented 1mg/kg/d by 4-6
  months

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Diet History and Assessment
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Medical Information
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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

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Drug-Nutrient Interaction

• Altered absorption
• Altered synthesis
• Altered appetite
• Altered excretion
• Nutrient antagonists

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Feeding and Developmental Information
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Feeding the Infant

• Feeding Relationship
• Feeding Development
• Feeding Difficulties

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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

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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

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Intervention
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• Adequate intake vs feeding relationship
• Concentrating formula vs fluid status
• impact on tolerance, compliance, errors, cost
• solution to problem vs exacerbating problem

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Case Reports

• Joey
• Sierra
• Lucy
• Adam

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Joey

• 7 months old
• Weight 6 kg (lt 3rd percentile)
• Length 65 cm (3rd percentile)
• Birth History 34 weeks Gestation, 1100 grams,
  IUGR
• History of reflux
• doesnt like solids
• ? Risk factors

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Joey

• History of IUGR
• History of GER
• ? Feeding difficulties

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Growth

• Joey (weight, length)
• 40 Weeks
• 1.8 kg, 46 cm
• 4 months
• 5 kg, 58 cm
• 5 months
• 5.6 kg, 62 cm

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Joey
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Joey

• 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, doesnt like solids

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Joey

• experiencing decrease in rate of weight gain,
  estimated intake appears adequate, hx GER and
  alteration in feeding (solids)

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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

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Growth

• Lucy

• Birthweight 2.8 kg
• 2 months 3.2 kg
• 6-7 g/d estimated weight gain
• ? Risk factors

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Lucy

• Birthweight 2.8 kg
• 2 months 3.2 kg
• 6-7 g/d estimated weight gain

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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 lt67 kcal/kg/d

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Feeding Information

• Lucy
• tires, desaturates, increased work of breathing

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• Lucy
• Inadequate growth. Breastmilk intake appears
  inadequate based on pre/post weights. CHDD.
  Feeding difficulties (tires, length of time)

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Adam

• Age 14 months
• Wt 12.8 kg 90-95th ile
• Length 78 cm 50th ile
• Wt/ln gt 95th ile

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GrowthAdam

• 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

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Adam
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Adam
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Adam

• 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

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Feeding Information

• Adam
• Behavioral issues (anxiety, hoarding, gorging)

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Adam

• Weight/length gt95th percentile. Intake exceeds
  RDA for age. Hx FTT and behavioral issues around
  feeding (anxiety, gorging, hoarding)

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Adam
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Adam

• 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.

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