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Decoding Failure to Thrive & Picky Eaters: The Truth About Liquid Calories

Understand the impact of Failure to Thrive (FTT) on growth and development. Learn why Pediasure might not be the solution, the dangers of juice and milk intake, and the addictive nature of sugar. Discover how dietary choices can affect weight gain, and when to supplement for picky eaters.

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Decoding Failure to Thrive & Picky Eaters: The Truth About Liquid Calories

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  1. Failure to Thrive and Picky Eaters Why liquid calories are not the answer

  2. Disclosures • I have no financial disclosures

  3. Objectives • Definition of failure to thrive (FTT) • Sugar guidelines (AHA/WHO) and addiction • Why not Pediasure • Weight gain and WIC foods • When to supplement • Picky eaters

  4. Definition FTT • Failure to thrive is defined as decelerated or arrested physical growth • It is a sign of undernutrition • FTT is a clinical finding and should never be a diagnosis on its own Cole, 2011

  5. Definition • BMI for age less than the 5th percentile • Length for age less than 5th percentile • Weight for age less than 5th percentile • Weight deceleration crossing two major percentile lines • Weight less than 75% of median weight for age • Weight less than 75% of median weight for length • Weight velocity less than 5th percentile Cole, 2011

  6. Diagnosis • Any single indicator has a low positive predictive value for true undernutrition • In one study, 27 percent of infants met at least one definition for FTT during the first year of life (Olsen, 2007) • Weight for length is a good indicator of acute undernutrition (Shah, 2002)

  7. Normal growth variants • Genetics- children of small parents • Large-for-gestational-age infants who regress toward the mean • Constitutional delay in growth • Premature infants whose growth parameters are normal when corrected for gestational age Cole, 2011

  8. Growth charts

  9. Source: Cole SZ, Lanham JS. Failure to Thrive: An Update. Am Fam Physician.2011;83(7):829-834.

  10. Why is FTT important? • Malnutrition can impact growth potential and cognitive development • Obese patients can have significant micronutrient deficiencies (Via, 2012) • Good nutrition is the goal, not just weight gain

  11. Dietary History Nutrition • Overall calories • Set meals vs grazing • Types of food • Juice and milk intake Occupational Therapy • Choking/gagging • Frequent respiratory infections • Overstuffing mouth • Issues with specific or mixed textures

  12. Why are juice and milk bad? • Can interfere with proper nutrition • Can fill kids up so they decrease their intake of solid foods • Excess milk can cause anemia • Juice causes cavities and can increase risk of obesity

  13. Excess juice contributes to FTT • Study looked at 8 children, 14-27 months old with FTT • 12 to 30oz per day of fruit juice which contributed to 25-60% of daily energy intake • Had lower dietary protein, fat, and micronutrient intake • Decrease in weight and linear growth that coincided with juice consumption • Their diet only provided 78% to 92% of recommended energy intake for age and weight • After nutritional intervention, dietary intake increased to 96% to 116% of recommended intakes. • Weight gain increased significantly in the first month and persisted for follow up of 5 to 18 months Smith, 1994

  14. Juice affects of stature • 163 children that were 2 and 5 years old • Dietary intake recorded over 14 days • Adjusted for child age, gender and energy intake (excluding fruit juice) and maternal height • Child height was inversely related to apple juice and grape juice intake (Dennison, 1999) • Related study showed >12oz juice per day to be correlated to short stature (Dennison, 1997)

  15. My child has FTT what should I give them? • Pediasure

  16. Liquid calories • Teaches kids to be picky eaters • Perpetuates sweet tooth • Can lead to obesity

  17. How much added sugar do we consume? • 1 to 3 year olds: 12 teaspoons/day • 4 to 8 year olds: 21 teaspoons/day • 14 to 18 year olds: 34.3 teaspoons/day Source: National Cancer Institute and National Health and Nutrition Examination Survey

  18. Is sugar addictive? • Chronic smokers could reduce tobacco cravings better than sugar cravings • Sugar affects dopamine receptors similarly to cocaine • After consuming sugar there is a surge in serotonin in the brain DiNicolantonio, 2018

  19. Oregon Research Institute

  20. Intense Sweetness Surpasses Cocaine Reward • Drug naive rats were allowed to choose between water sweetened with saccharin versus IV cocaine • 132 rats Lenoir, 2007

  21. S-/C+ S+/C- S+/C+ Lenoir M, Serre F, Cantin L, Ahmed SH. Intense Sweetness Surpasses Cocaine Reward. PLoS ONE. 2007;2(8): e698.

  22. Lenoir M, Serre F, Cantin L, Ahmed SH. Intense Sweetness Surpasses Cocaine Reward. PLoS ONE. 2007;2(8): e698.

  23. Rats and sugar conclusions • 94% of rats preferred saccharin • Same preference observed with sucrose • Increased doses of cocaine were not able to overcome rats choice of saccharin

  24. Reward dysfunction and compulsive eating • Wanted to test effects of restricted or extended access to a palatable diet • Rats had timed access to palatable diet for 40 consecutive days • 0 hr (chow-only) • 1 hr (restricted access) • 18-23 h (extended access) • Also had ad lib access to standard chow • Palatable diet: bacon, sausage, cheesecake, pound cake, frosting, and chocolate Johnson, 2010

  25. 40 days of access to palpable diet Chow Only 0 hour Restricted Access 1 hour Extended Access 18-23 hour

  26. Johnson PM, Kenny PJ. Addiction-like reward dysfunction and compulsive eating in obese rats: Role for dopamine D2 receptors. Nature neuroscience. 2010;13(5):635-641.

  27. After 40 days of access to palpable diet Chow Only 0 hour Restricted Access 1 hour Extended Access 18-23 hour • Permitted only 30min access per day to palatable diet for 5-7 days until stable intake • Then split into 2 groups

  28. Unpunished Rats Punished Rats Chow Only Restricted Extended Chow Only Restricted Extended

  29. Johnson PM, Kenny PJ. Addiction-like reward dysfunction and compulsive eating in obese rats: Role for dopamine D2 receptors. Nature neuroscience. 2010;13(5):635-641.

  30. Infants and sugar A study of 200 infants showed preference for sugar • At birth all infants preferred a sweet solution over water • At age 6 months the preference for the sweet solution was linked to dietary experience • Infants repeatedly fed sweetened water had greater preference for it • Offering foods without added sugar should be advised to help set the infants threshold for sweetness at a lower level De Cosmi, 2017

  31. Sugar: 26gm Sugar: 28gm

  32. Healthy weight gain foods Proteins Fats • Full fat Greek yogurt • Cheese • Nut butters • Cottage cheese • Eggs • Beans • Meats • Chia or flax seeds • Whole milk (8-12oz per day) • Butter • Cream cheese • Cheese • Heavy cream • Dressings • Avocado • Hummus • Coconut oil • Olive oil

  33. Behaviors around weight gain • Three meals and two snacks per day • No grazing • Limit milk and juice intake • Eat at the table as a family (high chair/booster) • Avoid distractions such as screens

  34. WIC foods

  35. WIC foods Plain: Cal: 75 Fat: 2g Protein: 5.5g Sugar: 9g Vanilla: Cal: 105 Fat: 1.5g Protein: 5.5g Sugar: 17g Plain Lowfat: Cal: 75 Fat: 1.75g Protein: 5.5g Sugar: 8g Vanilla Lowfat: Cal: 100 Fat: 1.5g Protein: 5g Sugar: 17g Strawberry: Cal: 70 Fat: 0g Protein: 5g Sugar: 8g Vanilla: Cal: 70 Fat: 0g Protein: 5g Sugar: 9g

  36. WIC Foods Vanilla: Cal: 130 Fat: 7g Protein: 2g Sugar: 14g Plain Nonfat: Cal: 60 Fat: 0g Protein: 5g Sugar: 8g Vanilla Lowfat: Cal: 87 Fat: 1g Protein: 3g Sugar: 21g Plain Nonfat: Cal: 60 Fat: 0g Protein: 4.5g Sugar: 6.5g Vanilla Lowfat: Cal: 105 Fat: 1g Protein: 3g Sugar: 17g Plain Nonfat: Cal: 65 Fat: 0g Protein: 6g Sugar: 7.5g Vanilla Lowfat: Cal: 100 Fat: .75g Protein: 3.5g Sugar: 15g

  37. 1 Large Egg Cal: 78 Fat: 5g Protein: 6g

  38. An Egg a Day… • 163 infants age 6 to 9 months • 83 infants ate an egg per day for 6 months • Egg group • Increased length for age z score by 0.63 • Increased weight z score for age by 0.61 • Reduced stunting by 47% • Reduced underweight by 74% • Reduced intake of sugar sweetened foods Iannotti, 2017

  39. WIC Foods 2 Tbsp Cal: 188 Fat: 16g Protein: 8g Sugar: 3g

  40. Breakfast Ideas • Yogurt Parfait • ½-2/3 cup Whole fat yogurt • 2-3 Tbsp Frozen or fresh berries or other fruit • 2-3 Tbsp Cereal • 1 Tbsp Chopped nuts • Peanut butter roll up • 2-3 Tbsp peanut butter • 1 Whole grain tortilla • 1 Banana • Scrambled eggs with cheese and veggies • Can also add a splash of cream • Oatmeal • Add ins of butter and/or peanut butter

  41. Snack Ideas • Bean and cheese burrito/quesadilla • Peanut butter balls • Peanut butter • Oats • Chia/flax seeds • Cottage cheese with fruit or vegetables • Vegetables dipped in hummus or guacamole • Tuna salad • Tuna • Mayo or cream cheese • Celery

  42. When to supplement

  43. Source: Cole S, Lanham J. Failure to Thrive: An Update. Am Fam Physician. 2011 Apr 1;83(7):829-834.

  44. What to supplement • Home made high calorie smoothies • Fruits • Vegetables • Fats: cream, avocado, chia seeds, etc • Proteins: peanut butter, Greek yogurt, etc

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