1. Chapter 13 Child and Preadolescent Nutrition: Conditions and Interventions

2. Introduction
Discussion of nutrition needs of children with chronic conditions
Cystic fibrosis
Diabetes mellitus
Cerebral palsy
Phenylketonuria
Behavioral disorders

3. “Children Are Children First” What does that mean?
Expectations that children will become more independent in making food choices, assisting with meal preparation, & participating at meal times with other family members apply to children with special health care needs
Expectations are the same for all children with or without special needs

4. Nutritional Requirements of Children with Special Health Care Needs
Children with special health care needs vary in nutritional requirements & health needs:
Low energy intake with small muscle size
High protein, fluid or fiber
Increases or decreases in vitamins or minerals
Frequent hospitalizations
Nutrient & health guidelines may not apply because of health needs

5. Energy Needs
Energy needs vary depending on special health care condition
Lower calories needed by children with slow growth or decreased muscles such as in Prader-Willi syndrome
Increased calories needed as activity increases such as in ADHD or ASD

6. Protein Needs Protein needs vary by condition
Recovery from burns & cystic fibrosis increases protein needs to 150% DRI
PKU and other protein-based inborn errors of metabolism require decreased protein
Some conditions may require hydrolyzed or specific amino acids

7. Other Nutrients
Adequate vitamins & minerals should be provided in a well-balanced diet
Conditions that interfere with adequate nutrient intake include:
Chewing or other feeding problems
Side effects from prescribed medications
Food refusals
Treatment of condition that includes restriction of certain foods

8. Growth Assessment
CDC 2000 growth charts are a good starting place for assessing the growth of any child
Adjustments may need to be made for children with some conditions that affect the rate of growth

9. Growth Assessment
Long-term health goals less important for children with life-shortening conditions
Warning signs for growth problems:
Plateau in weight
Pattern of weight gain & then loss
Failure to regain weight lost during an illness
Unexplained/unintentional wt gain

10. Growth Assessment & Interpretation in Children with Chronic Conditions
Factors that affect growth:
Age of condition onset
May determine if growth charts will be applicable
Secondary conditions
May interfere with accurate measurements
Activity/inactivity level

11. Body Composition and Growth
Health conditions may alter muscle size, bone structure, fat stores
Down syndrome results in short stature, low muscle tone, & low weight
Cerebral palsy & spina bifida may reduce muscle tone
Spina bifida may impact muscles only in the lower extremities

12. Special Growth Charts
Growth charts are available for some special conditions (See Table 13.1)
Conditions that do not have growth charts include:
Juvenile rheumatoid arthritis
Cystic fibrosis
Rett syndrome
Spina bifida
Seizures
Diabetes

13. Special Growth Charts

14. Nutrition Recommendations
Assess intake to determine if nutrients and energy are adequate
Children with special health needs benefit from same dietary recommendations as other children

15. Methods of Meeting Nutritional Requirements
Most children will be able to eat and drink like everyone else
Gastrostomy feeding may be required for:
Kidney disease
Some cancers
Severe cerebral palsy
Cystic fibrosis

16. Nutritional Supplements and Formula

17. Feeding and Eating Schedule

18. Vitamin and Mineral Supplements for Chronic Conditions
Supplements may be beneficial for conditions to assure adequate intake
Conditions that require supplements:
Chewing problems need liquid supplements
Diabetes or on ketogenic diets should avoid supplements with added CHO
PKU should avoid supplements with certain artificial sweeteners
Cystic fibrosis requires fat-soluble vitamins
Galactosemia (restricts dairy) requires calcium

19. Fluids Conditions that impact fluid status and increase needs include:
Uncontrollable drooling
Constipation from neuromuscular disorders
Multiple medication use

20. Eating & Feeding Problems in Children with Special Health Care Needs
Eating and feeding problems are diagnosed when children have difficulty with:
Accepting foods
Chewing them safely
Ingesting enough foods and beverages
70% of children with developmental delays have feeding difficulties

21. Eating & Feeding Problems in Children with Special Health Care Needs-Specific Disorders
Cystic fibrosis
Diabetes mellitus
Seizures
Cerebral palsy
Phenylketonuria (PKU)
Attention deficit hyperactivity disorder (ADHD)
Pediatric HIV

23. Cystic fibrosis One of most common lethal genetic conditions
Interferes with lung function
Causes decreased absorption nutrients
Malabsorption due to lack of pancreatic enzymes

24. Cystic fibrosis Dietary considerations:
Calories & protein increase 2 to 4 fold
Enzymes taken with meals to aid in digestion
Frequent meals & snacks
Fat-soluble vitamin supplements
Gastrostomy feeding at night may be needed to boost energy intake

25. Diabetes Mellitus Disorder in insulin & blood glucose regulation
Type 1—virtually no insulin production
Type 2—associated with obesity
Treatment includes:
Timing & composition of meals & snacks
Insulin injections—for type 1
Exercise
Summer camps for diabetic children

26. Seizures Uncontrolled electrical disturbances in brain
Seizures = Epilepsy
Results of a seizure range from mild blinking to severe jerking
Postictal state—time after seizure of altered consciousness

27. Seizures
Treatment:
Feeding or eating during postictal state not recommended due to chocking risk
Medications—may impact growth and/or appetite
Ketogenic diets—severely low-CHO diet with increased calories from fat

28. Cerebral Palsy
Group of disorders resulting from brain damage with impaired muscle activity & coordination
Spastic quadriplegia presents most nutritional problems

29. Cerebral Palsy Nutrition concerns:
Slow growth
Difficulty feeding & eating
Athetosis (less common form of CP)—uncontrolled movement which increases energy expenditure

30. Growth Chart

31. Phenylketonuria (PKU)
Inborn error of metabolism
Body lacks enzyme needed to metabolize phenylalanine
Require intervention to manage breakdown of dietary proteins

32. Phenylketonuria (PKU)
Diet is adequate in vitamins, minerals, pro, fat and calories
Nutrients are often provided in liquid rather than solid form
Dietary treatment includes avoiding meats, eggs, dairy products, nuts & soy beans

33. Attention Deficit Hyperactivity Disorder (ADHD)
Most common neurobehavioral problem (~5% to 8% of children)
Chaotic meals & snacks with difficulty staying seated
May be given fewer opportunities in the kitchen due to impulsiveness

34. Attention Deficit Hyperactivity Disorder (ADHD)
Nutritional concerns:
Medications:
May decrease appetite & growth
Medication peak activity is aimed at school hours
Appetite returns to normal when meds are not given such as on weekends & school holidays
No evidence of nutrition as a cause and treatment but families may choose herbal medicines anyway

35. Pediatric HIV Nutrition is important for HIV management
Antiretroviral therapy depresses appetite & food intake
Other nutrition concerns:
Control food-related infections
Access to determine need for complete nutritional supplements
Referrals to food banks
Dietary approaches have to customized

36. Childhood Celiac Disease
Chronic condition increasing in prevalence
Underdiagnosed in children
May interfere with learning and growth
Once diagnosed, will need gluten free diet for life

37. Dietary Supplements and Herbal Remedies
Use of supplements or herbs has not been shown to improve prognosis for special health needs
However, nutritional claims abound
Families hear from one another about various nutrient claims
May use diet claims for one condition and expect it to work for a different condition

38. Dietary Supplements and Herbal Remedies
Strategies to counter unscientific claims include:
Recognize the benefits of supports for families (e.g. advocacy groups)
Improve communication with health care providers
Provide factual information without endorsing any claim & allow families to make informed choices

39. Sources of Nutrition Services
Supplemental Social Insurance (SSI)
Americans With Disabilities Act
USDA Child Nutrition Program
USDA 504 Accommodation
Individuals with Disabilities Education Act (IDEA)
Maternal and Child Health Block Grants

40. Nutrition Intervention Model Program
Maternal and Child Health Bureau (MCH) is part of the department of Health and Human Services (HHS)
Funds nutrition services for chronically ill children
Develops and promotes model programs by funding competitive grants
Pediatric Pulmonary Centers
Bright Future Guidelines