pediatric nutrition and obesity brenda beckett, pa-c

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Pediatric Nutrition and Obesity Brenda Beckett, PA-C

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Post on 25-Dec-2015




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  • Slide 1
  • Pediatric Nutrition and Obesity Brenda Beckett, PA-C
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  • Key Nutritional Concepts in Children Nutritional requirements Feeding patterns of infants and children Vitamin supplements Brief assessment of nutritional status Common feeding and nutritional concerns
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  • Influences on Nutrient Requirements Rate of growth Highest in early infancy Body composition Needs of the brain Composition of new growth Fat needs
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  • Energy Kilocalorie(or Calorie)- unit of heat measurement Definition-amount of heat necessary to raise the temperature of one kilogram of water 1 degree
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  • 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
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  • 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
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  • 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
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  • 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
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  • Protein Needs Newborn 2.5 g/kg/day 12 months 1.5-2 g/kg/day Adolescent 1-1.5 g/kg/day
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  • Fat Needs Main dietary energy source for infants 45-50% of calories Required for : Absorption of fat-soluble vitamins Myelination of CNS Brain development
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  • Carbohydrate Needs In the form of lactose for infants 40 % of calorie intake Converted to glucose, the principle fuel for the brain
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  • 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
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  • Feeding Patterns Breast Milk Advantages Economical/convenient Psychological/emotional bond Easier to digest Immunologic Allergy-protective Infection preventive
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  • Contraindications to Breast 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
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  • Composition (calories: 20kcal/oz) ProductProtein SourceCHO Source Fat Source Breast40% casein 60% whey lactoseHuman milk fat Cows Milk80% casein 20% whey lactosebutterfat Milk-based formula Nonfat cows milklactoseCoconut, soy oils Soy-protein formula Soy proteinCorn syrup, sucrose Coconut, soy oils
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  • 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
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  • 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
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  • Infant Feedings How much ? First 6 weeks q1-3h 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)
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  • 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)
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  • Im 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.
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  • 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
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  • Some Foods to avoid in 1 st year of life Honey Eggs Seafood Peanuts Nuts
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  • 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
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  • 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
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  • Supplemental Fluoride Recommendations Concentration of Fluoride in Water
  • Triceps skin fold >85% obesity >95% severe obesity Direct measure of subcutaneous fat. Variability by experience.
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  • 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
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  • Complications of Childhood Obesity Pseudotumor Cerebri Orthopedic Problems SCFE Blounts Disease Sleep Apnea Gall Bladder Disease Type II Diabetes Mellitus Hyperlipidemia HTN Cardiovascular disease
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  • 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
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  • 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
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  • Blounts Disease Bowing of tibia and femur resulting from overgrowth of medial aspect of the proximal tibial metaphysis 2/3 of patients with Blounts are obese
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  • 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
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  • Sleep apnea (cont.) Enlarged tonsils and adenoids Increased fat mass Increased muscle relaxation during sleep
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  • Sleep Apnea Diagnosis and Treatment Sleep study Weight loss Tonsillectomy/adenoidectomy CPAP
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  • Gall Bladder Disease More common in obese patients Among adolescents with cholecystitis, 50% are obese Symptoms-abdominal pain, tenderness Diagnosis-ultrasound
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  • 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
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  • 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
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  • 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
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  • Evaluation for Treatment Child/family needs to be ready for change If not ready, and decrease childs 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
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  • 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
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  • 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
  • TV Viewing/Screen Time AAP 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
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  • Advice to Parents To Increase Childs 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
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  • Treatment-Medical Goals Hypertension-decrease blood pressure, hopefully without medication Reverse abnormal lipid profile Improve DM II
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  • 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
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  • 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.
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  • 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
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