Chapter 12

1. Chapter 12 Growth and Development Issues in Promoting Good Health

2. Learning Objectives Describe nutritional needs of children and adolescents. Assess a child’s nutritional needs based on growth charts. Describe methods to promote optimal nutritional intake. Describe assessment and intervention strategies for common childhood health concerns. Apply knowledge of the nutrient needs to the meal environment. • 2

3. Development: Ability of Body Parts to Function Nutritionally poor-quality diet can impair cognitive function and neurologic development Milk intake associated with increased cognitions Nerve function requires B vitamins, vitamins C, E, K, and iodine (Bourre, 2006) Poor nutritional intake of CHO can have short-term deficits in cognition Breakfast leads to improved mental performance in school Children with poor school performance found less likely to eat high-protein foods, have less vitamins and minerals in diet, and higher sugar and fat intake (Fu et al., 2007)

4. Bone Growth: Best Barometer of Nutritional Status Bone, as healthy, living tissue, needs a variety of nutrients for growth It may generally be said that a child who follows the growth curve for height is meeting nutrient needs Chronic inadequate protein, kilocalories, vitamins, and minerals will stunt growth

5. Stunted Growth Stunting is shown with Nigerian children, born in the same month in the same village, who have genetically similar parents. (Photo courtesy of Michael Latham, Division of Nutritional Sciences, Cornell University, Ithaca, NY, and David Morley, Institute of Child Health, London, England.)

6. Growth Charts http://www.cdc.gov/growthcharts/ Based on percentiles (e.g., if child is 75th percentile for height, this means 25 children of the same age and gender are taller and 75 are shorter) Most important is that the child “follows the curve” Body mass index for children calculated same as for adults but ideal numbers based on percentiles Optimal: 5th – 95th percentile (under 2 years old) Over 2 years old BMI <5th percentile = underweight BMI <25th percentile = risk for underweight BMI >85th percentile = risk for overweight BMI >95th percentile = overweight

7. Kilocalorie Needs During Childhood 80 kcal/kg BW for prepubescent children 45 kcal/kg BW for active adolescent males 38 kcal/kg BW for active adolescent females 30 kcal/kg BW for non-active adolescents Needs based on level of activity, chronological age and individual growth rate

8. Fluid Needs for Children The Adequate Intake (AI) is about 2.5 liters/day for older children; see DRI A child with constipation should be assessed for fluid intake Athletic children need to have fluid goals determined by weight changes

9. Toddler Feeding Guides Young children like plain, simple foods; avoid mixtures Rule of thumb: 1 tbsp of each food per serving for each year of age Provide cups with handles; “sippy” cups avoid spills Promote “one-taste” rule, but avoid food battles Provide structured choices (e.g., “Would you like carrots on this side of the plate or the other side?”) Age + 5 for fiber goal

10. Picky Eaters Tastes are learned; research shows a food has to be tried 10 times before acceptance Offer a new food with well-liked foods (e.g., offer broccoli with macaroni and cheese) Practice patience May be related to tactile defensiveness; speech-language pathologist may be helpful Avoid authoritarian approach since related to poor vegetable intake

11. Preschool Age Encourage food diversity by involving child in food shopping and preparation; help children identify foods by looking at food labels Make eating fun; read Green Eggs and Ham, sing “Popeye the Sailor Man” Avoid using food bribes Food jags are common, with same foods desired for several weeks at a time Exposure to a variety of foods before age 4 encourages the child to continue acceptance of these foods when older

12. Early School Years Encourage breakfast for enhanced school performance Help children learn about good nutrition through the MyPyramid Food Guidance System. Ask “What food group is cantaloupe in?” Promote concept of “All foods can fit”—avoid labeling foods “bad” and “good”; use Pyramid concept Remember parent role, “Provide nutritious food in a pleasant environment,” and child’s role, “Choose what, when, and how much to eat” (per Ellyn Satter, RD)

13. Adolescent Years Recognize that body fat increase precedes puberty Remember parent role: have a variety of foods available for choices teen can make (e.g., popcorn, pretzels, and fruits instead of chips and cookies only) Help teen pack foods for delayed meals, such as when sports events delay dinner Teens need high kilocalorie, protein, and calcium and vitamin D intake for good growth Help teens in decision making for food purchases

14. Help Prevent Childhood Obesity Discourage excess television and computer use Encourage physical activity Promote high-fiber foods for satiety and encouragement of bone growth from minerals, especially magnesium Promote appropriate milk and water intake; discourage sweet beverages—juice diluted with mostly seltzer is a healthy alternative to soda pop Encourage children to eat fruit rather than drink it

15. Provide Nonfood Rewards Praise Hugs Talking and telling stories Give flowers Give stickers

16. Childhood Issues Related to Poor Weight Gain Celiac disease: an immune-type response among those with genetic predisposition to gliadin protein as found in gluten portion of certain grains: wheat, barley, and rye Can result in diarrhea, poor growth, osteoporosis, iron-deficiency anemia Cystic fibrosis: defect in sodium and chloride transport Results in thick mucous secretions Treatment: pancreatic enzymes, high-fat andhigh-kilocalorie diet, fat-soluble vitamin supplementation, EFAs, calcium

17. Anemia and Iron-Deficiency Generally due to periods of rapid growth (early childhood and adolescence) Preference for low-iron foods contributes Possible malabsorption due to parasites from lack of hand-washing after outdoor playing or due to celiac disease Adolescent girls high-risk with menstrual losses and rapid growth

18. Critical Thinking • Joey and Andrea were at the pediatrician’s office with their young son Nick and were voicing concerns about his lack of growth. The nurse practitioner noted positive interaction between the child and his parents and with her. A review of Nick’s usual food intake suggested a good nutritional intake. She then reviewed his chart: Dominic Luis B____; age: 4 years, today’s height: 38 inches; weight: 33 lb; birth length: 20.5 inches; birth weight: 8 lb 10 oz; history of chronic anemia treated with FeSO4, history diarrhea. She decided to run some laboratory tests—a B12 level and TTG antibody screen—especially given his Italian heritage. • Using growth charts found in Appendix 10, determine whether there have been changes in growth percentiles from Nick’s birth to his current age. Describe his growth based on the percentiles. • What is Nick’s BMI percentile? • What are possible reasons for the parental concern about Nick’s perceived lack of growth? • What are the reasons for the laboratory tests ordered? • If the tests come back positive for TTG antibodies, what course of action is advised?

19. Baby-Bottle Tooth Decay Examples of baby-bottle tooth decay. (Courtesy of Ferguson F, Department of Children’s Dentistry, School of Dental Medicine, SUNY at Stony Brook, Stony Brook, NY.)

20. Food Allergies Top 8 allergenic foods make up about 90% of food allergies Milk Eggs Peanuts Tree nuts (such as almonds, cashews, walnuts) Fish (such as bass, cod, flounder) Shellfish (such as crab, lobster, shrimp) Soy Wheat Ensure positive nutritional intake to support growth and development needs; refer to RD as needed Increase intake of foods high in vitamin E and carotenoids for possible reduced sensitivity Children tend to outgrow food allergies

21. Asthma: An Inflammatory Condition Avoid food allergens as needed Eggs, milk, soy, peanut, wheat, fish Refer to RD if food restrictions are followed Provide foods high in magnesium and zinc or supplements with 100% DRI Vitamin C and magnesium levels associated with asthma in adults Consider omega-3 fats for anti-inflammatory functions

22. Childhood Constipation Generally result of inadequate fluids and fiber General treatment Increase fluids, fiber, exercise Use caution with laxatives Epsom salts can provide excessive amount of magnesium for children and have been linkedwith toxicity for this population Avoid laxative abuse, because peristalsis of GItract can be seriously impaired

23. Attention Deficit Hyperactivity Disorder (ADHD) Conflicting research on whether restrictions of sugar or food additives help Newer research indicates magnesium deficiency may be a cause, with good response to supplementation noted Do not exceed DRI for children

24. Autism: Sensory Deficits with Reduced Social Interaction Child exhibits strong need to maintain routines and avoidance of anything new Acceptance of new foods is extremely gradual Diagnosis made in: 1 in 2500 children in the 1980s 1 in 300 in the mid-1990s Now estimated 1 in 200 children (Liptak et al., 2008) Possible role of gliadin protein as found in gluten and casein (milk protein) Any restrictive diet necessitates supervision by an RD

25. New Insights into Autism Low mineral status: magnesium (Strambi et al., 2006), iodine, potassium, lithium with high zinc levels (Adams et al., 2006) Rise in rate coincided with folate fortification of food supply in the 1990s to reduce incidence of neural tube defects. However, children born with autism may have a variant enzyme with high folate needs (previously may have been miscarried prior to folate fortification); increased folate intake throughout life for such children may reduce incidence of autism (Rogers, 2008)

26. Preventing Eating Disorders Do not discuss weight around children of any age Promote positive self-esteem in children Do not restrict food intake or label foods “good” and “bad” “All foods can fit” Encourage and respect children’s ability to recognize their hunger and satiety cues and feelings

27. Recognizing Eating Disorders Anorexia nervosa: food restricting (may be masked as vegetarian diet or complaints of GI discomfort) Bulimia: purging with vomiting and/or laxative abuse Bulimorexia: combination of anorexia and bulimia

28. Anorexia Nervosa Indicators Weight loss of at least 25% of original body weight Bizarre eating habits (cutting food into extremely tiny pieces or having food rituals) Compulsive exercise habits Amenorrhea (lack of menstrual cycle) among girls Disturbed body image with irrational, intense fear of becoming obese and refusal to maintain appropriate body weight Underlying low self-esteem Need to gain control in life that feels out of control

29. Other Physical Indicators of Anorexia Nervosa Abnormally dry skin and reduced secretions Fine hair covering the body Poor hair growth Yellowing of the skin with hyperpigmentation Acne and inflammatory skin condition or dandruff Coldness of the extremities with bluish discoloration Impaired wound healing Edema Scurvy Pellagra: 4 Ds: diarrhea, dermatitis, dementia, and death (provide vitamin B3 if risk of pellagra)

30. Bulimia: Purging Behavior Dehydration, dry mouth caused by vomiting and/or laxative abuse Dental erosion from purging—dental professionals play key role in identifying bulimia

31. Dental Erosion Bulimia-induced dental erosion. (From Sapp JP, Eversole LR, Wysocki GW: Contemporary oral and maxillofacial pathology, ed 2, St Louis, 2004, Mosby.)

32. Developmental Disability Severe, chronic disability that occurs before age 22 Mental retardation, Autism, Cerebral palsy, Epilepsy, Down syndrome, Prader-Willi syndrome Nutritional needs may be altered because of medications, hypermetabolism, or hypometabolism related to excess movements or poor muscle tone Eating problems may occur from anatomic defectsand malformations such as cleft palate Eating problems may result from neuromuscular dysfunction Hyperactive gag reflex, tongue thrust, poor lip closure, inability to chew and swallow,inability to eat independently

33. Study Guide • What is the best barometer of nutritional status in children? • What does a growth percentile mean? • When reading growth charts what is the most important thing to consider? • According to BMI for children, what is the ideal range? • What are calorie needs for children based on? • Be able to identify food related issues for toddlers, preschoolers, early school years and adolescents • How many times might a picky eater need to be exposed to a food before accepting it? • What is iron deficiency anemia usually due to? • What is tooth decay in babies often caused by? • What mineral deficiency is thought to be related to ADHD?

34. Study Guide (continued) • How can a parent help prevent childhood obesity? • What are the top 8 allergenic foods • What is childhood constipation generally caused by? • What protein is thought to affect autism and what 2 foods are often restricted to avoid this protein? • What B vitamin may need to be increased in autistic children? • How can a parent help prevent eating disorders in their children? • Indicators of anorexia • Differences between anorexia, bulemia and bulemorexia • How may nutrition be affected by development disability?