Child Health Nursing Partnering with Children & Families

Child HealthNursingPartnering withChildren & Families Kristine Ruggiero CPNP, MSN, RN Chapter 9 Nutrition pp 318-344 © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Child Health Nursing: Partnering with Children & Families By Jane W. Ball and Ruth C. Bindler

Nutrition • Overview: • Nutritional Needs • Infancy • Todlerhood • Preschool • School age • Adolescence • Nutritional challenges • Nutritional assessment • Physical and behavioral measurement • Common nutritional concerns • Overweight and obese • Collaborative care • Dietary deficiencies (iron, ca, vit d, folic acid, protein-energy) • Feeding and eating disorders • Pica • Ftt

Nutritional concepts • Nutrition: • Taking in food and assimilating it metabolically for use by the body. • Macronutrients: • Major building blocks • Carbohydrates, proteins and fats • Micronutrients: • Substances needed in small quantities for health body functioning.

Carbohydrates • Energy source: composed of carbon, hydrogen, and oxygen. • Saccharides (sugar molecules) • 50% of daily calories • Fiber= indigestible carbohydrate components, ensures healthy movement of fecal matter thru bowel

FIGURE 9–16While a child’s nutritional status influences health, it is also important to consider conditions that may affect the child’s nutrition and include this knowledge in your assessment. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Proteins • Amino acid compounds • 9 essential and 12 nonessential amino acids • Catabolism and anabolism • Nitrogen balance • Deficiency disorders

Fats • Energy source • Cellular processes and blood clotting • Fatty acids • Saturated • Unsaturated • Monounsaturated • Polyunsaturated

Glycemic Index • The blood glucose response to 50g of carbohydrate from any specific food as compared to the glucose level after ingestion of white bread • Low glycemic index has been found to have beneficial effects such as reducing serum lipids, insulin levels and improving serum glucose control

How are nutritional needs of the infant different from the adult? • Increased energy expenditure • Rate of growth: doubles by 6 months, triples by 1 year • Organ size and immaturity • Physiological changes

Nutritional Needs: Preterm and SGA Infants • Preterm (<37 weeks) and SGA (<2700 g) infants • Medical problems • Immature body systems • High calorie/kg intake to provide energy for necessary weight gain; may need up to 140 kcal/kg/day

Nursing strategies for Preterm and SGA infants • Specialized feeding methods • Parenteral nutrition • Gavage/ tube feedings • Transition to oral feedings • Assist families w/ teaching feeding methods • Assessment of growth and development

FIGURE 9–3This premature baby cannot yet coordinate suck and swallow. Gavage feeding is being used until the baby can effectively acquire nutrients. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Nutritional Needs: Term Newborn • Infants need minimum of 120 cal/kg/day to maintain weight and growth • 20 cal/oz is the usual calories found in formula • Feedings/day q3-4 hrs= 6-8 feedings/ day

Question… • How much formula would an infant who weighs 4.3 kg need at each feeding if they feed every 4 hours?

Answer…Let’s break it down • 1. Infant weight in kg is multiplied by 120 calories/ number of feedings per day • Baby weight= 4.3 kg • 2. Calories needed/day= 4.3 x 120 • Calories needed/day= 516 calories/ day • 3. calories needed per feeding= 516/6 • Calories needed per feeding= 86 • 4. ounces per feeding= calories needed per feed/number of calories per ounce of formula • 86/20= 4.3 ounces/ feeding

Breast and Formula Feedings • Breast milk: advantages include: • Excellent nutrition • Promotion of GI function • Fostering immune defense • lower incidence of OM’s, Type 2 Diabetes, and obesity • Psychological benefits • Economic advantage

Breast Feeding • Nursing role: • Includes education, and encouragement to foster breastfeeding • Help mothers to have positive experience w/ Breastfeeding • Encouragement • Lactation consultant/ group support

Contraindications to breastfeeding • Chemotherapy • Active untreated maternal TB • Maternal HIV/AIDS • Maternal primary herpes in the breast • Certain medications (chloramphenicol) • Use of alcohol and recreational drug abuse

FIGURE 9–4Breastfeeding offers many physical and emotional benefits for the infant. This new mother is learning to breastfeed her baby. How can nurses encourage mothers to have positive breastfeeding experiences? Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Formula Feeding Infants (newborn- 6 months) • Types of formulas • Ready to feed, powder, and concentrate (p 323, Table 9-7) • Specialized formulas for specific needs (PKU, allergies) • Nursing strategies • Education • Partent-infant relationship • Prevention of early childhood caries

Introducing solid foods • When is an infant ready to begin solid foods? • 4-6 months of age • Introduction of foods b/f or after this period increases risk of food allergies • Readiness for solid foods • Extrusion reflex, swallowing • Sitting skills • Interest

FIGURE 9–5The baby who has developed the ability to grasp with thumb and forefinger should receive some foods that can be held in the hand. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Infants age 6-12 monthsDevelopmental Readiness • Initial introduction of foods • Appropriate first foods: rice cereal • Weaning occurs at 12 months • Longer bottle feeding increases • Dental caries • Otitis media • allergies

General nutrient requirements of an infant • Introduction of whole milk at 1 year, and low-fat milk at 2 years • Fluoride supplements at 6 months if not in water • Iron enriched cereals should be started first • New foods added gradually • Introduce veggies b/f fruits • No honey b/f 1 year…infant botulism

FIGURE 9–6Early childhood caries. This child has had major tooth decay related to sleeping as an infant and toddler while sucking bottles of juice and milk. Courtesy of Dr. Lezley Mcllveen, Department of Dentistry, Children’s National Medical Center, Washington, DC. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Feeding 9-12 months • Finger foods • Peeled fruit • Cheese and soft cooked vegetables • Delay introduction of peanuts/ peanut butter until 1 year of age (unless h/o allergies in family, then 3 years of age) • No yolks until 8-10 months of age, or whole eggs until 1 year of age • Carbs and fats needed for energy and growth • Introduction of a cup (b/t 8-9 months)

Nutritional needs of the toddler • Remember developmental level • Goal is to gain control of bodily functions • Physiologic anorexia • Nutritional needs • Restrict fat to less than 30% of calories • Low fat milk (2%) • Adequate protein

FIGURE 9–7Toddlers should sit at a table or in a high chair to eat, to minimize chance of choking and to foster positive eating patterns. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Nutritional needs of the preschooler • Food jags (eating only a few foods for a few days of weeks) • Socialization (associative play) • Help with food preparations • Dental care • Meal and snack patterns • Nutritional requirements

FIGURE 9–8 Preschoolers learn food habits by eating with others. Engaging them in food preparation enhances knowledge of food and promotes intake at meals. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Nutritional needs of the school-age child • Appropriate food choices • School involvement • Growth spurts • Dental care

Nutritional needs of the adolescent • Growth rate • Calorie needs • Mineral and vitamin needs • Food choices

Nutritional assessment • Family history • Developmental history • Medical history • Physical examination of growth parameters • Height • Weight • Head circumference

Assessment of Growth • Measure using appropriate tools • Growth charts • Gender specific • Pre-term or specific medical conditions

FIGURE 9–10The nurse accurately measures the child and then places height and weight on appropriate growth grids for the child’s age and gender. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

FIGURE 9–11Growth chart with first few entries in same channel and then a change indicated. The growth for the child indicated on this chart remained steady and in the same channel (75th percentile) for some months. Then the weight measurement decreased to another channel. What kind of dietary assessment will you complete with the parents? What could be the possible causes? Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Nutritional assessment includes physical assessment and lab findings • H&H • Blood Chemistry • Lipid Profile • Renal and Liver function tests

Nutrition Assessment • Dietary intake • 24 hour food recall • 3 day food history • Genogram to recognize nutrtional risk (heart disease and hypertension)

Overweight and Obesity • Public health epidemic in US • Increasing incidence • Factors influencing obesity include: • Genetics • Psychological • Environmental (excessive TV, lack of exercise, % of calories from fat)

Obesity by the numbers • Childhood obesity has reached epidemic levels in developed countries. • Twenty five percent of children in the US are overweight and 11% are obese. About 70% of obese adolescents grow up to become obese adults • US children at risk for being overweight= 25% • Overweight + obese children in US= 15% • Increase in obesity since 1960= 300%

Overweight and Family History • When a child has one obese parent, chances of the child being overweight are increased by 220%. In families where both parents are overweight, the incidence of obesity in children increases by 320%. • Finally, the child who has obese parents, and is overweight as an adolescent has an 80% risk of being an obese adult

Definitions of Obesity and Overweight • The Center for Disease Control and Prevention defined overweight as at or above the 95th percentile of BMI for age and "at risk for overweight" as between 85th to 95th percentile of BMI for age.

Treatment of obesity • Medical treatment and referrals • Nutrition and behavioral counseling • Treat family • Focus on family environment • Nonjudgmental support • Focus on concern for health, not appearance

Treatment of obesity • Discourage food as a reward • Encourage healthy eating patterns • Family meals around table • Plan for small changes one at a time • Decrease sedentary behavior • Decrease tv time to 2 hrs/day

Specific Dietary Deficiencies • Calcium • Iron • Vitamin D: • Rickets • Folic acid: • Prevention of neural tube defects and cleft defects

PICA • Ingestion of nonfood substances or atypical ingestion of foods • Pregnant women and young children • Commonly ingested substances • Lead paint • Soil contaminated by lead based gas fumes • Strong association w/ anemia • Treatment

What is failure to thrive? • Organic vs Non-organic FTT: • Nonorganic, NOFTT; also called psychosocial failure to thrive • is defined as decelerated or arrested physical growth (height and weight measurements fall below the fifth percentile, or a downward change in growth across two major growth percentiles) associated with poor developmental and emotional functioning. Usually occurs in a child younger than 2 y.o w/ no known medical condition • Organic failure to thrive • occurs when there is an underlying medical cause.

FIGURE 9–14Infants with failure to thrive may not look severely malnourished, but they fall well below the expected weight and height norms for their age. This infant, who appears to be about 4 months old, is actually 8 months old. He has been hospitalized for feeding disorder of infancy. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

FTT Treatment • Based on individual child • Management: • Assessment and case findings • Infant/ child family hx • Paren (caregiver)- child interactions • Adult and feeding behaviors • Nursing Diagnoses • Planning and implementation • Monitor intake and growth patterns • Teach nutrition and feeding strategies • Observe feeding and parent-child interactions

Any ???s Special thanks to Lorraine Murphy for helping write and give this lecture

Child Health Nursing Partnering with Children & Families