Nutrition Management in Children with Special Health Care Needs (CSHCN) Jackie Maurer MS, RD

Children with Special Health Care Needs (CSHCN) Introduction Children with Special Health Care Needs (CSHCN) Definition: Children with congenital or acquired conditions affecting physical/cognitive growth and development and who require more than the usual pediatric health care; also refers to children who have developmental disabilities, chronic conditions, or health related problems as well as those who are at risk for these conditions (JADA. 1995;95:809)

Introduction Nutrition Intervention Critical aspect Interdisciplinary Preventive and therapeutic Family centered Community based Culturally competent

Objectives Understand basic measures of growth & development Acquire fundamental skills in global assessment techniques Appreciate general medical nutrition therapy for lung diseases Experience oral supplements that promote nutrition status

GROWTH & DEVELOPMENT Weight Growth chart Technique Primary indicator for over-/under- nutrition Growth chart Reflects growth pattern Technique Needs to be consistent and accurate (ie no shoes, no diapers)

GROWTH & DEVELOPMENT Height Technique: Has slower response to nutrition changes May indicate chronic under-nutrition if measurements continually trend down Technique: 0-36 months - Recumbent length 2-20 years - Standing height

GROWTH & DEVELOPMENT Head Circumference Last indicator to be affected by undernutrition < 3 yr old Possible nutritional insult with downtrends, accompanied by decreases in weight and height > 3 yr old Decreases are generally not nutrition-related FOR MORE INFO... See CDC web site, http://www.cdc.gov/growthcharts, to download charts.

ASSESSMENT SKILLS Subjective Global Assessment (SGA) Nutrition History Simple technique for assessing nutritional status Evaluates body fat and muscle stores Involves visual review of physical body May be applied by any healthcare worker Nutrition History Interview reveals dietary habits Quick tool for assessing one’s ability to meet, fail, or exceed nutritional needs

SGA METHOD Muscle Stores Fat Stores Temple Eye fat pad Clavicle Shoulder Scapula Upper joint area Interosseus area Fat Stores Eye fat pad Cheek pad Tricep pinch REFERENCE: Detsky, A, et al. Journal of Enteral and Parenteral Nutrition. 11:8, Jan/Feb, 1987.

http://www.eneph.com/feature_archive/nutrition/v25n4p190.html

DIET HISTORY METHOD What is the home life/meal pattern? How much is consumed? Food allergies or intolerances? Who is present at mealtimes? Is the child interested in eating? Any problems with chewing or swallowing? Gagging or choking? Are there any foods or textures that the child has difficulty with? Does the child eat non-foods ? Any weight change perceived? What religious or cultural backgrounds are present?

ASTHMA & NUTRITION Malnutrition of excess Cycle of inactivity Steroid induced Potential food allergy triggers Nutrient Medication Interactions

ASTHMA & NUTRITION General guidelines 1. No skipping meals (Eat min 3 x day) 2. Maintain a “normal”, balanced diet and choose sensible portions 3. Lose weight, if needed 4. Avoid excessive salt, fat, sweets 5. Increase dairy or supplements 6. Exercise daily

ASTHMA & EXERCISE Tips 20 minutes total 3 times per week Check local pollen, mold, spore levels. Lengthen the time between breaks while conditioning occurs. Wear scarves over mouth and nose in winter to keep heat & moisture in lungs. Warm-up to lessen chances of EIB. Do pursed lip breathing when medication is not readily available. 20 minutes total 3 times per week Aerobic activity Avoid asthma triggers May lessen Exercise Induced Asthma (EIB)

ASTHMA & FOOD ALLERGIES Food allergies - usually NOT common trigger Occurs in <5% of asthmatics Difficult to diagnose Skin tests, Blood test (RAST) Food diary, elimination diet Symptoms hives, itching, eczema, sneezing, coughing, swelling of throat, nasal stuffiness, vomiting, diarrhea, cramping, collapse and sometimes death

POTENTIAL FOOD ALLERGENS Milk and dairy products No link to increased mucus production or bronchoconstriction Wheat Soy Eggs Peanuts Tree nuts Fish and shellfish Chocolate Corn Tomatoes Citrus fruits Other grains Beef Chicken Sulfite-containing

ASTHMA & FOOD AIDS? Conflicting evidence that foods can prevent asthma Of three scientific papers on asthma & omega-3 fatty acids: 1 showed favorable results 1 showed no results 1 showed negative results w/ worse asthma

BPD: Bronchopulmonary Dysplasia Nutrition Concerns ?Prenatal undernutrition, premature growth issues Increased caloric intake to maintain normal or catch-up growth Suboptimal intake due to increased effort of breathing during eating and appetite suppressing medications Delayed development of oral feeding skills

BPD & NUTRITION 1. Concentrate infant formula Nutrition Therapy 2. Initiate adjuvant nutrition via enteral route as indicated 3. Assess feeding skills 4. Occupational therapy/feeding specialist referral

BPD & FEEDING SKILLS Feeding Assessment Responses to tactile input irritability, frenzy, drowsy, staring, silent cry Feeding position Oral motor control tongue retraction/protrusion, jaw excursion Physiologic control heart rate Sucking, swallowing, breathing Caregiver/infant feeding interactions

CYSTIC FIBROSIS & NUTRITION Multifactorial risks for malnutrition Intake Decreased appetite Decreased volume consumed Physical/mechanical/mental inability to meet nutritional needs orally Output Increased energy output to meet cost of breathing and coughing, higher during pulmonary exacerbations. Malabsorption

CF & NUTRITION Basic Nutrition Guidelines Oral Supplementation 1. High calorie diet (moderate fat) 2. Snacks 2-3 times/day 3. Salt repletion, especially with sweating 4. Pancreatic enzymes Fat soluble vitamins in water miscible form (ADEK) Oral Supplementation Calorically dense Sample tasting

Childhood Obesity 1980 and 1994, children and adolescents considered to be overweight (BMI-for-age > 95th percentile) increased by 100% in the United States. Thirteen percent of children age 6-11 and 14 percent of adolescents age 12-19 are estimated to be overweight

Childhood Obesity DEFINITION: BMI Percentiles (2 to 20 y.o.) 85-95th %ile = at risk >95th%ile Overweight Associated risks: Hyperlipidemia, glucose intolerance, hepatic steatosis, cholelithiasis, early maturation. hypertension, sleep apnea

CDC.org

Childhood Obesity - Factors Familial influence Fat parent = fat child Model: eating & activity Physical Inactivity TV Cuts in PE class Heredity Fatness regional fat distribution response to overfeeding

Childhood Obesity - Management CDC.org

Childhood Obesity – Treatment Physical Activity Diet Management Controlled weight gain Behavior Modification

Dietary Management Focus on energy dense, whole foods Limit sugar packed drinks and snacks Watch portion sizes Over Choose

Thank You! Questions?