Looking at Special Dietary Needs Through Different Eyes

Loriann Knapton, DTR, SNS, Nutrition Program Consultant

November 4, 2008

Learning about the nature and severity of

the child’s special dietary needs and

working together to provide what’s best for

the childshould be the major

focus.

Children with a Disability

Schools must make substitutions of foods in the reimbursable meal for students who have a disability that restricts their diet.

What are Disabilities?

Disability is defined in : Section 504 of the Rehabilitation Act of 1973 Americans with Disabilities Act of 1990 Part B of the Individuals with Disabilities

Education Act (IDEA) Individual Education Plan (IEP)

Explanation of these disabilities found on pages 3-5 of the USDA guidance Accommodating Children with Special Dietary Needs in the School Nutrition ProgramsWebsite link to USDA guidance: http://fns.dpi.wi.gov/fns_market1

Food Related Disabilities

Some that require menu modifications:

Severe Food Allergies (Food Anaphylaxis)

Metabolic Diseases such as Diabetes, Celiac Disease (Gluten-free Diet) and Phenylketonuria (PKU)

Prescribed diet for child with autism (one of the thirteen disability categories recognized in the Individuals with Disabilities Act)

Disability

Accommodation MUST be made, based on a completed physician’s statement

No extra charge

A disability determination can only be made by a licensed physician

Statement for Children with Disabilities

What must the physician’s statement include?

What the disability is How it restricts diet Major life activity affected Foods to be omitted Foods to be substituted

Physician’s Form (for documentation)http://fns.dpi.wi.gov/files/fns/doc/

spec_diet_restrict.doc

Eating and Feeding Evaluation: Children with Special Needs FIGURE 1: .PART A Student’s Name

Age

Name of School

Grade Level Classroom

Does the child have a disability? If Yes, describe the major life activities affected by the disability. Does the child have special nutritional or feeding needs? If Yes, complete Part B of this form and have it signed by a licensed physician.

Yes Yes

No No

If the child is not disabled, does the child have special nutritional or feeding needs? If Yes, complete Part B of this form and have it signed by a recognized medical authority.

Yes No

If the child does not require special meals, the parent can sign at the bottom and return the form to the school food service. PART B

List any dietary restrictions or special diet. List any allergies or food intolerances to avoid. List foods to be substituted. List foods that need the following change in texture. If all foods need to be prepared in this manner, indicate “All.” Cut up or chopped into bite size pieces: Finely ground: Pureed: List any special equipment or utensils that are needed. Indicate any other comments about the child’s eating or feeding patterns. Parent’s Signature Parent’s Printed Name and Phone Number

Date:

Physician or Medical Authority’s Signature Physician or Medical Authority’s Printed Name and Phone Number

Date:

Under no circumstances are

school food service staff to

revise or change a diet prescription or medical order.

Documentation

The diet orders do not need to be renewed on a yearly basis; however, schools are encouraged to ensure that the diet orders reflect the current dietary needs of the child.

Medical Requests for Children with Special Dietary Needs(not considered a disability)

The school food service may make food substitutions, at their discretion, for individual children who do not have a disability, but who are medically certified as having a special medical or dietary need.

Examples include: Lactose intolerance Food intolerances or allergies where there is

not the concern of a life-threatening reaction

Not to be confused with….

Fluid Milk Substitutions in the School Nutrition Programs(Final Rule published September 12, 2008)

Current requirements on meal variations for students with disabilities and for students with medical or other special dietary needs remain unchanged.

Offering fluid milk substitutes to students under this ruling is totally at the School Food Authority’s (SFAs) discretion.

Nondairy beverages offered as fluid milk substitute be nutritionally equivalent to fluid milk and provide specific levels of calcium, protein, vitamins A and D, magnesium, phosphorus, potassium, riboflavin and vitamin B-12.

Website: fns.dpi.wi.gov/fns_regs

Goals of the Child Nutrition Program for Students with Special Dietary Needs

Meet the nutritional needs, as specified by the United States Department of Agriculture (USDA) meal pattern requirements and the child’s personalized diet plan.

Prepare the food items exactly as the diet order specifies, including texture and consistency of the item. If the diet plan is unclear, contact the medical authority involved in prescribing the diet plan for further clarification.

Ensure food safety.

Goals of the Child Nutrition Program for Students with Special Dietary Needs

(continued)

Be knowledgeable of the policies and procedures in place for the district/site as they pertain to children with identified special dietary needs and the role of food service personnel in the case of a medical emergency.

Give appropriate feedback to the multidisciplinary team whenever applicable.

90% of foods causing food allergies

Cow’s milk

Egg

Soybeans

Wheat

Peanut/tree nut

Fish/shellfish

Celiac Disease

Celiac Disease: An autoimmune disorder in which the body attacks itself.

Permanent sensitivity to gluten, a protein found in wheat, rye, & barley

Eating food containing gluten damages the villi (lining of the small intestine), which results in mal-absorption of nutrients

Gluten Free diet for life is only treatment

Gluten Containing Grains Barley Barley malt, extract, flavoring Bran Bulgur Couscous Durum Einkorn Emmer Farina Faro Flour Graham flour, graham

crackers Kamut Matzo flour, meal Malt, malt flavorings

Orzo Panko Rye Seitan Semolina Spelt Triticale Udon Untested Oats Wheat berry Wheat bran Wheat germ Wheat germ oil Wheat gluten Wheat starch

Hidden sources of gluten Bouillon Breading Broth Brown Rice syrup Coating mix Communion wafers Croutons Candy Imitation Bacon/seafood Luncheon Meats Marinades, thickeners Modified food starch Processed cheese

Roux Sauces Seasoning packets/mixes Self-basting poultry Soup base Soy sauce Stuffing Herbal Supplements Vitamin & mineral

supplement Over the counter/prescription

medications Lip-gloss, balms, lipstick Play dough

Questionable ingredients Carmel color – if made in US product is safe. Food label will

confirm derivation of product.

Flavorings – gluten containing grains rarely used. Mostly derived from corn; exceptions include barley malt flavorings, is usually listed on the label and flavorings in meat products

Dextrin – may be derived from arrowroot, corn, potato, rice,

tapioca, sago or wheat

Modified food starch – may be derived from corn, potato, tapioca, wheat or other starches. No requirement for the identification of plant source.

Starch – FDA regulations start “ starch” implies cornstarch; if

alternative starch is used it must be listed i.e.. Wheat starch

Gluten Free Diet

Any of the following words on food labels usually means that a grain containing gluten has been

used:

Stabilizer Hydrolyzed Vegetable ProteinStarch Flour or Cereal ProductsFlavoring Vegetable ProteinEmulsifier Malt or Malt FlavoringFood StarchModified Starch or Modified Vegetable Gum

Gluten-Free Grains Acorn Cottonseed Quinoa Almond Dal Red rice Amaranth Dasheen flour Rice, rice bran, rice flour Arborio rice Enriched rice Risotto Aromatic rice Fava bean Sago Arrowroot Flaxseed Sesame Basmati rice Garbanzo Sorghum Brown rice, Brown rice flour Glutinous rice Soy,soybean,tofu Buckwheat Hominy Starch (made from corn or

rice) Calrose Instant rice Sunflower see Canola Job’s tears Sweet rice flour Cassava Millet Tapioca Chestnut Modified corn starch Taro flour Chickpea Modified tapioca starch Teff Corn, corn flour, Peanut flour Wild rice Corn gluten, Potato flour Corn Malt, cornmeal Potato starch flour Cornstarch

Gluten Free School MenuExample Chicken fajitas (prepared from fresh

boneless chicken breast meat and gluten free seasoning) served with corn tortillas/green peppers/onions/salsa/sour cream

Steamed brown/white rice Steamed broccoli cuts Fresh fruit choice Milk (unflavored)

Gluten Free School MenuExample Cheeseburger Made with 100% lean

ground beef and block cheddar cheese (not processed)/gluten free bun

Oven fries prepared from fresh potatoes or gluten free French fries.

Steamed green beans Chilled Peaches Flourless Peanut butter cookie Milk (unflavored)

Gluten Free Peanut Butter Cookie1 cup creamy peanut butter or Almond Butter1 cup white sugar1 large eggSugar for rolling.

Combine all ingredients. Take 1 teaspoon of dough,form into a ball and roll in sugar. Place ball on bakingsheet and flatten with a fork. Bake cookies at 350degrees for 8 minutes.

Watch carefully when baking as they over bake and burn easily.

Yield: 1 dozen small cookies

Must utilize appropriate preparation methods to avoid cross

contamination.

Gluten and Casein Free Dietsometimes prescribed for children with Autism (recognized disability)

Acceptable foods Rice, potato, and

soy products Milks Flours

Fresh fruits, vegetables, meats

Arrowroot Nuts Beans Tapioca

Casein

Food sources Typical dairy foods – milk, butter,

cheese, yogurt Milk solids (curds) and whey Sodium caseinate – ingredient in

some processed foods “Natural ingredients” – may contain

dairy products

Gluten and Casein Free Diet Foods to avoid

Milk and milk derived products Wheat, barley, oats, rye, and buckwheat

flours and products “Natural ingredient” foods “Hydrolyzed vegetable protein” Carmel coloring – may contain gluten Vinegars – check label for food source Chocolates

Diabetic Requests

Supervision of menus/meals: how many carbs are served?

What steps are taken if child doesn’t take/eat planned items: Other selections or substitutions

Menu available for review; notify parents/nurse if there are changes

Phenylketonuria (PKU) Phenylketonuria, or PKU for short, is an

inherited, genetic condition in which the body can’t process phenylalanine (Phe), an amino acid found in many foods.

Too much Phenylalanine is toxic to the

brain. High Phe levels over an extended period of time can lead to vomiting, irritability, eczema, seizures, psychological and behavioral issues, and severe mental retardation.

PKU Diet Phenylalanine is found in:

All protein-containing foods (eg, meat, eggs, dairy, nuts)

Many other foods that are not

generally thought of as containing protein (eg, most wheat products, such as pasta and bread, and some fruit, such as oranges and cherries).

PKU MenuExample

When dealing with special dietary needs remember to…. Work with the team: Parents, doctors,

school nurse, teachers, administrators, school foodservice staff

Keep the lines of communication open Look through the eyes of your

customer…

A Child who just wants to be like everyone else.

RESOURCES Diabetes

The American Diabetes Association: http://www.diabetes.org

Gluten Free diets Celiac Sprue Association: http://www.csaceliacs.org

Phenylketonuria PKU support:

http://www.pku.com

Autism Autism Society of America:

http://www.autism-society.org

Food Allergies The Food Allergy and Anaphylaxis Network:

http://www.foodallergy.org