Chapter 13Child and Preadolescent Nutrition:

Conditions and Interventions

Nutrition Through the Life Cycle Judith E. Brown

“Children Are Children First” What does that mean?

• Expectations that children will become more independent in making food choices, assisting with meal preparation, & participating at meal times with other family members apply to children with special health care needs

• Expectations are the same for all children with or without special needs

Nutritional Requirements of Children with Special Health

Care Needs• Children with special health care needs vary

in nutritional requirements & health needs:– Low calorie– High protein, fluid or fiber– Increases or decreases in vitamins or minerals – Frequent hospitalizations

• Nutrient & health guidelines may not apply because of health needs

Energy Needs

• Energy needs vary depending on special health care condition

• Lower calories needed by children with slow growth or decreased muscles such as in Prader-Willi syndrome

• Increased calories needed as activity increases such as in ADHD or autism

Protein Needs

• Protein needs vary by condition

• Recovery from burns & cystic fibrosis increases protein needs to 150% DRI

• Phenylketonuria and other protein-based inborn errors of metabolism requires decreased protein

• Some conditions may require hydrolyzed or specific amino acids

Other Nutrients

• Adequate vitamins & minerals should be provided in a well-balanced diet

• Conditions that interfere with adequate nutrient intake include: – Chewing or other feeding problems– Side effects from prescribed medications– Food refusals– Treatment of condition that includes restriction of

certain foods

Growth Assessment

• CDC 2000 growth charts are a good starting place for assessing the growth of any child.

• Adjustments may need to be made for children with some conditions that affect the rate of growth

Growth Assessment

• Long-term health goals less important for children with life-shortening conditions

• Warning signs for growth problems:– Plateau in weight– Pattern of weight gain & then loss– Failure to regain weight lost during an illness– Unexplained/unintentional wt gain

Growth Assessment & Interpretation in Children with

Chronic Conditions• Factors that affect growth:

– Age of condition onset• May determine if growth charts will be applicable

– Secondary conditions• May interfere with accurate measurements

– Activity/inactivity level

Body Composition and Growth

• Health conditions may alter:– Muscle size– Bone structure– Fat stores

• Down syndrome results in short stature, low muscle tone, & low weight

• Cerebral palsy & spina bifida may reduce muscle tone

• Spina bifida may impact muscles only in the lower extremities

Special Growth Charts

• Growth charts are available for some special conditions as noted on the next slide (See Table 13.1)

• Conditions that do not have growth charts include:– Juvenile rheumatoid arthritis

– Cystic fibrosis

– Rett syndrome

– Spina bifida

– Seizures

– Diabetes

Special Growth Charts

Nutrition Recommendations

• Assess intake to determine if nutrients are adequate

• Children with special health needs benefit from same dietary recommendations as other children

Methods of Meeting Nutritional Requirements

• Oral feeding is preferred method of feeding

• Gastrostomy feeding may be required for:• Kidney disease

• Some cancers

• Severe cerebral palsy

• Cystic fibrosis

Vitamin and Mineral Supplements for Chronic

Conditions• Supplements may be beneficial for conditions to

assure adequate intake• Conditions that require supplements:

– Chewing problems need liquid supplements– Diabetes or on ketogenic diets should avoid supplements

with added CHO– PKU should avoid supplements with certain artificial

sweeteners– Cystic fibrosis requires fat-soluble vitamins– Galactosemia (restricts dairy) requires calcium

Fluids

• Conditions that impact fluid status and increase needs include:

– Drooling from cerebral palsy– Constipation from neuromuscular disorders– Multiple medication use

Eating & Feeding Problems in Children with Special Health

Care Needs• Eating and feeding problems are diagnosed

when children have difficulty with:– Accepting foods– Chewing them safely– Ingesting enough foods and beverages

• 70% of children with developmental delays have feeding difficulties

Eating & Feeding Problems in Children with Special Health

Care Needs-Specific Disorders• Cystic fibrosis • Diabetes mellitus• Seizures• Cerebral palsy• Phenylketonuria (PKU)• Attention deficit hyperactivity disorder

(ADHD)• Pediatric HIV

Cystic fibrosis

• Common lethal genetic condition

• Interferes with lung function

• Causes decreased absorption nutrients

• Malabsorption due to lack of pancreatic enzymes

Cystic fibrosis

• Dietary considerations:

– Calories & protein increase 2 to 4 fold

– Enzyme taken with meals to aid in digestion

– Frequent meals & snacks

– Fat-soluble vitamin supplements

– Gastrostomy feeding at night may be needed to boost energy intake

Diabetes Mellitus

• Disorder in insulin & blood glucose regulation • Type 1—virtually no insulin production• Type 2—associated with obesity• Treatment includes:

– Timing & composition of meals & snacks

– Insulin injections—for type 1

– Exercise

• Summer camps for diabetic children

Seizures

• Uncontrolled electrical disturbances in brain

• Seizures = Epilepsy

• Results of a seizure range from mild blinking to severe jerking

• Postictal state—time after seizure of altered consciousness

Seizures

• Treatment:

– Medications—may impact growth and/or appetite

– Ketogenic diets—severely low-CHO diet with increased calories from fat

Cerebral Palsy

• Group of disorders resulting from brain damage with impaired muscle activity & coordination

• Spastic quadriplegia presents most nutritional problems

Cerebral Palsy

• Nutrition concerns:– Slow growth– Difficulty feeding &

eating

• Athetosis (less common form of CP)—uncontrolled movement which increases energy expenditure

Growth Chart

Phenylketonuria (PKU)

• Inborn error of metabolism

• Body lacks enzyme needed to metabolize phenylalanine

• Require intervention to manage breakdown of dietary proteins

Phenylketonuria (PKU)

• Diet is adequate in vitamins, minerals, pro, fat and calories

• Nutrients are often provided in liquid rather than solid form

• Dietary treatment includes avoiding meats, eggs, dairy products, nuts & soy beans

Modified Food Pyramid for PKU

Attention Deficit Hyperactivity Disorder (ADHD)

• Most common neurobehavioral problem (~5% to 8% of children)

• Chaotic meals & snacks with difficulty staying seated

• May be given fewer opportunities in the kitchen due to impulsiveness

Attention Deficit Hyperactivity Disorder (ADHD)

• Nutritional concerns:– Medications:

• Ritalin or Adderal• Both may decrease appetite & growth• Medication peak activity is aimed at school hours• Appetite returns to normal when meds are not given

such as on weekends & school holidays

– No evidence of nutrition as a cause and treatment but families may choose herbal medicines anyway

Pediatric HIV

• Nutrition is important for HIV management• Antiretroviral therapy depresses appetite & food

intake• Other nutrition concerns:

– Control food-related infections – Access to determine need for complete nutritional

supplements– Referrals to food banks

• Dietary approaches have to customized

Dietary Supplements and Herbal Remedies

• Use of supplements or herbs has not been scientifically shown to improve prognosis for special health needs

• However, nutritional claims abound

• Families hear from one another about various nutrient claims

• May use diet claims for one condition and expect it to work for a different condition

Dietary Supplements and Herbal Remedies

• Strategies to counter unscientific claims include:

– Recognize the benefits of supports for families (e.g. advocacy groups)

– Improve communication with health care providers

– Provide factual information without endorsing any claim & allow families to make informed choices

Sources of Nutrition Services

• USDA Child Nutrition Program– School breakfasts & lunches must be modified

for special needs children

• Maternal & Child Health Block Program of the U.S. Department of Health & Human Services (HHS)– Funds for nutrition services such as special

formulas or food & nutrition education

Public Schools Regulations

• 504 Accommodation– Requires that school provide a written plan to

accommodate for special health care needs

• Individuals with Disabilities Education Act (IDEA)– Requires each special needs child to have a

written plan that may include nutrition-related goals & objectives as needed

Nutrition Intervention Model Program

• Maternal and Child Health Bureau (MCH) is part of the department of Health and Human Services (HHS)– Funds nutrition services for chronically ill

children– Develops and promotes model programs by

funding competitive grants