Pediatric Nutrition and Obesity
Brenda Beckett, PA-C
Key Nutritional Conceptsin Children
Nutritional requirements Feeding patterns of infants and children Vitamin supplements Brief assessment of nutritional status Common feeding and nutritional
concerns
Influences on Nutrient Requirements
Rate of growth– Highest in early infancy
Body composition– Needs of the brain
Composition of new growth– Fat needs
Energy
Kilocalorie(or Calorie)- unit of heat measurement
Definition-amount of heat necessary to raise the temperature of one kilogram of water 1 degree
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
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
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
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
Protein Needs
Newborn– 2.5 g/kg/day
12 months– 1.5-2 g/kg/day
Adolescent– 1-1.5 g/kg/day
Fat Needs
Main dietary energy source for infants– 45-50% of calories
Required for :– Absorption of fat-soluble vitamins– Myelination of CNS– Brain development
Carbohydrate Needs
In the form of lactose for infants– 40 % of calorie intake
Converted to glucose, the principle fuel for the brain
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
Feeding PatternsBreast Milk
Advantages– Economical/convenient– Psychological/emotional bond– Easier to digest– Immunologic
• Allergy-protective• Infection preventive
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 …
Composition (calories: 20kcal/oz)
Product Protein Source CHO Source
Fat Source
Breast 40% casein
60% whey
lactose Human milk fat
Cow’s Milk 80% casein
20% whey
lactose butterfat
Milk-based formula
Nonfat cow’s milk lactose Coconut, soy oils
Soy-protein formula
Soy protein Corn syrup,
sucrose
Coconut, soy oils
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
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
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)
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)
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.
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
Some Foods to avoid in 1st year of life
Honey Eggs Seafood Peanuts Nuts
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
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
Supplemental Fluoride Recommendations
Concentration of Fluoride in Water <0.3 ppm
Age Supplemental Fluoride (mg/d)
6 mo to 3 yr 0.25
3-6 yr 0.5
6-12 yr 1.0
Assessment of Nutritional Status
Diet History– Quantity of foods– Quality of foods– Variety of foods
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.
Feeding Concerns
Constipation Spitting up Toddler feedings Deficiencies Excesses
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
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
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
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
Eating habits
Important to start early Patterns started in the 1st years often
continue Avoid mealtime stress Respect the child’s appetite
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
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
Malnutrition
Worldwide, a leading cause of mortality in children
Caused by either inadequate intake or inadequate absorption of food
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
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
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
Childhood Obesity
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
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
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
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
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
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
Factors contributing to obesity
Change in dietary intake-i.e. types of foods
Increase caloric intake Decrease in physical activity Increase in inactivity
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
Effects of obesity on major organ systems
Musculoskeletal Endocrine Gastrointestinal Respiratory Cardiovascular Reproductive Neurological
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
Create an alliance by asking focused questions
Instead of asking, “Why can’t you stop eating?”
Try instead, “Do you ever feel out of control while you are eating?”
Instead of asking, “Why do you eat out at restaurants 5 nights a week?’
Try instead, “What are some of the barriers you are encountering when you try to prepare a meal at home?”
Instead of asking…
“Why do you take you kids to fast food eateries for French fries and soda after school for a snack?”
Try instead….
Understanding the family
Economic limitations Social concerns Language issues Cultural norms Schedule issues
Family History
Obesity Hypertension High Cholesterol/Triglycerides Diabetes
Conditions associated with childhood obesity
Genetic Syndromes associated with childhood obesity (usually also have developmental delay and other sequelae)– Prader-Willi– Bardet-Biedl– Turner syndrome
Endocrine Disorders– Hypothyroidism– Cushing’s
Psychiatric Disorders– Eating disorders– Depression
Assessment of Childhood Obesity
Height, Weight plotted BMI-Body Mass Index
– Body weight (in kg) divided by the Height (in meters squared)
– Measured in units kg/m squared Triceps skin fold Compare these to norms in age group
BMI-Body Mass Index
Anthropometric index of weight and height A screening tool, not a diagnostic tool In children, BMI changes with age and
gender BMI is plotted on the appropriate chart for
gender, and is evaluated using specific cut off points compared to values of other children of the same gender and age
BMI
BMI can be used to track body size through life
BMI found to correlate with health risks CDC recommends use of BMI for age and
gender for age 2 and older Shape of BMI curve shows adiposity rebound
– Decline in BMI until age 4-6, and then increase– Reflects normal pattern of growth– Theory that early adiposity rebound may be
associated with adult obesity
Steps to plotting the BMI
Be careful to obtain accurate height and weight
Select BMI chart for gender and age Calculate BMI Plot measurement Interpret plotted measurement
Calculating the BMI
[Weight(kg)/ height(cm)/height(cm)] x10,000
[Weight(lb)/height(in)/height(in)]x703
Triceps skin fold
>85% obesity >95% severe obesity
Direct measure of subcutaneous fat. Variability by experience.
Genetic/Endocrine causes of obesity rare
Over 90% of obese children have no known genetic or endocrine cause for obesity
Many have positive family history of obesity
Complications of Childhood Obesity
Pseudotumor Cerebri Orthopedic Problems
– SCFE– Blount’s Disease
Sleep Apnea Gall Bladder Disease Type II Diabetes Mellitus Hyperlipidemia HTN Cardiovascular disease
Pseudotumor cerebri
Increased intracranial pressure with papilledema, and normal CSF without ventricular enlargement
Can present with headaches, vomiting, blurred vision
Fundoscopic exam on obese patients Diagnosis of exclusion-need to R/O all
other causes of increased ICP
SCFE-Slipped Capital Femoral Epiphysis
Hip motion is limited on abduction and internal rotation
Patient may present with a limp, or complain of groin, thigh or knee pain
Immediately suspect in obese patient with any abnormal gait
Diagnose with x-ray, often bilateral, so compare both
Blount’s Disease
Bowing of tibia and femur resulting from overgrowth of medial aspect of the proximal tibial metaphysis
2/3 of patient’s with Blount’s are obese
Sleep Apnea
Intermittent or prolonged obstruction of the upper airway during sleep
Disrupts normal ventilatory pattern in sleep, and normal sleeping patterns– Nighttime awakenings– Restless sleep– Difficulty awakening in the morning– Decreased concentration/poor school performance
Abnormal sleep patterns reported in many obese children
Sleep apnea (cont.)
Enlarged tonsils and adenoids Increased fat mass Increased muscle relaxation during
sleep
Sleep ApneaDiagnosis and Treatment
Sleep study
Weight loss Tonsillectomy/adenoidectomy CPAP
Gall Bladder Disease
More common in obese patients Among adolescents with cholecystitis,
50% are obese Symptoms-abdominal pain, tenderness Diagnosis-ultrasound
Hyperlipidemia
All obese patients, esp. adolescents need screening. Can screen younger.
Elevated LDL, Triglycerides, lowered HDL
Increases risk for cardiovascular disease
May improve with weight reduction
Glucose Intolerance/ DM II
Glucose intolerance precursor of diabetes
Acanthosis nigricans: increased skin pigmentation and thickness of skin between folds
Obesity contributes to insulin resistance, and resulting hyperglycemia
BMI assessment
95%ile for age/gender: obesity-in depth medical assessment (fasting glucose, insulin, liver profile, lipid profile)
85-95%ile for age/gender: at risk-evaluate carefully– Pay attention to secondary complications of obesity– Pay attention to family history– Lab tests/further medical assessment as indicated
Recent large changes in BMI– Evaluate and treat
BMI most reliable indicator. Correlates best with complications of childhood obesity
Evaluation for Treatment Child/family needs to be ready for change If not ready, and decrease child’s self esteem:
will make it difficult later to make improvements Ask patient and family
– How concerned are you?– Do you believe that weight loss is possible?– What do you think you could change?
Involves time commitment – Dietary and activity evaluation– Revisits
Treatment-Weight goals
Develop awareness in patient and family Consult with a dietician Identify problem behaviors
– High caloric foods– Eating patterns– Obstacles
Modify current behavior– What small changes can make a difference?
Continued awareness
Treatment-Weight Goals (cont.) Maintain baseline weight
– Modest changes in appearance– Initial success– Gradual decrease in BMI as child grows in
height Continue prolonged weight maintenance(if
no other medical symptoms) until BMI is below the 85%ile
If older than 7, and severely obese or has other associated medical symptoms, weight loss recommended– Weight loss of 0.5 kg/month– Goal to achieve a BMI <85%ile
Treatment-Weight Goals (cont.)
If weight loss is too rapid, risks of gall bladder disease, risk of malnutrition
Possibility decrease growth velocity Possible emotional problems
– Self-esteem issues– Eating disorders
Drugs for treatment of weight loss are not recommended in children
Weight loss surgery
Can be safe and effective for severely obese adolescents
Potential risks and long term complications
Effect on growth and development unknown
Need to change lifestyle, diet, exercise
Advice to parents to help children limit caloric intake
Praise you kids!!! Avoid using food as a reward Be a role model for your kids Establish meal and snack times Offer healthy choices Limit high calorie foods kept at home Avoid prepackaged and sugared foods Follow the food pyramid recommendations
using oils and fats sparingly, 3 servings of dairy, 2-3 servings of proteins, 5-8 portions fruits and veggies, 6-10 servings of grains
Diet(cont.)
Fad diets (ie. Atkins, South Beach, diet of the week)-The positives:– May “jump start” weight loss– 2 times the amount of weight loss – Parents are familiar with these diets
Fad diets-The negatives:– Hard to follow for child– Too restrictive– MAJOR risk of developing serious metabolic side
effects Not recommended by AAP
Diet(cont.)
Healthy food, healthy choices Portion control Allowing room for error
Treatment –Increased Physical Activity
Track all activity to see where improvements can be made– Vigorous activity– Activities of daily living
Track all sedentary activity– TV– Computer– Sitting down time
TV Viewing/Screen Time
AAP– Children <2 should not be exposed to TV at all– Children >2 should be limited to 2 hours max/day
HMS studied 1200 children– Every hour of additional TV viewing associated with
deficits in diet• Increased trans fats• Increased fast foods• Decreased healthy food choices
Other studies– Increased TV viewing directly correlated with
increased rate of obesity
Advice to Parents To Increase Child’s Activity Level
Limit screen time Incorporate activity into daily life Encourage participation in sports Encourage and provide opportunity for
outdoor play Establish regular family activities-walks,
bike rides, playing catch
Treatment-Medical Goals
Hypertension-decrease blood pressure, hopefully without medication
Reverse abnormal lipid profile Improve DM II
Treatment -Overall Intervene early-the risk of obesity increases
as age increases Back to basics: Increase activity level,
decrease caloric intake Family must change Provider educates families on medical
complications of obesity (HTN, abnl Lipid profile, DM II)
Involve all family members Small gradual changes Encourage NOT criticize
Why is it important to address the issue of childhood obesity with
your patients? Major public health concern, increasing at
alarming rates Early evaluation and treatment may help prevent
disease progression Help prevent associated health problems Though genetic and endocrine problems are rare
causes, need to consider these and evaluate Emphasizing healthy eating and exercise
promotes a healthy lifestyle that can have lasting effects.
5 – 2 – 1 – Almost None
5 servings fruits and vegetables No more than 2 hrs screen time / day 1 hour of activity per day Limit sugary drinks
