Learning objectives • Bone Growth Regulation and pattern • Optimizing Nutrition And Bone Health in Children with Cerebral Palsy • Developmental stages in child feeding • Picky Eaters vs Avoidant/Restrictive Food Intake Disorder (ARFID)

1. Optimizing nutrition and
growthfor children with
special Health care needs
By Dr Ola alkhars
A General PediatricConsultant at King Faisal
General Hospital Al-Ahsa
Saudi Board in pediatric At MCH Al Ahsa
25/6/2021

2. Learning objectives
• Bone Growth Regulation and pattern
• Optimizing Nutrition And Bone Health in Children with Cerebral Palsy
• Developmental stages in child feeding
• Picky Eaters vs Avoidant/Restrictive Food Intake Disorder (ARFID)

3. Bone Growth Regulation
GabbitasB & CanalisE 1996 Retinoicacidstimulatesthe transcriptionof insulin-like growthfactorbindingprotein-6inskeletal cells.Journalof CellularPhysiology169 15–22.
(https://doi.org/10.1002/ (SICI)1097-4652(199610)169:1<15::AID-JCP2>3.0.CO;2-H)
IGF2
Intrauterine
Growth
IGF1
Regulates and
maintenance
postnatalskeletal
growth

4. Prepubertal
Skeletal growth
• (TH) increases both hepatic and skeletal IGF1 expression
during a critical prepubertal growth period

5. Pubertal Skeletal growth
IGF1 & sex
steroid
signaling
interaction
Preservation
of cortical
bone

6. Linear GrowthDetermined by
1. The cell proliferation at the
Epiphyseal growth plates of
long bones
2. GH/IGF1 axes
Linear growth, or height gain, isdeterminedbythegrowthplate, theareaof
cartilaginoustissuegrowingnear theendof thelongbonesinchildrenandadolescents. 1
Eachlongbonehasat least twogrowthplates, whichdeterminethefuturelengthandshape
of thematurebonethroughaprocesscalledchondrogenesis. 1
Therateof growthplatechondrogenesis(G
PC)isregulatedbymanyfactorsincluding
hormonal mechanisms, andlocal intracellular andextracellular G
PCmatrixfactors.1,2
Dysfunctionof theG
PCcanbecausedbyaprimar ydefect inthegrowthplate, or a
secondarydefect inwhichthegrowthplateisadverselyaffectedbyadisorder elsewherein
thebodylikeundernutrition.1
Nutritional Impacts on Growth Trajectories
Nutritionprovidestherequired “buildingblocks” for optimal growth, including
energy, proteinsandmicronutrients. Conversely, nutrient deficienciesareconsidereda
eadingcauseof underweight andshort stature(stunting)inchildren.3
Thebest exampleof
how nutritionaffectslinear growthisthe“catch-upgrowth” (CU)phenomenon..
Catch-upgrowthisthephaseof rapidlinear growththat allowsachildtoaccelerate
oward, andevenresumehisor her pre-illnessgrowthcurve. 4
Undernutritioncanleadto
educedplasmalevelsof insulin, insulin-likegrowthfactor-1, thyroidhormone, leptinand
exhormones, andincreasesinthelevel of glucocorticoids, all factorswhichcan
negativelyaffect G
PC.2
Withproper nutrition, theslowedsenescent G
PCshowsagreater
growthratethanexpectedfor age, resultinginCU.5
Effects of a Nutritional Supplement on Catch-Up
(CU) Growth
Clinical studieshaveshownCUin4to8weeksafter providingcomplete, balanced
Oral Nutritional Supplements(ONS)toyoungchildrenwithweight-for -height <25th
percentile.6
For underweight andshort staturechildren, earlydetectionfollowedby
nutritional counselingwithONScanrestoretheir growthpotential.
40
BODY MASS INDEX (BMI=KG/M 2
) FOR AGE IN PERCENTILES
Figure 3
Figure 2 GROWTH TRAJECTORIES
RESTINGZONE
PROLIFERATIVE
ZONE
PREHYPERTROPHIC
ZONE
HYPERTROPHIC
ZONE
TRABECULAR
BONE

7. linear bone growth

9. IGF1 regulation by nutrition
IGF1
Intestinal
microbiota
SCFA
Arginine
HalmosT, SubaI. A növekedésihormonésazinzulinszerűnövekedésifaktorokélettani szerepe[The physiological role of growthhormone andinsulin-likegrowthfactors].OrvHetil.2019
Nov;160(45):1774-1783. Hungarian.doi:10.1556/650.2019.31507. PMID: 31680542.

10. The present data indicate that children with an
arginine intake between 2·8 and 3·2 g/d grew
0·33 cm/year faster compared with children
with an arginine intake below 2·2 g/d.

11. Poor Nutrition and IGF1
Protein
restriction
Osteoblasts
resistant to
IGF1 action

13. Nutritional
Needs
• Energy requirement
• Any special needs
• Activity level
• Mechanical issues
• Behavioral issues

14. Causes for Nutrition Concern
ALTERED NUTRITIONAL
NEEDS
PHYSICAL PROBLEMS BEHAVIORALISSUES

15. Medical conditions requiring dietary modifications
• Cysticfibrosis (CF)
• Diabetes – type 1
• Coeliac disease
• Congenital heart disease
• Inflammatorybowel diseases
• Non -functioning GI
• Feed intolerance
• Fat malabsorption
• Carbohydrate intolerances
• Food Allergy
• CKD
• Hepatic Failure
• Phenylketonuria
• Inherited metabolic disorders
• Prader-Willi syndrome
• Epilepsy
• Neurological impairment, e.g. CP
and Down’s syndrome
• Cancer
• Burns

16. Optimizing
Nutrition
in Children with
Jesus AO, Stevenson RD. Optimizing Nutrition and Bone Health in Children with Cerebral Palsy. Phys Med Rehabil Clin N Am. 2020 Feb;31(1):25-37. doi: 10.1016/j.pmr.2019.08.001. Epub 2019 Nov 6. PMID:
31760992.

18. Risk factors of malnutrition
Impairment of oral motor function
⚫ Swallowing disorders
⚫ Recurrent Aspiration
Cognitive impairment
⚫Difficulties communicating
hunger
Impaired Gastrointestinal muscle tone
⚫ limited absorption of nutrients
⚫ vomiting
⚫ GER .
⚫ Constipation

19. Factors contributing to diminished bone health
Malnutrition
Medications ( blocking or altering the
absorption or metabolism of nutrients)
Atypical muscle tone and function
Lack of weight-bearing( reduced periosteal
expansion )(decreased cortical bone area )
Binkley T, Johnson J, Vogel L, et al. Bone measurements by peripheral quantitative computed tomography (pQCT) in children with cerebral palsy. J Pediatr 2005;147(6):791–6.
Al Wren T, Lee DC, Kay RM, et al. Bone density and size in ambulatory children with cerebral palsy. Dev Med Child Neurol 2011 ;53(2):137–41.

20. Bone mineral density

21. Effect of chronic
malnutrition
• Impairs the rate of longitudinal bone growth
and length of the growth plate
• Bone mineral density
• Impaired circulation with poor wound healing

22. Effect of chronic malnutrition
-Quality of life
-Play, activities
-Neurodevelopment, IQ,
behavior & Attention
Health
care costs

23. Nutritional Assessment

24. SGA-Subjective Global
Nutritional Assessment

26. ASSESSMENTOF GROWTH AND NUTRITIONIN
CHILDREN WITH CP
• Height and weight(less helpful in
determining percent body fat)
• CP-specificgrowth curves based
on the severity of gross motor
impairment
• portray how a large clinical sample
has grow
• Not reflect optimal growth
with appropriate nutrition

28. Challenges to following growth as a reflection
of nutrition and health
• Fixed joint contractures
• Scoliosis
• Involuntary muscle spasms
• Poor cooperation because of cognitive defects

29. Indicators for estimating body fat
• Triceps skinfold thickness
• Subscapular skinfold thickness
Henderson RC, Lark RK, Gurka MJ, et al. Bone density and metabolism in chil- dren and adolescents with moderate to severe cerebral palsy. Pediatrics 2002;110:e5.

30. MUAC: mid upper arm circumference
An Independent indicator for diagnosing malnutrition
Should be part of the full anthropometric assessmentin all
patients
A more sensitive prognostic indicator for mortality than WT/HT

31. •

32. Utility of MAUC measurement
• Superior predictor of short and
long-term mortality risk
• Stronger correlation with
duration of preceding illness
• Earlier discharge

34. ASSESSMENT OF GROWTH AND NUTRITION
• Sexual maturation
• For girls with CP, more advanced sexual maturation was associated with higher
percent body fat.
• For boys with CP, however, more advanced sexual maturation was associated with
less body fat.
WorleyG, Houlihan C, Herman-Giddens M, et al. Secondary sexual characteris-tics in children with cerebral palsy and moderate to severe motor impairment:a cross-sectional survey. Pediatrics 2002;110(5):897–902.

35. Laboratory assessment
• Decreasedalbumin
Henderson RC, Lin PP, Greene WB. Bone -mineral density in children and adoles- cents who have spastic cerebral palsy. J Bone Joint Surg Am 1995;77:1671–81.

36. Management
⚫ Pediatrician can treat any GER, oesophagitis,
slow gastric emptying or constipation
⚫Speech and language therapist can assess biting
and chewing skillsand safety of swallow
⚫ Occupational therapist can advise on the most
appropriateseating for mealtimes and on any
eating aidsthat will help.
⚫ Physiotherapist can advise on an ideal position
for oral feeding
assess the type of stander
Weight bearing
⚫ Dietitian can assess their nutritionalintakewith
the current regimen and suggest improvements.

37. Management
• Thickening liquids
• Tube feeding ( NGT, g-tube or j-tube +/- fundoplication)
• Oral nutrition supplements or complete enteral nutrition formulas to
meet the basic macro- and micronutrient, calorie, and protein
requirements

38. INTERVENTIONS FOR OPTIMIZING BONE HEALTH
• Calcium supplementation
S/E Cardiovascular events
Constipation
Gastrointestinalsymptoms
Nephrolithiasis
Bolland MJ, Grey A, Reid IR.Calciumsupplements andcardiovascular risk:5 years on. Ther AdvDrug Saf2013;4(5):199–210.
• Vitamin D supplementation(1000 to 8000 IU units daily) targeted serum 25-
hydroxy vitamin D level is at least 30 to 40 ng/mL in non-ambulatory children
• Stoss therapy” Doses of 100,000 to 600,000 units of vitamin D can be given orally
as a single dose, followed by a maintenance regimen
.

39. INTERVENTIONS FOR OPTIMIZING BONE HEALTH
• Bisphosphonates
Controversial
S/E : fever, bone pain, N/V
Hypocalcemia and hypophosphatemia
• Pamidronate
• Increases bone mineral density typically during the period of treatment
• Fracture free for 5 years or more.
Allington N, VivegnisD, Gerard P. Cyclic administration ofpamidronate totreat osteoporosis inchildrenwith cerebral palsy ora neuromuscular disorder:a clinical study. ActaOrthopBelg2005;71(1):91–7.
Boyce AM, Tosi LL, PaulSM. Bisphosphonate treatmentfor children with disablingconditions. PMR 2014;6(5):427–36

40. AREAS FOR DISCOVERY
• Low frequency (or whole-body) vibration
Vibrations force the muscles to contract and relax quickly
• Safe
• Time-efficient
• Building strength
• Decreasing spasticity
• Increasing functionality
Ali O, Shim M, Fowler E, et al. Growth hormone therapy improves bone mineral density in children with cerebral palsy: a preli minary pilot study. J Clin Endocrinol Metab 2007;92:932–7.
.

41. J Clin Endocrinol Metab, Volume 92, Issue3,1 March 2007, Pages 932–937, https://doi.org/10.1210/jc.2006-0385
The contentofthis slidemay besubjectto copyright: pleaseseetheslide notes for details.
Fig. 4. Effect of GH therapy on BMD SDS (based on height age) in
CP patients. Shown are ΔBMD SDS in the treated and ...
Exogenous GH therapy
• Increased both lineargrowth and bone
mineral density
• Minimal Side effects

42. Causes for Nutrition Concern
ALTERED NUTRITIONAL
NEEDS
PHYSICAL PROBLEMS BEHAVIORALISSUES

43. DEVELOPMENTALSTAGESIN
INFANT AND TODDLER
FEEDING

45. Total daily
energy
intake
increases,
but variety
of foods
remains
limited
AAcquisition
of food
repertoire
influenced
by previous
food
exposure
and food
choice
behaviors

47. Definitions by Dovey et al
Picky /Fussy Eaters
• Children who consume an
inadequate variety of foods though
rejection of a substantialamount
of food that are familiar (as well as
unfamiliar) to them’
• peak prevalence at about age 3
years
Food Neophobia
• (reluctance to eat, or the
avoidance of, new foods)
TaylorCM, EmmettPM.Pickyeatinginchildren:causesandconsequences.Proc NutrSoc.2019;78(2):161-169. doi:10.1017/S0029665118002586

48. Avoidant/Restrictive
FoodIntakeDisorder
(ARFID)
• The presence of nutritional
deficiency as a result of
inadequate food intake, failure to
gain weight in children, a decline
in psychological function, and a
dependency on supplements to
maintain nutritional health

49. Associations
with Picky
Eating
• Low birth weight, prematurity
• Breastfeeding < 6 months
• Dysfunctional family dynamics

50. Causes of
picky eating
• Early feeding difficulties.
• late introduction of lumpy foods at weaning
• Pressure to eat
• Early choosiness especially if the mother is
worried by this
• Protective factors include provision of fresh foods
and eating the same meal as the child

51. Red Flags
• Chewing or swallowing dysfunction
(dysphagia)
• Coughing, choking, gagging when
drinking liquids or eating solids
• Recurrent aspiration pneumonia
• Feeding interrupted by crying
• Vomiting and/or diarrhea
• Atopic dermatitis

52. Red Flags
• Developmental problems
(prematurity, congenital
anomalies, autism)
• Measurements more than 2 SD
below mean (<5th %ile)

53. Consequences
of picky eating
• A possible distortion of nutrient intakes particularly
zinc and iron
• Constipation
• Developmental difficulties

54. Health
outcomes
• Thinness during adolescence
• Eating disorder
• Adult picky eater

55. Advice for
health
professionals
• Reassure the care giver
Indication for Referral to a pediatric dietician or
psychologist
1. Child fulfil the diagnostic criteria for ARFID
2. have special dietary requirements for a chronic
disease as
• Type 1 diabetes
• Metabolic disorder
• Cystic fibrosis
• Learning difficulties
• Autistic spectrum disorders

56. Strategies for
parents/caregivers
by Levene and
Williams
(1)Having realistic expectations of children’s portion sizes
(2) Graded and repeated exposure to unfamiliar foods (10–15 positive experiences may be needed)
(3) Using non-food rewards to provide motivation
(4) Having a positive approach, avoiding negativity and pressure to eat
(5) Parental modelling of eating fruit and vegetables and trying unfamiliar foods
(6) Promoting appetite by limiting snacks and energy-providing drinks in between meals
(7) Having social food experiences such as family meals with all members eating the same food
(8) Focusing on long-term goals and being consistent.

58. Nutritional Genomics
• The interaction between bioactive
food components and the genome
• Classification
• Nutrigenetics
Heterogeneous response of
gene variants to nutrients,
dietary components and
developing nutraceticals
• Nutrigenomics
The influence of nutrients on
genes expression
Deals with the gene products

61. Conclusion
• Good nutritional care in the early period leading to improve quality of
life and reduce rate of mortality in children with special health need
• Optimizing bone health often focuses on prevention rather than
treatment of reduced bone mineral density.
• Identifying high risk Picky eater children, giving support and parental
advice at an early age is very important to to avert more serious
outcomes.

62. Thank you