Pediatric Nutrition and Obesity

1. Pediatric Nutrition and Obesity Brenda Beckett, PA-C

2. Key Nutritional Conceptsin Children • Nutritional requirements • Feeding patterns of infants and children • Vitamin supplements • Brief assessment of nutritional status • Common feeding and nutritional concerns

3. Influences on Nutrient Requirements • Rate of growth • Highest in early infancy • Body composition • Needs of the brain • Composition of new growth • Fat needs

4. Energy • Kilocalorie(or Calorie)- unit of heat measurement • Definition-amount of heat necessary to raise the temperature of one kilogram of water 1 degree

5. Energy needs of children • Vary by age • Vary by body size • Vary by growth rate at a point in time • Vary by activity • Periods of rapid growth and development increase caloric needs

6. Energy (Calorie) Needs • Newborn • 120 kcal/kg/day • 6-12 months • 90 kcal/kg/day • Decrease 10 kcal/kg for each succeeding 3 year period • Adolescent • 40 kcal/kg/day

7. Protein • Consists of amino acids • Essential nutrient for forming new cells • Arrangement of amino acids in a protein molecule determine its type • Essential amino acids-needed to form new tissue in the body. Must be present in the diet • Nonessential amino acids can be synthesized, and do not need to be supplied in the diet

8. Too much and too little • Proteins cannot be stored effectively • Not enough protein-muscle tissue may be broken down to supply amino acids to the brain and for enzyme synthesis • Inborn errors of metabolism-problems in the breakdown of amino acids, at any point in the cycle

9. Protein Needs • Newborn • 2.5 g/kg/day • 12 months • 1.5-2 g/kg/day • Adolescent • 1-1.5 g/kg/day

10. Fat Needs • Main dietary energy source for infants • 45-50% of calories • Required for : • Absorption of fat-soluble vitamins • Myelination of CNS • Brain development

11. Carbohydrate Needs • In the form of lactose for infants • 40 % of calorie intake • Converted to glucose, the principle fuel for the brain

12. Requirements for 2 year olds • Similar to adults (transition) • High fiber, limit sodium, limit fats • Carbs : 55 % of total cal (10% simple sugars) • Protein: 15-20% of total cal • Total Fat : less than 30% of total cal • Sat Fats : less than 10% • Chol : less than 300mg/day

13. Feeding PatternsBreast Milk • Advantages • Economical/convenient • Psychological/emotional bond • Easier to digest • Immunologic • Allergy-protective • Infection preventive

14. Contraindications toBreast Feeding • Maternal Infection • TB • HIV (in developing countries) • ? Hepatitis C • Drugs • Illicit drugs • Radioactive compounds • Antineoplastic agents • Lithium • Ergots • Gold salts • Tetracycline • Plus many more …

15. Composition (calories: 20kcal/oz)

16. Infant Formula • Approx. 20 kcal/oz (human milk 22kcal/oz) • Protein, fat, carbohydrate similar • Mineral content in formula slightly higher • Some differences in electrolyte composition

17. Technique of bottle feeding • Comfortable position for infant • No “bottle propping” • Comfortable temperature for the infant(discourage microwave heating) • Avoid air in the bottle • Burping, spitting up • Discard unused portion of bottle

18. Infant Feedings • How much ? • First 6 weeks • q1½-3h • Breast fed 8-12x/24 hours • Formula fed 6-8x/24 hours • 2 months • q3-4h, 3-4 oz. • 6 months • q4-6h, 5-7 oz. (this does not include solids)

19. How to tell if the infant is ready for solids • Interested in what parent is eating • Seems to be hungry between feedings • Wakes at night to feed, after already sleeping through the night • Sits with support • Holds head steady and upright • (double birth weight)

20. I’m still hungry !!! At a routine health maintenance visit, a mother asks if she may begin giving her 4 month old daughter solid foods. The infant is taking about 4-5oz. of formula q3-4h during the day and sleeps from 11pm to 6am without awakening for a feeding. Her birth weight was 7 lbs., and her current weight is 13 lbs. The PE, including developmental assessment, is normal for age.

21. Intro. To solid foods • Age 4-6 months • Iron fortified rice cereal, mix with breast milk • Veggies / Fruits • Feed with a spoon • By 10 months soft finger foods • By 12-15 months “regular” diet • Wide range of “normal” • Wait 3-5days between introducing a new food

22. Some Foods to avoid in 1st year of life • Honey • Eggs • Seafood • Peanuts • Nuts

23. Manageable Mealtimes • Encourage child to stay seated • Hands-on food, feed self (pincer grasp) • Introduce spoon (6-8 months) • Use a cup • Whole milk for 12-24 months of age • 2-3 years of age – transition to adult diet

24. Vitamin Supplements • Vitamin D • Low in breast fed babies • Vitamin B12 • if mom is strict vegetarian • Iron • *importance of screening • Fluoride • Dose dependent on age of child and fluoride content of water supply

25. Supplemental Fluoride Recommendations • Concentration of Fluoride in Water <0.3 ppm

26. Assessment of Nutritional Status • Diet History • Quantity of foods • Quality of foods • Variety of foods

27. Feeding Concerns A 4 month-old infant is brought to the office for a routine exam by his mother, who complains that her son is constipated. He grunts with each bowel movement, and his face turns bright red. He has soft BM’s every five days. The infant is breast-feeding and has not yet started other foods. On examination, the infant’s vital signs are normal, and the infant is at the 75th percentile for height and weight. The remainder of the PE is normal.

28. Feeding Concerns • Constipation • Spitting up • Toddler feedings • Deficiencies • Excesses

29. Constipation • Very uncommon in breast fed infants • Most infants have 1 or more stools/day, varying consistency is normal • Cause may be insufficient fluid intake • Add small amount of water to diet • Pear juice/prune juice

30. Diarrhea • Breast fed infants have looser stools than formula fed infants • Most likely causes of diarrhea in breast fed infants • Infectious • Food or medication taken by mother • Mild diarrhea may be due to overfeeding, more common in formula fed infants

31. Colic • Severe crying in infants younger than 3 months, with paroxysmal abdominal pain • Symptoms • Sudden onset, may last hours • Abdomen is tense • Legs may be drawn up, hands clenched • Seems relieved with passing gas • Occurs often at late afternoon or evening • Treatment • Try to prevent attacks by improving feeding technique, environmental controls • Identify possible food sensitivities in the mother’s diet, food allergies in infant

32. Feeding after age 1 • Most have adapted to a schedule of 3 meals a day • Decreased rate of growth in the 2nd year of life-decreased kcal/weight requirements • Children start to self select diet • Look at what they are eating over a week, not just a day to day basis

33. Eating habits • Important to start early • Patterns started in the 1st years often continue • Avoid mealtime stress • Respect the child’s appetite

34. Later childhood • Consider dietary needs and tastes as child gets older • Suggest that parents involve the child in meal planning and preparation • Be aware of adequate caloric intake, especially for athletes • Educate parents on eating disorders and obesity

35. So you have a picky eater… • Won’t eat at mealtime, will only eat 1 food, will only drink….what else? • Appetite reduced with slower growth • Eat when hungry • Look at food over 1 week, not daily • Disguise nutrient rich food in other foods • Is snacking an issue? • Try new foods in small portions • Involve your child • Be a positive role model

36. Malnutrition • Worldwide, a leading cause of mortality in children • Caused by either inadequate intake or inadequate absorption of food

37. Severe Malnutrition • Marasmus • Common in areas with insufficient food • Poor feeding habits • Failure to gain weight, • Loss of weight until emaciation results • Kwashiorkor • Severe protein deficiency with inadequate caloric intake • Loss of muscle tissue • Edema • Liver enlargement with fatty infiltrates • Secondary immunodeficiency

38. Vitamin Deficiencies • Not encountered very frequently in US • List of all doses recommended for children, and consequences of deficiency and overdose listed in any text

39. Multivitamins • Be aware many vitamins and minerals are toxic in large amounts • Choose a multi-vit for KIDS, not adult • Does not replace good nutrition • Always supervise • Not gum or candy—choking issue

40. Childhood Obesity

41. Objectives • Discuss societal trends contributing to obesity • Define obesity • Discuss medical complications of obesity • Review effective communication techniques for talking to patients and their families • Tools for assessment • Clinical evaluation of the obese child • Discuss disease processes associated with obesity • Discuss treatment goals

42. U.S. Statistics • Prevalence of childhood obesity has been rising dramatically • Over the past 30 years, the obesity rate in the U.S. has more than doubled for preschoolers and adolescents. • Over the past 30 years the obesity rate has more than tripled for children ages 6-11 years old. • In the U.S. as many 25-30% children may be affected

43. Maine Statistics • 27% of Maine high school students, 30% of Maine middle school students are overweight, or at risk of becoming overweight • 36% of Maine kindergarten students are overweight or at risk of becoming overweight

44. National Trends • Increase consumption of fast foods • Increase in portion size (SUPERSIZE) • Increase consumption of soft drinks • Increase amount of T.V. / video game viewing • Decrease in family meal times • Decrease time in physical education classes

45. Portion Comparison: over past 20 years • Bagel: 3 inch diam, 140 kcal. Now 6 inch diam, 350 kcal • Popcorn: 5 cups, 270 kcal. Now 11 cups, 630 kcal • Soda: 6.5 oz, 85 kcal. Now 20 oz, 250 kcal

46. Definition Obesity/Overweight • Preferred terms are “at risk for overweight” and “overweight” replacing “at risk for obesity” and “obesity” • “At risk” BMI for age between the 85th and 95th percentiles • Obese/Overweight BMI for age is at or greater than the 95th percentile

47. Factors contributing to obesity • Change in dietary intake-i.e. types of foods • Increase caloric intake • Decrease in physical activity • Increase in inactivity

48. Which one of these factors is found to correlate directly with childhood obesity? • Fast food • Soft drinks • Infrequent family meal time • Watching television • Decreased physical activity

49. Effects of obesity on major organ systems • Musculoskeletal • Endocrine • Gastrointestinal • Respiratory • Cardiovascular • Reproductive • Neurological

50. Tips on discussing childhood obesity • TREAT FAMILIES WITH SENSITIVITY • A lot of value in society placed on physical appearance • Often the parent(s) or other family members are obese as well • Beliefs that obesity is secondary to laziness • Family members may be embarrassed • Treat obesity as a chronic medical problem • Be a respectful and compassionate health care provider