looking at special dietary needs through different eyes loriann knapton, dtr, sns, nutrition program...
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Looking at Special Dietary Needs Through Different Eyes
Loriann Knapton, DTR, SNS, Nutrition Program Consultant
November 4, 2008
Learning about the nature and severity of
the child’s special dietary needs and
working together to provide what’s best for
the childshould be the major
focus.
Children with a Disability
Schools must make substitutions of foods in the reimbursable meal for students who have a disability that restricts their diet.
What are Disabilities?
Disability is defined in : Section 504 of the Rehabilitation Act of 1973 Americans with Disabilities Act of 1990 Part B of the Individuals with Disabilities
Education Act (IDEA) Individual Education Plan (IEP)
Explanation of these disabilities found on pages 3-5 of the USDA guidance Accommodating Children with Special Dietary Needs in the School Nutrition ProgramsWebsite link to USDA guidance: http://fns.dpi.wi.gov/fns_market1
Food Related Disabilities
Some that require menu modifications:
Severe Food Allergies (Food Anaphylaxis)
Metabolic Diseases such as Diabetes, Celiac Disease (Gluten-free Diet) and Phenylketonuria (PKU)
Prescribed diet for child with autism (one of the thirteen disability categories recognized in the Individuals with Disabilities Act)
Disability
Accommodation MUST be made, based on a completed physician’s statement
No extra charge
A disability determination can only be made by a licensed physician
Statement for Children with Disabilities
What must the physician’s statement include?
What the disability is How it restricts diet Major life activity affected Foods to be omitted Foods to be substituted
Physician’s Form (for documentation)http://fns.dpi.wi.gov/files/fns/doc/
spec_diet_restrict.doc
Eating and Feeding Evaluation: Children with Special Needs FIGURE 1: .PART A Student’s Name
Age
Name of School
Grade Level Classroom
Does the child have a disability? If Yes, describe the major life activities affected by the disability. Does the child have special nutritional or feeding needs? If Yes, complete Part B of this form and have it signed by a licensed physician.
Yes Yes
No No
If the child is not disabled, does the child have special nutritional or feeding needs? If Yes, complete Part B of this form and have it signed by a recognized medical authority.
Yes No
If the child does not require special meals, the parent can sign at the bottom and return the form to the school food service. PART B
List any dietary restrictions or special diet. List any allergies or food intolerances to avoid. List foods to be substituted. List foods that need the following change in texture. If all foods need to be prepared in this manner, indicate “All.” Cut up or chopped into bite size pieces: Finely ground: Pureed: List any special equipment or utensils that are needed. Indicate any other comments about the child’s eating or feeding patterns. Parent’s Signature Parent’s Printed Name and Phone Number
Date:
Physician or Medical Authority’s Signature Physician or Medical Authority’s Printed Name and Phone Number
Date:
Under no circumstances are
school food service staff to
revise or change a diet prescription or medical order.
Documentation
The diet orders do not need to be renewed on a yearly basis; however, schools are encouraged to ensure that the diet orders reflect the current dietary needs of the child.
Medical Requests for Children with Special Dietary Needs(not considered a disability)
The school food service may make food substitutions, at their discretion, for individual children who do not have a disability, but who are medically certified as having a special medical or dietary need.
Examples include: Lactose intolerance Food intolerances or allergies where there is
not the concern of a life-threatening reaction
Not to be confused with….
Fluid Milk Substitutions in the School Nutrition Programs(Final Rule published September 12, 2008)
Current requirements on meal variations for students with disabilities and for students with medical or other special dietary needs remain unchanged.
Offering fluid milk substitutes to students under this ruling is totally at the School Food Authority’s (SFAs) discretion.
Nondairy beverages offered as fluid milk substitute be nutritionally equivalent to fluid milk and provide specific levels of calcium, protein, vitamins A and D, magnesium, phosphorus, potassium, riboflavin and vitamin B-12.
Website: fns.dpi.wi.gov/fns_regs
Goals of the Child Nutrition Program for Students with Special Dietary Needs
Meet the nutritional needs, as specified by the United States Department of Agriculture (USDA) meal pattern requirements and the child’s personalized diet plan.
Prepare the food items exactly as the diet order specifies, including texture and consistency of the item. If the diet plan is unclear, contact the medical authority involved in prescribing the diet plan for further clarification.
Ensure food safety.
Goals of the Child Nutrition Program for Students with Special Dietary Needs
(continued)
Be knowledgeable of the policies and procedures in place for the district/site as they pertain to children with identified special dietary needs and the role of food service personnel in the case of a medical emergency.
Give appropriate feedback to the multidisciplinary team whenever applicable.
90% of foods causing food allergies
Cow’s milk
Egg
Soybeans
Wheat
Peanut/tree nut
Fish/shellfish
Celiac Disease
Celiac Disease: An autoimmune disorder in which the body attacks itself.
Permanent sensitivity to gluten, a protein found in wheat, rye, & barley
Eating food containing gluten damages the villi (lining of the small intestine), which results in mal-absorption of nutrients
Gluten Free diet for life is only treatment
Gluten Containing Grains Barley Barley malt, extract, flavoring Bran Bulgur Couscous Durum Einkorn Emmer Farina Faro Flour Graham flour, graham
crackers Kamut Matzo flour, meal Malt, malt flavorings
Orzo Panko Rye Seitan Semolina Spelt Triticale Udon Untested Oats Wheat berry Wheat bran Wheat germ Wheat germ oil Wheat gluten Wheat starch
Hidden sources of gluten Bouillon Breading Broth Brown Rice syrup Coating mix Communion wafers Croutons Candy Imitation Bacon/seafood Luncheon Meats Marinades, thickeners Modified food starch Processed cheese
Roux Sauces Seasoning packets/mixes Self-basting poultry Soup base Soy sauce Stuffing Herbal Supplements Vitamin & mineral
supplement Over the counter/prescription
medications Lip-gloss, balms, lipstick Play dough
Questionable ingredients Carmel color – if made in US product is safe. Food label will
confirm derivation of product.
Flavorings – gluten containing grains rarely used. Mostly derived from corn; exceptions include barley malt flavorings, is usually listed on the label and flavorings in meat products
Dextrin – may be derived from arrowroot, corn, potato, rice,
tapioca, sago or wheat
Modified food starch – may be derived from corn, potato, tapioca, wheat or other starches. No requirement for the identification of plant source.
Starch – FDA regulations start “ starch” implies cornstarch; if
alternative starch is used it must be listed i.e.. Wheat starch
Gluten Free Diet
Any of the following words on food labels usually means that a grain containing gluten has been
used:
Stabilizer Hydrolyzed Vegetable ProteinStarch Flour or Cereal ProductsFlavoring Vegetable ProteinEmulsifier Malt or Malt FlavoringFood StarchModified Starch or Modified Vegetable Gum
Gluten-Free Grains Acorn Cottonseed Quinoa Almond Dal Red rice Amaranth Dasheen flour Rice, rice bran, rice flour Arborio rice Enriched rice Risotto Aromatic rice Fava bean Sago Arrowroot Flaxseed Sesame Basmati rice Garbanzo Sorghum Brown rice, Brown rice flour Glutinous rice Soy,soybean,tofu Buckwheat Hominy Starch (made from corn or
rice) Calrose Instant rice Sunflower see Canola Job’s tears Sweet rice flour Cassava Millet Tapioca Chestnut Modified corn starch Taro flour Chickpea Modified tapioca starch Teff Corn, corn flour, Peanut flour Wild rice Corn gluten, Potato flour Corn Malt, cornmeal Potato starch flour Cornstarch
Gluten Free School MenuExample Chicken fajitas (prepared from fresh
boneless chicken breast meat and gluten free seasoning) served with corn tortillas/green peppers/onions/salsa/sour cream
Steamed brown/white rice Steamed broccoli cuts Fresh fruit choice Milk (unflavored)
Gluten Free School MenuExample Cheeseburger Made with 100% lean
ground beef and block cheddar cheese (not processed)/gluten free bun
Oven fries prepared from fresh potatoes or gluten free French fries.
Steamed green beans Chilled Peaches Flourless Peanut butter cookie Milk (unflavored)
Gluten Free Peanut Butter Cookie1 cup creamy peanut butter or Almond Butter1 cup white sugar1 large eggSugar for rolling.
Combine all ingredients. Take 1 teaspoon of dough,form into a ball and roll in sugar. Place ball on bakingsheet and flatten with a fork. Bake cookies at 350degrees for 8 minutes.
Watch carefully when baking as they over bake and burn easily.
Yield: 1 dozen small cookies
Must utilize appropriate preparation methods to avoid cross
contamination.
Gluten and Casein Free Dietsometimes prescribed for children with Autism (recognized disability)
Acceptable foods Rice, potato, and
soy products Milks Flours
Fresh fruits, vegetables, meats
Arrowroot Nuts Beans Tapioca
Casein
Food sources Typical dairy foods – milk, butter,
cheese, yogurt Milk solids (curds) and whey Sodium caseinate – ingredient in
some processed foods “Natural ingredients” – may contain
dairy products
Gluten and Casein Free Diet Foods to avoid
Milk and milk derived products Wheat, barley, oats, rye, and buckwheat
flours and products “Natural ingredient” foods “Hydrolyzed vegetable protein” Carmel coloring – may contain gluten Vinegars – check label for food source Chocolates
Diabetic Requests
Supervision of menus/meals: how many carbs are served?
What steps are taken if child doesn’t take/eat planned items: Other selections or substitutions
Menu available for review; notify parents/nurse if there are changes
Phenylketonuria (PKU) Phenylketonuria, or PKU for short, is an
inherited, genetic condition in which the body can’t process phenylalanine (Phe), an amino acid found in many foods.
Too much Phenylalanine is toxic to the
brain. High Phe levels over an extended period of time can lead to vomiting, irritability, eczema, seizures, psychological and behavioral issues, and severe mental retardation.
PKU Diet Phenylalanine is found in:
All protein-containing foods (eg, meat, eggs, dairy, nuts)
Many other foods that are not
generally thought of as containing protein (eg, most wheat products, such as pasta and bread, and some fruit, such as oranges and cherries).
PKU MenuExample
When dealing with special dietary needs remember to…. Work with the team: Parents, doctors,
school nurse, teachers, administrators, school foodservice staff
Keep the lines of communication open Look through the eyes of your
customer…
A Child who just wants to be like everyone else.
RESOURCES Diabetes
The American Diabetes Association: http://www.diabetes.org
Gluten Free diets Celiac Sprue Association: http://www.csaceliacs.org
Phenylketonuria PKU support:
http://www.pku.com
Autism Autism Society of America:
http://www.autism-society.org
Food Allergies The Food Allergy and Anaphylaxis Network:
http://www.foodallergy.org