Module 2: Growth Assessment Part 2: Ends of the Spectrum


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Service providers who receive high nutrition risk referrals, particularly Registered Dietitians, need to be knowledgeable about general and clinical pediatric nutrition as well as counselling skills for working with families and children.

This is the second of five self-directed training modules available in PowerPoint presentations that have been developed and evaluated to respond to this need

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Module 2: Growth Assessment Part 2: Ends of the Spectrum

  1. 1. A Preschool Nutrition Primer for RDs Pediatric Growth Assessment Part II: Ends of the Spectrum Nutrition Screening Tool for Every Preschooler Évaluation de l’alimentation des enfants d’âge préscolaire
  2. 2. Learning Objectives Understand the complex and influencing factors in childhood overweight and obesity. Know how to assess childhood overweight and obesity and the appropriate nutritional interventions in a primary care setting. Understand the types of Failure to Thrive (FTT) and the risk factors. Know how to assess FTT and the appropriate nutritional interventions in a primary care setting.
  3. 3. Presentation Outline Overweight and Obesity Population and individual level influences and actions Risk factors and potential causes Assessing obesity and healthy weights in children Recommended treatment strategies Nutritional assessment and interventions Case Study Take home messages Failure to Thrive (FTT) Definition Classifications Risk Factors Clinical Presentation Treatment Team and RD Role Feeding Observation and Diet Instruction/Education Case Studies
  4. 4. Factors Impacting Child Growth & Preventing Obesity Policies Public Subsidized Health Nutrition to Fish, Fruit Change Education Intervention Vegetable Change Studies Food Products Local Nutrition/ Behavior Supply Restaurant Use Media to Change Counseling Program Change Menus Food Norms Teach MD’s to Food Supply Educate Patients About Diet upstream midstream downstream
  5. 5. Action on Obesity: Three Different Paradigms Population oriented Individually-oriented Population-oriented Individual oriented Educational, Environmental High Risk and and Clinical Treatment Policy Preventive Approaches Services Approaches Upstream Downstream
  6. 6. What Can We Do Level 1: Strengthening individual knowledge and skills Level 2: Promoting community education Level 3: Educating service providers Level 4: Fostering coalitions Level 5: Changing organizational practice Level 6: Influencing policy and legislation
  7. 7. Obesity Almost all cases of childhood obesity are caused by: Calorie Intake > Calorie Need Calorie needs are individual and are affected by the amount of physical activity a child gets
  8. 8. The Great Obesity Debate Energy balance Individual foods/drinks Physical inactivity TV/computer Food choices The food industry Eating behaviours Agriculture policy Meals away from home Cost of food Genetics School lunches Community design Vending machines Automobile culture Environment Parenting Individual responsibility Fast food
  9. 9. Medical Conditions Associated with Pediatric Obesity Genetic Monogenic disorders (melanocortin-4 receptor mutation, leptin deficiency, proopiomelanocortin deficiency Syndromes (prader-willi, bardet-biedl, cohen, alstrom, frohlich) Neurologic Brain injury, brain tumor, cranial irradiation, hypothalamic obesity Endocrine Hypothyroidism, cushing syndrome, growth hormone deficiency, pseudohypoparathyroidism Psychological Depression, eating disorders Drug-Induced Tricyclic antidepressants, oral contraceptives, antipsychotics, sulfonylureas, glucocorticoids
  10. 10. Medical Co-Morbidities Metabolic Type 2 diabetes, metabolic syndrome Orthopedic Femoral epiphysis, blount’s disease Cardiovascular Dyslipidemia, hypertension, Lt ventricular hypertrophy, athlerosclerosis Psychological Depression, poor quality of life Neurological Pseudotumor cerebri Hepatic Non-alcoholic fatty liver disease or steatohepatitis Pulmonary Sleep apnea, asthma Renal Proteinuria
  11. 11. Other Factors Obesity is also related to a child’s environment School environment Community environment Family/Parent environment Family/parent environment is the area most easily changed by clinical counselling, other environments are more effected by a public health approach
  12. 12. Assessing Obesity Treatments for overweight/obese children are rarely implemented under 2 years of age. Thorough nutrition assessments are needed to guide and plan interventions as obesity has many contributing factors.
  13. 13. Weight Goals Achieve a Healthy Weight <85th %ile Normal Maintain BMI % weight/height 85th- 95th %ile Overweight Maintain wt to decrease BMI with age/ht >95th %ile Obese Wt maintenance or gradual wt loss Adult BMI >30 Obesity Gradual wt loss 1-2 kg/month) >95th %ile co- Obese with co- Gradual wt loss 1-2 morbidity morbidity kg/month)
  14. 14. Current Recommendations (Gold Standard) for Obesity Little known re: strategies and effectiveness with the preschool population. For school age and adolescents, use multi- component family based programs Behavioural counselling Increased physical activity Parent training/modeling Dietary/nutrition education Interdisciplinary and comprehensive programs Ongoing follow-up for at least 3 months
  15. 15. Nutritional Assessment Subjective and objective data Detailed food frequency and diet recall Questions about meals/snacks, beverages, cooking methods, restaurant/take-out meals, friends, school theme days etc Questions about physical activity and screen time Nutrient analysis and estimated needs Readiness/barriers to change Establishing a care plan and goals
  16. 16. Motivational Techniques Focus on health benefits Self-worth should not rely on appearance Stages of change Pre-contemplation, contemplation, preparation, action, maintenance Help to understand your client’s perspective Target interview toward client’s concerns Avoids antagonism and keep relationship open
  17. 17. Motivational Techniques Motivational Interviewing Non-directive questions Reflective listening Compare values and current health practices Use importance or confidence rulers Non-judgemental approach evoking motivation rather than imposing it. Encourage goal setting, monitoring behaviours targeted for change, use positive reinforcement.
  18. 18. How Could Nutrition Care be Optimized? Earlier referral? Increased frequency of visits Distance may be a factor Multi-disciplinary team approach Exercise specialist, behaviour expert Positive reinforcement for behaviour goals Caregiver continuity-consistent RD Behaviour modeling Parents’ lifestyle? Siblings? Others?
  19. 19. Key Concepts in Nutrition Interventions Ellyn Satter - Division of Responsibility Parents - Food Preparation and purchasing - Meal timing and location Children - How much to eat - Whether to eat or not
  20. 20. Focus on Healthy Eating Increase vegetables and fruit Aim for 5 servings a day, but start with small steps, if they eat none, try for 1 serving. Increase fibre Whole grains, whole fruits & veggies, beans/legumes. Make healthy choices more often Low fat dairy, lean meats/protein, limit added fats.
  21. 21. Focus on Healthy Eating Limit sweet drinks Rethink your drink choices Watch fruit flavoured drinks, soft drinks, and sports and energy drinks consumption. Limit energy-dense, but not nutrient-dense snack foods. Limit meals/snacks eaten away from home.
  22. 22. Focus on Healthy Eating What is a snack – What is a meal Portions, nutritional quality, healthy choices, variety Meal and snack schedules/timing Eating cues Eating for hunger/stopping when full Family views of food (food for enjoyment vs nourishment) Family meals Foods eaten away from home Grandma, multiple caregivers, daycare, school, restaurants
  23. 23. Physical Activity Assess level of activity Stress that activity is a major component of healthy weights Limiting screen time to 1-2 hours a day and increasing active play/physical activity Recommend community resources and programs for individuals with low incomes e.g. sponsored YMCA programs, sports tax credits, free community events
  24. 24. Take Home Message Factors are complex and rooted in many sectors. Begins in early childhood: focus on children (via families, schools, community) is critical. Education along with environmental and policy approaches. Start with educating yourself and others about healthy weights approach. Advocate for model programming.
  25. 25. Failure to Thrive (FTT) No consistent method of identifying/defining. Generally accepted as growth that deviates from the norm; assess progression of growth longitudinally. A single growth measurement does not provide info or deviation of a growth pattern. A symptom rather than a diagnosis ? May be defined as any of the following: Wt for age < 5th percentile without a constitutional delay Wt for ht (or BMI) < 5th percentile Decreased growth velocity with weight dropping > 2 major percentiles over 3-6 months
  26. 26. Classifications of FTT Organic Non-Organic Due to an underlying Social or behavioural medical condition dysfunction ↓ oral intake or ↓ oral intake ↓ absorption or ↓ utilization of nutrients Can be organic and/or non- organic
  27. 27. Risk Factors of FTT Organic Inability to consume adequate kcal (dysphasia, cerebral palsy) Inability to retain (GERD, malabsorption) ↑ kcal need (CHD, BPD) Altered growth potential (premie, IUGR, chromosomal anomalies)
  28. 28. Risk Factors of FTT Non-Organic Psychosocial issues Poverty Disordered feeding environment Dysfunctional parent-child interaction Neglect Sick/difficult child Parental stress (depression, drug abuse, isolation) Lack of Knowledge/Misinformation Intellectual impairment ↓ breast milk production, errors in formula preparation ↑ juice consumption Misperceptions about normal infant/child diet Unusual health/cultural beliefs
  29. 29. Clinical Presentation Wt loss or decreased growth velocity May be classified as organic or non-organic, or not classified yet Often a history of poor feeding/food aversion Anemia (in up to 50% of FTT cases)
  30. 30. Treatment Team Pediatrician Dietitian Social Worker Registered Nurse Child Psychologist/Psychiatrist or Behaviourist Community Agencies (e.g. Health Unit (HBHC program), Children’s Treatment Centre, CAS)
  31. 31. Role of the Dietitian: Nutrition Assessment Get accurate anthropometrics Growth history from birth (call Family Doctor) Lab values (CBC, ferritin, sweat Chloride) Detailed diet history from birth Outputs-urine and stools Emesis Sleep patterns Social history (caregivers, home environment) Estimate kcal intake & requirements for catch-up growth Observe feeding
  32. 32. Feeding Observation (Caregiver and Child) Look for: Eye contact Physical contact Attentiveness to child’s cues Use of distractions Role modeling/eating with child Caregiver’s tolerance level/expectations Caregiver’s reaction to child not eating Reactions in a stressed environment-caregiver and child Division of Responsibility (Ellyn Satter)
  33. 33. Diet Instruction/Education Infants Hypercaloric EBM/formula (24-30+ kcal/oz) ± high calorie foods/boosters Toddlers/older children Hypercaloric milk/beverage + high kcal foods/boosters (Pediasure, Instant Breakfast drinks, Resource JFK…) …May require tube feeding
  34. 34. Considerations for Tube Feeding Long term versus short term use (G-Tube/NG- Tube). Overall diet (for a long period of time), and whether child may be able to meet nutritional requirements by mouth. Formula type and concentration. Qualify for formula coverage from the government. Support and ability from family to carry out. Support for family (professional assistance and training for pump machines…if necessary). Consultation and discussion with multi- disciplinary team.
  35. 35. Nutrition Care Plan and Education Review normal diet for age (+ boosters) Avoid grazing Limit juice (less than 8 oz/day) Limit milk consumption (2 cups/day for preschoolers) Assist with feeding techniques e.g. utensils, approach, remove distractions, feeding team support if necessary (OT, Speech Path, RD) Assist with establishing a schedule e.g. 3 meals/day + 2-3 snacks, > 2 hrs apart Division of responsibility Parent = what, when, where Child = how much, whether to eat or not
  36. 36. Calorie Boosters Hospital For Sick Children. Guidelines for Energy Boosting, 1994. Sudbury & District Health Unit. Adding Extra Nutrition for Toddlers and Preschoolers.
  37. 37. Acknowledgements Presentation adapted from: Childhood Obesity (primary, secondary and tertiary intervention) and A Clinical Outpatient Nutrition Perspective (Janice Piper, RD, Alice Gerhardt, RD, Jill Schweyer, RD, and Laura West, RD); Failure to Thrive (Jody Coles, RD), April 2008, Northern Ontario Dietetic Internship Pediatric Video series; and, NutriSTEP Validation RD Training (Lee Rysdale, RD), April 2005. Presentations available from: Lee Rysdale at Content revisions by Jane Lac, RD. Consultant.