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

2.  NEW To connect audio, please telephone 1-800-866-260-9581 (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”. 10/19/2012 2 University of New Mexico * Department of Pediatrics * Envision New Mexico

3. 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

4. Kirsten Bennett MS, RD, LD Envision New Mexico Pediatric Nutrition Telehealth November 2, 2012 11/02/2012 4 University of New Mexico * Department of Pediatrics * Envision New Mexico

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6.  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? 11/02/2012 6 University of New Mexico * Department of Pediatrics * Envision New Mexico

7.  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 11/02/2012 7 University of New Mexico * Department of Pediatrics * Envision New Mexico

8.  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? 11/02/2012 8 University of New Mexico * Department of Pediatrics * Envision New Mexico

9. A. Anthropometrics B. Biochemical C. Clinical D. Dietary E. Environment F. Feeding skills/development G. Growth pattern 11/02/2012 9 University of New Mexico * Department of Pediatrics * Envision New Mexico

10.  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? 11/02/2012 10 University of New Mexico * Department of Pediatrics * Envision New Mexico

11.  13-35 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 11/02/2012 11 University of New Mexico * Department of Pediatrics * Envision New Mexico

12.  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. 11/02/2012 12 University of New Mexico * Department of Pediatrics * Envision New Mexico

13.  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 11/02/2012 13 University of New Mexico * Department of Pediatrics * Envision New Mexico

14.  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 11/02/2012 14 University of New Mexico * Department of Pediatrics * Envision New Mexico

15.  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 11/02/2012 15 University of New Mexico * Department of Pediatrics * Envision New Mexico

16.  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) 11/02/2012 16 University of New Mexico * Department of Pediatrics * Envision New Mexico

17.  “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 11/02/2012 17 University of New Mexico * Department of Pediatrics * Envision New Mexico

18.  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” 11/02/2012 18 University of New Mexico * Department of Pediatrics * Envision New Mexico

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20.  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 11/02/2012 20 University of New Mexico * Department of Pediatrics * Envision New Mexico

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22.  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 11/02/2012 22 University of New Mexico * Department of Pediatrics * Envision New Mexico

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24.  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 11/02/2012 24 University of New Mexico * Department of Pediatrics * Envision New Mexico

25.  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 10-15 times  Model eating the new food  Be sensitive to temperature, smell and texture 11/02/2012 25 University of New Mexico * Department of Pediatrics * Envision New Mexico

26.  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 11/02/2012 26 University of New Mexico * Department of Pediatrics * Envision New Mexico

27.  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 11/02/2012 27 University of New Mexico * Department of Pediatrics * Envision New Mexico

28.  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 11/02/2012 28 University of New Mexico * Department of Pediatrics * Envision New Mexico

29.  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 11/02/2012 29 University of New Mexico * Department of Pediatrics * Envision New Mexico

30.  Allen R, Myers A. Nutrition in Toddlers. Am Fam Physician 2006; 74;1527-34.  Brown J, ed. Nutrition Through the Lifecycle, 2nd edition. 2005 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; 409-417  Morin K. Parental Style of Infant and Child Feeding: How Influential Is It?. Maternal and Child Nutrition. 2006; 31; 388 11/02/2012 30 University of New Mexico * Department of Pediatrics * Envision New Mexico

31.  Sass C. Yummy! Yucky! Icky! Tasty! Know What Your Clients Like (and Hate) to Eat. ADA Times 2007;4:12- 15.  Satter, E. Child of Mine, Feeding with love and good sense. 2000 Bull Publishing, Palo Alto, CA.  Strauss S. Clara M. Davis, The wisdom of letting children choose their own diets. CMAJ 2006: 175;1 199 - 1201  Wansink B. Nutritional Gatekeepers and the 72% Solution. J Am Diet Assoc 2006;106;1324-1327  Zero to Three available at www.zerotothree.org accessed 2/23/2007www.zerotothree.org 11/02/2012 31 University of New Mexico * Department of Pediatrics * Envision New Mexico

32.  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. 11/02/2012 32 University of New Mexico * Department of Pediatrics * Envision New Mexico

33. Envision New Mexico Staff Directory Telephone 505-925-7600www.EnvisionNM.org Jane McGrath, MD, FAAP Program Director jmcgrath@salud.unm.edu Kris Carrillo, LISW Program Operations Director kcarrillo@salud.unm.edu Dan Rifkin, MD Child and Adolescent Psychiatrist drifkin@salud.unm.edu 9/21/2012 33 University of New Mexico * Department of Pediatrics * Envision New Mexico Kirsten Bennett, MS, RD, LD QI Training, Consultation and Outreach kdbennett@salud.unm.edu Terri Chauvet Administrative Assistant III tchauvet@salud.unm.edu Carole Conley, LMSW QI Training, Consultation and Outreach cconley@salud.unm.edu Paula LeSueur, CFNP CHIPRA Manager plesueur@salud.unm.edu Kristine Lucero Accountant II krisgonzales@salud.unm.edu Fauzia Malik, MPAS QI Training, Consultation and Outreach fimalik@salud.unm.edu John Martinez QI Training, Consultation and Outreach johnLMartinez@salud.unm.edu Carolyn Salazar, RN QI Training, Consultation and Outreach carsalaz@salud.unm.edu Janette Schluter Program Data Specialist jschluter@salud.unm.edu McKane Sharff CHIPRA Program QI Specialist msharff@salud.unm.edu Jeanene Sisk Administrative Assistant II jsisk@salud.unm.edu Clancey Tarbox Program Coordinator ctarbox@salud.unm.edu Kevin Werling Systems Analyst ll kwerling@salud.unm.edu Michelle Widener Data Analyst miwidener@salud.unm.edu Nancy Vandenberg CHIPRA Program Youth Specialist nvandenberg@salud.unm.edu

34. Thank you 34