putting pediatric nutritional guidelines into practice alayne gatto mba rd csp clc ld fand

Putting Pediatric Nutritional Guidelines

into Practice

Alayne Gatto MBA RD CSP CLC LD FAND

DisclaimerAs a presenter, I have had complete and independent control over the planning and content of this presentation, separate from my primary employer, Mead Johnson Nutrition. Also, as an independent nutrition consultant, I am not endorsing any product names or labels that may be shown in the presentation, nor do I promote the use of any drug for indications outside the FDA-approved product label.

ObjectivesAfter this presentation, you will be able to:1. Recommend age- appropriate vitamins

and supplements to meet nutritional needs

2. Identify nutritional guidelines and put into practice for infants, toddlers and adolescents

3. Provide caregivers of picky eaters and petite children with food and beverage options to enhance nutritional intake and provide appropriate calories

Nutrition Guidance

Prevention of Rickets and Vitamin D Deficiency in Infants, Children and

AdolescentsPaper: Wagner, C.,Greer, F. & the Section on Breastfeeding and Committee on Nutrition, Pediatrics 2008(122), 1142-1152.

Recommendation:O Daily Intake of 400 IU/day for all infants,

children and adolescents beginning in the first few days of life.

O Premature Infants (according to Koletzko, 2014) require 400-1000 IU/day from milk and/or supplementation


Adolescents

Vitamin D:O Vitamin D2/Ergocalciferol: synthesized

by plantsO Vitamin D3/Choleocalciferol:

synthesized by mammalsO Source of Vitamin D for humans is

through its synthesis in the skin when UV-B converts through metabolic process (hydroxylation)

O Lab Measurement: 25-OH-D

Vitamin D synthesis


Adolescents

What affects Vitamin D absorption:-age-weight/BMI -skin pigmentation-lack of sun exposure or outdoor activity-sunscreen-latitude, season-cloud cover, air pollution


Adolescents

O Infants: All breastfeeding infants and infants that consume less than 1000mL/day (~33oz) of infant formula

1mL dropper or 1 drop = 400mLO Children/Adolescents: 400 IU through

food sources or supplementation ( 1 cup milk = 100 IU, salmon(3oz) = 400 IU; tuna(3oz) = 150 IU; egg (yolk) = 40 IU

O Serum 25(OH)D optimal level - > or = to 50nmol(20ng/mL)

Vitamin D


AdolescentsRickets 1. Symptomatic hypocalcemia

(including seizures)-occurs during periods of rapid growth before physiological or radiographic evidence is noted

2. Chronic Disease - rickets and/or decreased bone mineralization and normocalcemia or asymptomatic hypocalcemia

Vitamin Supplementation

The American Academy of Pediatrics does not recommend a universal multivitamin for children.O “At risk” vitamins/nutrients : Vitamin

D, Calcium, Iron, “Fiber”O Autism, ADHD, vegan, food allergies,

failure to thrive, specific medications

Nutrient LingoDRI – Dietary Reference IntakeGeneral term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and gender, include: RDA, AI, and UL (Upper Limit)RDA – Recommended Dietary AllowancesThe average daily dietary intake level, sufficient to meet nearly all (97-99%) of healthy individuals in this groupEAR – Estimated Average RequirementAn EAR is established from scientific evidence which calculates an RDAAI – Adequate IntakeBelieved to meets needs for all individuals within an age group but lacks data or uncertainty remains to establish a RDA with confidence

Calcium Calcium mg/day (AI) Supplement: Calcium Carbonate or Citrate? 1-3 years - 700mg4-8 years - 1000mg9-18 years - 1300mg

O Vitamin D facilitates calcium absorption and promotes bone mineralization

O Leafy greens (1/2 c spinach, 120mg), cheese slice (200mg), milk (300mg/cup), calcium-fortified foods, soy

Iron Iron mg/day (RDA) Supplement: Ferrous sulfate1- 3 years – 7 mg4-8 years - 10 mgGirls/Boys 9-13 years – 8 mgGirls 14-18 years - 15 mgBoys 14-18 years - 11 mg

Diet: 3 oz beef (3mg), ½ c beans (3mg), chicken, dried fruits, molasses, fortified cereals, leafy greens, 1 oz liver (7mg) 10 small clams (25mg)

FiberFiber – (g) 2010 Guidelines for Americans1- 3 years - 19 grams4-8 years - 25 gramsGirls 9-18 years - 26 gramsBoys 9-13 years - 31 gramsBoys 14-18 years - 38 grams

Diet: Peas (8g/cup), Broccoli, Avocados (6g/half), Lentils (15g/cup), Black Beans, Baked Beans, Berries (8g/cup), Chia seeds (1 Tbsp/5g), Flaxseed meal (1 Tbsp/~2g)Medication: Lactulose, Miralax, Metamucil

Gastroesophageal Reflux: Management Guidance for the

PediatricianPaper: Lightdale, J,, Gremse, D. & the Section on Gastroenterolgy, Hepatology and NutritionPediatrics May 2013: 131: 1684-1694

New GERD Management Guidelines:

1. Lifestyle Changes2. Medication3. Surgical Approaches

Gastroesophageal Reflux: Management Guidance for the Pediatrician

GER (reflux) – passage of gastric contents into the esophagus; typical of ~50-75% of all healthy term infants, common in preterm infants GERD – findings of mucosal injury on upper endoscopy; vomiting, poor weight gain, abdominal pain, esophagitis, wheezing, cough, regurgitation with vomiting and irritability, feeding refusal, arching of the back, poor weight gain, coughing, aversion to foodO Peak incidence of 50% at 4 months; 5-10%

at 1 year


PediatricianPositioningO Keeping completely uprightO Place in prone position (awake and

observed, lying flat with the chest down and back up)

O Semi-supine (carseat, bouncy chair) may exacerbate GER


PediatricianMaternal Diet for the Breastfed InfantO Milk cow protein allergy can mimic

GERD in infantsO 2-4 week trial of a maternal

exclusion diet that restricts at least milk and egg

O Pumped breast milk and thickened with (rice) cereal


PediatricianFormula O Reducing feeding volumes which

increasing frequency of the feedsO Adding (rice) cereal, up to 1Tbsp per

1oz formulaO Thickened feeds using a

commercially thickened rice formulaO Extensively hydrolyzed or amino acid

formula


PediatricianMedications - PPIs - Proton pump inhibitors

Lansoprazole (Prevacid), Omeprazole (Prilosec), Esomeprazole (Nexium)

Reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid. - superior efficacy compared to H2RAs (Zantac, Pepcid, Axid) - shorter half life noted in children, higher per kg dose - 30 minutes before a meal - overuse/Misuse of PPIs in the infant Population - Increased risk of pneumonia, gastroenteritis, NEC in preterm infants


PediatricianSurgical ApproachesO Fundoplication – gastric fundus is

wrapped around the distal esophagus

Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of

Complementary Foods and Hydrolyzed Formulas

Paper: Greer, FR,, Sicherer, SH. & Burks, A.W.Pediatrics May 2008:121: 183-191

O Although solid foods should not be introduced before 4-6months, there is no current evidence that delaying their introduction beyond this period has a significant protective effect on the development of atopic disease regardless of whether fed breast milk or formula. This includes the delay of fish, eggs and foods containing peanut protein.

http://wholesomebabyfood.momtastic.com/here/FoodChartbyFood.pdf




Solid Food IntroductionO Delay of complementary foods beyond 6 months may

lead to deficiencies in protein, iron, zinc and vitamins B and D, and have a negative effect on growth and development1

O The following feeding indicators have been associated with a reduced risk of stunting and being underweight2:

O Timely food introduction (6-8 months) (P<0.001)O Minimum acceptable diet*, dietary diversity and

consuming iron-rich foods (P<0.001)

*World Health Organization (WHO) guidance for minimum acceptable diet is at least 2-3 meals per day and a diverse diet.

1. Kuo AA et al. Matern Child Health J. 2011;15:1185-1194. 2. Marriott BP et al. Matern Child Nutr. 2012;8(3):354-370.

Sample Diet – 2 year old

High Calorie FoodsFruits – ½ c raisins (250), 1/2c dates or prunes(200), banana, mangoVegetables - 2 Tbsp avocado (50), 1c mashed sweet potato (250+), corn, carrots Meats/Proteins – 1 oz macademia nuts (200), dark meat, beef brisket, ground beef, “peanut” butter, bacon, baked beans, edaname(soy)Dairy /Milks– cheese, whole milk yogurts, smoothies, coconut milkGrains – muselix cereals, Grapenuts, Cracklin Oat Bran, granola, trail mixes, wheat germ, quinoa, whole grains“Fats”/Sugars – Nutella, salad dressings, mayonnaise, honey,

High calorie meals

DinnerO Pepperoni veggie pizza, carrot sticksO Whole wheat spaghetti and

meatballs, sauce, Parmesan cheese, peas

O Rice/beans/brisket, avocado/guacamole

O Dark meat chicken, mashed potatoes, corn

High calorie meals

LunchO Burrito with cheese, meat, rice ,

veggiesO Peanut butter and jelly/banana

sandwich, carrots and dipO Tuna salad on whole wheat, dried

fruitO Macaroni and extra cheese, cut up

mango and banana

High calorie meals

BreakfastO Whole milk Yogurt with granola and

berries O Oatmeal with wheat germ, milk, and

bananaO Tortilla with scramble

egg/cheese/veggiesO Cracklin oat bran cereal and

blueberriesO Smoothie made with milk, coconut

milk, fruit, avocado and flaxseed meal or chia seeds

High calorie beverages?

O High calorie beverages (30 calories/oz) can often be more harmful than helpful

O Encouraging hungerO Normal satiety cycleO Failure to Thrive Conditions

My Goals for You O Awareness of what nutrients infants

and children may be lackingO Able to back your recommendations

with reputable organizationsO Give examples of high calorie food

optionsO Promote the importance of good

nutrition with easeO Support growing, healthy children

putting pediatric nutritional guidelines into practice alayne gatto mba rd csp clc ld fand

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