NUTRITIONAL NEGLECT

1. �NUTRITIONAL NEGLECT� ARNE GRAFF MD MEDICAL DIRECTOR CAMS

2. CONTACT INFORMATION: CAMS (CHILD AND ADOLESCENT MALTREATMENT SERVICES) arne.graff@meritcare.com 701 234 6504 (office) 701 234 2000 (after hours)

3. DEFINITION: NEGLECT: when a child�s basic needs are not being met; an act of omission, not commission. �regardless of income� Chronic nature Definition varies by professional Often seen in �spectrum� view

4. DEFINITION (CONT): A child�s needs will vary depending on the developmental ability and age. Needs also may be impacted by cultural standards Occurs due to impoverished relationship between parent and child

5. EPIDEMIOLOGY: 3.5 MILLION CASE OF MALTREATMENT REFERRED YEARLY NEGLECT IS 62% OF TOTAL 0-3 Y/O HIGHEST RISK GROUP(73%) FATALITY RANGE: 32-42% OF ALL DEATHS

6. EPIDEMIOLOGY: MAJORITY OF REPORTS INVOLVE MINORITY AND POOR FAMILIES COMMON TO SEE CO-OCCURRENCE OF OTHER ABUSE

7. CONSEQUENCES: For Neglect (general): physical, behavioral, and social development consequences �through the lifespan� It affects ALL areas of human development

8. CONSEQUENCES: Appropriate neural pathways require an environment with stimulation Pathways not stimulated, decrease! Brain assumes: day to day survival mode Some areas (brain) underdeveloped Child needs predictable, constant, affectionate care

9. NURTITIONAL NEGLECT: MEDICAL NEGLECT FAILURE TO THRIVE MALNUTRITION

10. MEDICAL NEGLECT Failure to heed obvious needs of serious illness of child/infant Failure to follow provider�s instructions

11. Child�s Nutrition: Infant/child has 3X caloric intake compared to adult If intake is inadequate, protein and energy stores are mobilized and used. At same time energy expenditure is reduced; this is seen with decreased activity and growth.

12. NORMAL WT GAINS: 0-3 MOS 26-31g/d 3-6 MOS 17-18g/d 6-9 MOS 12-13g/d 9-12 MOS 9g/d 1-3 YRS 7-9g/d

13. CONSEQUENCES: Attachment disorders Difficulty in discriminating other�s emotion Avoidance in peer relationships Long term relationship difficulties Cognitive-behavior Effects Physical effects: death

14. GROWTH DISTURBANCES: COMMON IN FOSTER CHILDREN 10-15% HAD FTT OR GROWTH PROBLEM 18% OF ADOLESCENTS WERE OBESE (40-50% OF CHILDREN IN FOSTER CARE HAVE MAJOR MEDICAL PROBLEMS)

15. NUTRITION NEGLECT: FTT: malnourished infants failure to meet expected growth �organic vs non-organic� causes usually multifactorial

16. MALNOURISHED: MARASMUS: protein cal deficiency ** KWASHIOKOR: protein cal deficiency (marasmus is more common in USA kids) Marasmus Kwashiokor

18. MEASUREMENT CHARTS: USE THE CORRECT ONE! Some are specific (premie, Downs, etc) ACCURATE MEASUREMENT!! Charts are sex specific Apply to all races/nationalities Need to do �growth trajectory�--multiple dates

19. Measurement Methods: Gomez: ratio of child wt / median wt/ht Waterlow: child�s wt / median wt/ht for children with acute undernutrition > 2y/o use BMI

20. Inadequate Nutritional Intake Normal growth parameters Decel in wt; then decel in ht Lastly see decel in hc As stunting develops will see wt/ht return to normal range (false normal)

21. Genetic Short Stature: Also called: �constitutional growth delay� Normal parameters at birth Simultaneous decel in wt and ht before 2 y/o After age 2, normal growth velocity 25% of infants will shift to lower growth percentile in first 2 years of life and then follow that percentile

22. Premature infants Need to use specific charts May remain below average for 3 years What does the growth velocity show?

23. IUGR Intrauterine Growth Retardation Birth Wt <10% for gestational age Disproportionate growth parameters Increased risk for FTT due to behavior issues

24. FTT DEFINED(MEDICAL): WEIGHT < 5% GROWTH CROSSES 2 MAJOR LINES WT/HT OR HT/AGE <10% �SEVERE�: WT < 60% OF EXPECTED WT Medical Emergency: wt <70% of predicted wt

25. FTT DEFINITION: IT IS PROBLEM; NOT A DIAGNOSIS A CHANGE IN GROWTH AFTER STABLE PATTERN IS ATTAINED A FAILURE TO GAIN WT APPROPRIATELY IF SEVERE: HT AND HC FALL OFF

26. Thrive definition: REQUIRES: NUTRITION AFFECTION STIMULATION

27. FTT EPIDEMIOLOGY: 1-5% of ALL referrals to children�s hospitals Most common in poverty environment In some populations: 30-40% missed and not diagnosed!

28. FTT CONSEQUENCES: Developmental and behavioral problems Subtle neurological deficits--interfering with progress of feeding skills ie: fine motor skills not developing so difficulty with utensil use--seen by family as �refusal to eat�

29. FTT CONSEQUENCES: �Decreased immunological function� May result in increased susceptibility to infection; leads to increased cortisol levels; leads to altered immune and behavioral responses

30. FTT CONSEQUENCES: PERSISTANT SHORT STATURE SECONDARY IMMUNE DEFICIENCY PERMANENT DAMAGE TO BRAIN

31. IMMUNE DEFIENCY: Malnutrition decrease immune anorxia infections cycle continues on itself

32. CNS CHANGES: INFANT BRAIN IS MOST VULNERABLE DURING 24-47 WKS OF AGE. PLASTICITY HAS BEST CHANCE IF NUTRITIONAL PROBLEM IS CORRECTED BEFORE 1 YEAR OF AGE! RAPID GROWING BRAIN IS MORE SUSCEPTABLE TO NUTRIENT DEF.

33. CNS CHANGES: PROTEIN-ENERGY DECREASES: GLOBAL EFFECTS AREA SPECIFIC DEPENDS ON TIMING SPECIFIC NUTRIENTS AFFECT PATHWAYS

34. FTT RISK FACTORS: PREMATURITY DEVELOPMENTAL DELAY CONGENITAL ABNORMALITY(CLEFT) INTRAUTERINE EXPOSURE LEAD POISONING POVERTY ANEMIA

35. FTT RISK FACTORS: MEDICAL CONDITION SOCIAL ISOLIZATION HEALTH AND NUTRITIONAL BELIEFS LIFE STRESSORS POOR PARENTING SKILLS DISORGANIZED FEEDING TECHNIQUES SUBSTANCE ABUSE DV/OTHER ABUSE

36. PARENT RISK FACTORS: IMMATURITY MOOD DISORDER LIMITED SOCIAL SKILLS TROUBLE DEALING WITH �DIFFICULT TEMPERMENT CHILD� DRUG USE SOCIAL ISOLIZATION

37. REMEMBER: ALMOST EVERY ORGANIC DISEASE PROCESS CAN CONTRIBUTE TO FTT

38. AGE RISKS: < 1 MOS Poor suck; incorrect formula preparation; congenital syndrome; teratogenic exposure; poor feeding interactions; neglect; metabolic abnormality; chromosomal abnormality; anatomic abnormality

39. AGE RISKS: 3-6 MOS Underfeeding; improper formula preparation; milk-protein intolerance; oral-motor dysfunction; Celiac disease; Cystic Fibrosis; congenital heart disease; reflux

40. AGE RISKS: 7-12 MOS Feeding problems (autonomy struggles); oral-motor dysfunction (new textured foods); delayed introduction to solids; intolerance of new foods; intestinal parasites

41. AGE RISKS: > 12 MOS Coercive feeding; highly distractible child; distracting environment; acquired illness; new psychological stressor (divorce, etc)

42. CAUSES OF FTT: Inadequate energy intake Inadequate nutrient absorption Increased energy requirements Defective utilization

43. Inadequate Caloric Intake Incorrect formula preparation Unsuitable feeding habits (fad foods) Behavior problems affecting eating Poverty or food shortages Neglect Disturbed parent-child relationship Mechanical feeding difficulties

44. Inadequate Absorption Celiac disease Cystic Fibrosis Cows mild protein allergy Vitamin or mineral deficiency Biliary atresia or liver disease Short gut syndrome

45. Increased Metabolism Hyperthyroidism Chronic infection Malignancy Renal disease Hypoxemia (lung or heart disease)

46. Defective Utilization Genetic abnormalities Congenital infections Metabolic disorders

47. HISTORY: Prenatal: wt gain, smoking, illness, wanted pregnancy, labs, other pregnancy histories Delivery: type, trauma, meds, hospital course, Newborn: wt at delivery/discharge, meds, nurses notes (parent/infant interactions, feeding observed), medical problems, exam, APGARs, Ht, HC,

48. HISTORY: WELL CHILD: immunizations, all clinic records, any hospital visits, accidents, developmental evaluations, labs DIET: history from birth, current eating, where feedings occur, what happens during feedings, who helps/No one?, describe how formula is prepared, what is in refridgerator, does the child graze, vitamins, who else feeds child/infant (day care), when eating, food preferences

49. HISTORY: MUST GET ALL GROWTH RECORDS! MUST PLOT OUT GROWTH! FAMILY: history of illnesses, growth problems, mental health illnesses DEVELOPMENTAL HISTORY REVIEW OF SYSTEMS SOCIAL HISTORY FAMILY GROWTH: plot parents

50. DEVELOPMENT HISTORY TODDLER >1 Y/O Independence with self feeding skills Control over food choices Snacks introduced Change from �on demand� to timed meals

51. EXPECTED GENETIC POTENTIAL MID-PARENT FORMULA: dad�s ht (cm) + mom�s ht (cm) +/- 13 all divided by 2 for boys: add 13; for girls subtract 13 if parents was neglected may see short parent

52. DIET HISTORY: DIET INTAKE OK; BUT NUTRIENTS MAY BE MISSING DIET INTAKE OK FOR WT/HT BUT NOT FOR AGE

53. LAB: < 1% OF LABS WILL BE OF HELP CONSIDER: cbc, ua, uc, lytes, bun, cr, chem panel, Hiv, Tb, stool studies, lead level lab: guided by history and physical

54. X-ray Evaluation: Guided by history/exam Growth Arrest lines/Harris Lines: here horizontal lines demonstrate stress times; they are non-specific Bone Age used when wt/ht is good, but patient is short

56. EVALUATION TEAM: MEDICAL (provider, RN, Public health) SW PT, OT, SPEECH/SWALLOW MENTAL HEALTH ? LAW ENFORCEMENT NUTRITIONIST MEDICAL CONSULTANTS

57. Psyc assessment: May see intellectual and socioemotional development changes Looking for cognitive, motor, behavior, sociaoemotional delays Help in follow-up monitering

58. PARENTAL VIEWS: Was parent victim of nutritional abuse/neglect Cultural view/religious views Distrust of system/previous involvement �like other sibling�--? Also neglected?

59. TREATMENT: ESTABLISH MEDICAL HOME ESTABLISH DENTAL HOME COMPLETE HEALTH SCREENING COMPREHENSIVE MEDICAL EXAM ABILITY TO CLOSELY MONITER MULTIDISCIPLINE APPROACH HOSPITLIZATION UNCOMMON

60. TREATMENT: MUST ADDRESS: MEDICAL NUTRITIONAL PSYCHOLOGICAL ENVIRONMENTAL DEVELOPMENTAL

61. CULTURALLY SENSITIVE AVOID: Ethnocentrism: the belief that one�s culture is best Cultural Relativism: the belief that all cultures are equal precluding any judgement of another�s culture practice (FGM)

62. TREATMENT: PT, OT, SPEECH, DEVELOPMENTAL EVALUATIONS--also allows for independent observation of parent/child interactions (parent response to ques, watch parent make formula, position child held, messiness ok?, atmosphere at feeding) HOME visit: gives view of the eating environment (TV, chaos, food in refrigerator)

63. TREATMENT: SW: can evaluate services available; home visits; look for stressors, strengths and support systems, obstacles (religious, cultural, etc) Parenting skills?; parent knowledge

64. TREATMENT: MUST ENGAGE FAMILYIN PLAN FAMILY MUST AGREE TO A PLAN FAMILY IS TO UNDERSTAND PLAN YOU MUST DOCUMENT THAT THE FAMILY AGREES TO AND UNDERSTANDS PLAN!!

65. TREATMENT: PLAN: SIMPLE IS BEST!!! CATCH-UP GROWTH PARENT EDUCATION TREATMENT OF MEDICAL PROBLEMS Primary care provider MUST be on the same page!

66. TREATMENT: DOCUMENTATION MUST BE DONE REGARDING PARENT COOPERATION AND COMPLIANCE!! IF FAILING TO COMPLY, WITHOUT ADEQUET REASON, REFILE 960.

67. TREATMENT Influenza vaccine for children (even > 5) Teach families to watch for infections Child NEVER receives �clear liquid diet� for more than 24 hours

68. DIET TREATMENT: May take up to 2 weeks to catchup With increased wt--? Edema Often need 150% of daily recommended intake based on �expected� not actual weight Wt restores more quickly than Ht Nee 4-9 mos of accelerated growth to restore the wt/ht

69. TREATMENT WT: moniter over several days with consistent increases (don�t assume ok with one or two days of increase).

70. Refeeding Syndrome: With starvation you see decrease metabolic process. This results in decreased growth. To compensate the body uses endogenous stores of glycogen, fat, proteins With rapid feeding: the homeostasis that the body (in starvation) has attained, is lost. You may see electrolyte changes (abnormal)

71. Refeeding Syndrome: Blood volume is contracted with starvation. With eating, increased blood volume occurs which can lead to heart failure and edema. This results in electrolyte disturbances which can worsen heart function, causing more failure, etc. See life-threatening lyte abnormalities <Mg: seizures, hemorrhage, coma

72. Refeeding syndrome: Start with SLOW refeeding: often start with 50-75% estimated needs and increase by 10-20% per day Closely moniter (exam and labs)

73. BIBLIOGRAPHY UP TO DATE www.uptodate.com Treatment of Child Abuse, Reece R, John�s Hopkins University Press, 2000, Chapters 11,12 Krugman S, Failure to Thrive, AFP; 68(5); Sept 1 2003 Dubowitz H, Child Neglect: Guidance for the Pediatrician, Peds in Review; 21(4); Ap 2000 Kellogg N, Criminally Prosecuted Cases of Child Starvation Peds 116(6); Dec 2005: 1309-1316 Georgieff M, Nutrition and the developing brain: nutrient priorities and memeasurment, Am J Clin Nutr; 2007; 85(suppl): 614s-620s Allen R, Nutrition in Toddlers, AFP; Nov1 2006; 74(9): 1527-1532