Nutrition Beyond Infancy Christopher Lever MD

Objectives Obtain a complete nutritional history for children older than 12 months. Appreciate typical feeding concerns of parents for children at different ages. List some of the negative health consequences of inadequate nutrition in pediatrics. Have an approach to dietary and feeding problems in children and adolescents.

Cases Obesity Iron deficiency Vitamin D deficiency

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Picky eating three-year-old

Vitamin D Rickets. Role in cell growth, immunity, asthma, dental caries, autoimmune disease, diabetes, cancer pathogenesis, and resistance to tuberculosis. Osteoporosis may not technically exist in pediatrics, but vitamin D deficiency and poor weight-bearing exercise contribute to decreased peak bone density.

What is a healthy diet? Canada Food Guide is a wonderful starting point. Recognize that children have different nutritional needs.

What is a healthy diet? Canada Food Guide is a wonderful starting point. Recognize that children have different nutritional needs.

Is it hard to get a healthy diet? Fruit and vegetable intake is consistently low to all age groups. Sugar and fat intake are above nutritionally necessary levels in population surveys. Multivitamins, “meal replacements” and vegetable drink substitutes are widely popularized.

Where do the problems start? Food serves multiple purposes. Food is nutritionally necessary. Food is also a comfort and enjoyable. Food is also part of a relationship between people.

Why do we eat what we eat? Calories and building blocks for growth. Texture and flavor. Satiety.. Sociability.

Vulnerable parents All parents are somewhat vulnerable. Children have a changing growth profile. See next slide. Feeding cues are misread. The tired or upset child will frequently feed, but was not necessarily hungry. There is a culture of eating more food secures better health.

Food behaviors are established by six months of age Birthweight triples in the first 12 months but does not quadruple until 24 months. Growth velocity slows noticeably after twelve months. Gastrointestinal absorption improves with gut maturity. “Baby” fat stores are used up; ribs should be visible at three years of age.

Psychology of food Parents present with concerns about intake or quality in the diet, but failed to recognize their negative influence in feeding behavior. Examples include picky eating, failure to thrive, baby bottle tooth decay, iron deficiency anemia in younger children.

Obtaining a nutritional history Identify parent concern. Obtain specific information about serving size and food groups. Get specific information about where and how the child is fed. Ask about difficulties with certain textures. Identify associations with feeding. For example: video time, desert bribery, and the a la cart menu.

Toddler and preschooler Juice intake. Milk intake. Bottle use. Food neophobia. Portion size, snack size. Distractions during mealtime.

Child Juice and pop intake. Milk intake. Constituents of the school lunch. Eating in front of the TV.

Adolescent Pop intake. Eating outside the home. Eating with family. Dieting. Dietary supplements or meal replacement. Milk intake. High carbohydrate consumption.

Nutritional advice Recognize the parents role in feeding. Set proper expectations for the child or adolescent. Recognize the societal influence on nutrition. Recognize the cultural influence on nutrition.

The Golden Rule Children will always eat. They are capable of regulating their food intake. They generally react negatively to new foods, but will usually accept them with time and experience. Parents can either support or disrupt children’s food acceptance and food regulation.

Simplified Parents decide what food is available, when to eat, and where to eat. Children decide how much (or little) they will eat.

Caveats 1 Encourage parents to set the example: buy nutritious food, prepare nutritious food, and eat nutritious food. Discourage distraction such as television during mealtime. Be reasonable about quantity of all food types presented at a meal (too large or too small). Expect food neophobia. Continue to offer new things repeatedly and they will be accepted.

Caveats 2 Multivitamins are not required for a balanced diet. Try to avoid using the term “diet”. Refer to healthy lifestyle and nutrition. Be cautious about children who are small. Feeding them more does not necessarily make them healthier.

Summary Obtain a good dietary history. Appreciate typical feeding concerns in children. Recognize that obesity, dental carries, iron deficiency, and vitamin D deficiency are commonplace. Be able to offer advice to parents that promotes healthy eating.