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