9/21/2012 University of New Mexico * Department of Pediatrics * Envision New Mexico 1

 NEW To connect audio, please telephone (no access code needed)  Please mute/un-mute your telephone line by pressing *#. You may also press your mute button on your headset or speakerphone during the webinar when you are not speaking.  Do not place your phone on hold.  If you wish to receive CME/CEU/ or an attendance certificate, you must announce your name when we ask who is participating both at the start and at the end of the session.  If you are called on and do not wish to answer, feel free to say “pass”. 10/19/ University of New Mexico * Department of Pediatrics * Envision New Mexico

Disclosure:Accreditation:  UNM CME policy, in compliance with the ACCME Standards of Commercial Support, requires that anyone who is in a position to control the content of an activity disclose all relevant financial relationships they have had within the last 12 months with a commercial interest related to the content of this activity.  The presenter discloses that he/she/they have no relevant financial relationships with any commercial interest.  The University of New Mexico School of Medicine, Office of Continuing Medical Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.  The Office of Continuing Medical Education designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.  Envision NM is a division of the UNM Department of Pediatrics and receives funding from the NM Department of Health and the NM Human Services Department. 9/21/2012 University of New Mexico * Department of Pediatrics * Envision New Mexico 3

Kirsten Bennett MS, RD, LD Envision New Mexico Pediatric Nutrition Telehealth November 2, /02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

11/02/2012 University of New Mexico * Department of Pediatrics * Envision New Mexico 5

 What common developmental and behavioral milestones and observations impact nutritional status of toddlers?  When working with the parents of toddlers, what questions do they ask regarding eating and growth?  What strategies have you found helpful in working with this age group? 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 One of the most common behavioral issues brought to primary health care providers by parents (Davies et al.)  25-45% estimated for preschool-age  Up to 80% in children with developmental delay or disability (Davies et al.)  Feeding concerns include:  Food refusal  Disruptive meal time behavior  Rigid food preferences  Less than optimal growth  Failure to master self-feeding consistent with developmental level 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Is the parent or provider observing a “feeding problem” or “developmental variation”  What strategies that can be employed in the primary care setting for typically developing children and those with developmental delay or disability? 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

A. Anthropometrics B. Biochemical C. Clinical D. Dietary E. Environment F. Feeding skills/development G. Growth pattern 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 What distinguishes toddler growth when compared to infants and school-aged children?  Faster? Slower?  See handout “weight gain tables”  How do estimated nutrient needs compare to other stages of pediatric development? 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 months  WHO (REE) 56 kcal/kg/day  DRI 82 kcal/kg/day  Protein  1.05 g/kg/day DRI  3 years  WHO (REE) 64 kcal/kg/day  DRI 85 kcal/kg/day  Protein  1.05 g/kg/day DRI  4 years  WHO (REE) 47 kcal/kg/day  DRI 70 kcal/kg/day  Protein  0.95 g/kg/day DRI 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Concerns about feeding/eating behavior tend to be classified as existing solely within the child.  Children are part of a family and community.  Feeding disturbances for the most part are related to physical and psychosocial development in the context of the characteristics of the family. 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Infants up to age 6 months  Parents are responsible for what infants are offered; infants are responsible for how much they eat and everything else about eating  Cueing caregivers about hunger and satiety  6 months to 2 years  Maintain the above philosophy as the transition to semi-solid food and self-feeding occurs and the child “arrives” at the family table within the context of the child’s individual development 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 After the child participates in family meals with the meals-plus-snacks routine:  Parents are responsible for providing appropriate food at appropriate times in appropriate quantities (the “what”, “when”, and “where”)  Children remain responsible for whether they eat or not and how much 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Clara Marie Davis: “The self-selection of diets by young children” (Strauss,S)  Study of 15 children for up to 4 ½ years  “eating experiment” orphanage in Montreal  Infants/children allowed to choose how much or how little to eat of 33 available foods  Result of trend in pediatrics to “prescribe” diets that children then refused to eat making the mothers frantic 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 In 1939, based on her experiment, pediatricians began to alter the “prescriptive’ approach to infant feeding  Children in the experiment were all healthy and grew appropriately  The “trick” was offering foods considered to be healthy and nutritious  Data not available for current analysis  After her death in 1959 and before 2000, the records of the experiment were thrown away.  When she presented her work, she did not present any breakdown of the data (charts, tables, or analysis of intake) 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 “Problems”  Behavioral manifestations that are serious enough to disrupt the child’s functioning with peers, in school, and/or in the family  May result in nutritional, medical, or growth concerns (Davis et al.)  “Developmental Variations”  Behaviors that parents may raise as a concern with their primary care provider, but that are within the range of expected behaviors for the age of the child and stage of development  Keep in mind the developmental progress of delayed children (expectations) should match developmental stage and not age of the child  Overall health and development is not compromised 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Infants  Distracted feeding at the breast  Infant wants to see what is going on  Preference for a particular position or nipple for bottle feeding  Varying quantities of intake (self-regulation)  Toddlers  “food jags”  Differing quantities of food each day  neophobia  School-age children  Refusal of food once eaten secondary to “peer pressure” 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

11/02/2012 University of New Mexico * Department of Pediatrics * Envision New Mexico 19

 Food preferences are allowed!  Taste is complex  Smell (odor)  Sight (visual appeal)  Touch (texture)  Categories of describing food  Salty (salts), sour (acids), sweet (sugar and proteins), bitter, savory 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

11/02/2012 University of New Mexico * Department of Pediatrics * Envision New Mexico 21

 Strengthening the feeding relationship  Define roles of parent and child  Be creative with food choices  Where can we get the nutrients of concern within the child and parents’ comfort zone?  Stop the food fights !  Empower parents/caregivers to adhere to their role  Timing of meals and snacks (3 meals/3 snacks)  Meals and snacks in prearranged locations  Decreased distraction  Offer healthy, nutrient-dense foods  “gate keeper” approach  Educate on appropriate expectations for intake  Quantity  Self-feeding  Communication of hunger/thirst 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

11/02/2012 University of New Mexico * Department of Pediatrics * Envision New Mexico 23

 Nutrient quality  Offer 3-4 healthy food items at meals and 2-3 at snacks  Portions should be child-sized  Allow children to serve themselves if possible.  Rule of thumb: 1 Tablespoon of each food for each year of age  Hand size: 1 serving is what will fit into the palm of the hand (as we get older our portion sizes increase – to a point!)  Milk/dairy servings are 2-8 oz. depending on the age of the child  Incorporate variety  Involve the child in food preparation and meal readiness 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Get an idea of the core foods a child likes  Get an idea of how much the child likes these foods (magnitude)  These pieces of information may offer clues about how to introduce new foods that have a higher probability of being accepted  Offer foods the child does like with the new foods being presented  Offer the new food times  Model eating the new food  Be sensitive to temperature, smell and texture 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Offer developmentally appropriate finger foods  Allow the child to hold a spoon while being fed and try to feed herself  Get Messy!  Learning to eat neatly is a life-long quest  Bibs, old shirts, “disaster mats” under chairs  Some children eat better when they feed themselves 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Meal times for young children may be short – 10 minutes or so  Have the food ready before calling everyone to dinner  Restaurant meals can be frustrating for families  Allow the child to be excused when he or she is done 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 9-month-old girl  Lindsey; 24-month-old girl  Sabrina; 21 month old with seizure disorder  2-year-old girl  18-month-old boy  Chrissy ; 22 month female 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Assess the growth and development of the child  Children who are meeting expectations are likely doing well  Determine if the feeding concern is a “Problem” or “Developmental Variation”  Assess the “Feeding Relationship”  Refer if necessary 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Allen R, Myers A. Nutrition in Toddlers. Am Fam Physician 2006; 74;  Brown J, ed. Nutrition Through the Lifecycle, 2nd edition Wadsworth Publishing  Davies W, Berlin K, Sato A, Fischer E, Arvedson J, Satter E, Silverman A, Rudolph C. Reconceptualizing Feeding and Feeding Disorders in Interpersonal Context: The case for a Relational Disorder. Journal of Family Psychology, 2006; 20;  Morin K. Parental Style of Infant and Child Feeding: How Influential Is It?. Maternal and Child Nutrition. 2006; 31; /02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 Sass C. Yummy! Yucky! Icky! Tasty! Know What Your Clients Like (and Hate) to Eat. ADA Times 2007;4:  Satter, E. Child of Mine, Feeding with love and good sense Bull Publishing, Palo Alto, CA.  Strauss S. Clara M. Davis, The wisdom of letting children choose their own diets. CMAJ 2006: 175;  Wansink B. Nutritional Gatekeepers and the 72% Solution. J Am Diet Assoc 2006;106;  Zero to Three available at accessed 2/23/2007www.zerotothree.org 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

 If you wish to receive CME/CEU/ or an attendance certificate, please tell us your name.  Please un-mute your telephone line by pressing *6. 11/02/ University of New Mexico * Department of Pediatrics * Envision New Mexico

Envision New Mexico Staff Directory Telephone www.EnvisionNM.org Jane McGrath, MD, FAAP Program Director Kris Carrillo, LISW Program Operations Director Dan Rifkin, MD Child and Adolescent Psychiatrist 9/21/ University of New Mexico * Department of Pediatrics * Envision New Mexico Kirsten Bennett, MS, RD, LD QI Training, Consultation and Outreach Terri Chauvet Administrative Assistant III Carole Conley, LMSW QI Training, Consultation and Outreach Paula LeSueur, CFNP CHIPRA Manager Kristine Lucero Accountant II Fauzia Malik, MPAS QI Training, Consultation and Outreach John Martinez QI Training, Consultation and Outreach Carolyn Salazar, RN QI Training, Consultation and Outreach Janette Schluter Program Data Specialist McKane Sharff CHIPRA Program QI Specialist Jeanene Sisk Administrative Assistant II Clancey Tarbox Program Coordinator Kevin Werling Systems Analyst ll Michelle Widener Data Analyst Nancy Vandenberg CHIPRA Program Youth Specialist

Thank you 34