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

2. 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)

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

4. 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

5. 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)

6. 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

7. 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, to download charts.

8. 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

9. 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.

11. 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?

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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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 are estimated to be overweight

25. 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

26. CDC.org

27. 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

28. Childhood Obesity - Management
CDC.org

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

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

31. Thank You! Questions?