Transcript Putting_Pediatric_Nutritional_Guidelines_into___Practicex

Putting Pediatric
Nutritional Guidelines
into Practice
Alayne Gatto MBA RD CSP CLC LD FAND
Disclaimer
As a presenter, I have had complete and
independent control over the planning and
content of this presentation, separate from my
primary employer, Mead Johnson Nutrition.
Also, as an independent nutrition consultant, I
am not endorsing any product names or labels
that may be shown in the presentation, nor do
I promote the use of any drug for indications
outside the FDA-approved product label.
Objectives
After this presentation, you will be able to:
1. Recommend age- appropriate vitamins and
supplements to meet nutritional needs
2. Identify nutritional guidelines and put into
practice for infants, toddlers and
adolescents
3. Provide caregivers of picky eaters and
petite children with food and beverage
options to enhance nutritional intake and
provide appropriate calories
Nutrition Guidance
Prevention of Rickets and Vitamin D
Deficiency in Infants, Children and
Adolescents
Paper: Wagner, C.,Greer, F. & the Section on
Breastfeeding and Committee on Nutrition,
Pediatrics 2008(122), 1142-1152.
Recommendation:
O Daily Intake of 400 IU/day for all infants,
children and adolescents beginning in the first
few days of life.
O Premature Infants (according to Koletzko, 2014)
require 400-1000 IU/day from milk and/or
supplementation
Prevention of Rickets and Vitamin D Deficiency
in Infants, Children and Adolescents
Vitamin D:
O Vitamin D2/Ergocalciferol: synthesized by
plants
O Vitamin D3/Choleocalciferol: synthesized by
mammals
O Source of Vitamin D for humans is through
its synthesis in the skin when UV-B converts
through metabolic process (hydroxylation)
O Lab Measurement: 25-OH-D
Vitamin D synthesis
Prevention of Rickets and Vitamin D Deficiency
in Infants, Children and Adolescents
What affects Vitamin D absorption:
-age
-weight/BMI
-skin pigmentation
-lack of sun exposure or outdoor activity
-sunscreen
-latitude, season
-cloud cover, air pollution
Prevention of Rickets and Vitamin D Deficiency
in Infants, Children and Adolescents
O Infants: All breastfeeding infants and
infants that consume less than
1000mL/day (~33oz) of infant formula
1mL dropper or 1 drop = 400mL
O Children/Adolescents: 400 IU through food
sources or supplementation ( 1 cup milk =
100 IU, salmon(3oz) = 400 IU; tuna(3oz) =
150 IU; egg (yolk) = 40 IU
O Serum 25(OH)D optimal level - > or = to
50nmol(20ng/mL)
Vitamin D
Prevention of Rickets and Vitamin D
Deficiency in Infants, Children and
Adolescents
Rickets
1. Symptomatic hypocalcemia (including
seizures)-occurs during periods of rapid
growth before physiological or radiographic
evidence is noted
2. Chronic Disease - rickets and/or decreased
bone mineralization and normocalcemia or
asymptomatic hypocalcemia
Vitamin Supplementation
The American Academy of Pediatrics does not
recommend a universal multivitamin for
children.
O “At risk” vitamins/nutrients : Vitamin D,
Calcium, Iron, “Fiber”
O Autism, ADHD, vegan, food allergies, failure
to thrive, specific medications
Nutrient Lingo
DRI – Dietary Reference Intake
General term for a set of reference values used to plan
and assess nutrient intakes of healthy people. These
values, which vary by age and gender, include: RDA, AI,
and UL (Upper Limit)
RDA – Recommended Dietary Allowances
The average daily dietary intake level, sufficient to meet
nearly all (97-99%) of healthy individuals in this group
EAR – Estimated Average Requirement
An EAR is established from scientific evidence which
calculates an RDA
AI – Adequate Intake
Believed to meets needs for all individuals within an age
group but lacks data or uncertainty remains to establish
a RDA with confidence
Calcium
Calcium mg/day (AI)
Supplement: Calcium Carbonate or Citrate?
1-3 years - 700mg
4-8 years - 1000mg
9-18 years - 1300mg
O Vitamin D facilitates calcium absorption and
promotes bone mineralization
O Leafy greens (1/2 c spinach, 120mg), cheese
slice (200mg), milk (300mg/cup), calciumfortified foods, soy
Iron
Iron mg/day (RDA)
Supplement: Ferrous sulfate
1- 3 years – 7 mg
4-8 years - 10 mg
Girls/Boys 9-13 years – 8 mg
Girls 14-18 years - 15 mg
Boys 14-18 years - 11 mg
Diet: 3 oz beef (3mg), ½ c beans (3mg),
chicken, dried fruits, molasses, fortified
cereals, leafy greens, 1 oz liver (7mg)
10 small clams (25mg)
Fiber
Fiber – (g) 2010 Guidelines for Americans
1- 3 years - 19 grams
4-8 years - 25 grams
Girls 9-18 years - 26 grams
Boys 9-13 years - 31 grams
Boys 14-18 years - 38 grams
Diet: Peas (8g/cup), Broccoli, Avocados (6g/half), Lentils
(15g/cup), Black Beans, Baked Beans, Berries (8g/cup),
Chia seeds (1 Tbsp/5g), Flaxseed meal (1 Tbsp/~2g)
Medication: Lactulose, Miralax, Metamucil
Gastroesophageal Reflux: Management
Guidance for the Pediatrician
Paper: Lightdale, J,, Gremse, D. & the Section on
Gastroenterolgy, Hepatology and Nutrition
Pediatrics May 2013: 131: 1684-1694
New GERD Management Guidelines:
1. Lifestyle Changes
2. Medication
3. Surgical Approaches
Gastroesophageal Reflux: Management
Guidance for the Pediatrician
GER (reflux) – passage of gastric contents into the
esophagus; typical of ~50-75% of all healthy term
infants, common in preterm infants
GERD – findings of mucosal injury on upper
endoscopy; vomiting, poor weight gain, abdominal
pain, esophagitis, wheezing, cough, regurgitation
with vomiting and irritability, feeding refusal,
arching of the back, poor weight gain, coughing,
aversion to food
O Peak incidence of 50% at 4 months; 5-10% at 1
year
Gastroesophageal Reflux: Management
Guidance for the Pediatrician
Positioning
O Keeping completely upright
O Place in prone position (awake and
observed, lying flat with the chest down and
back up)
O Semi-supine (carseat, bouncy chair) may
exacerbate GER
Gastroesophageal Reflux: Management
Guidance for the Pediatrician
Maternal Diet for the Breastfed Infant
O Milk cow protein allergy can mimic GERD in
infants
O 2-4 week trial of a maternal exclusion diet
that restricts at least milk and egg
O Pumped breast milk and thickened with
(rice) cereal
Gastroesophageal Reflux: Management
Guidance for the Pediatrician
Formula
O Reducing feeding volumes which increasing
frequency of the feeds
O Adding (rice) cereal, up to 1Tbsp per 1oz
formula
O Thickened feeds using a commercially
thickened rice formula
O Extensively hydrolyzed or amino acid formula
Gastroesophageal Reflux: Management
Guidance for the Pediatrician
Medications - PPIs - Proton pump inhibitors
Lansoprazole (Prevacid), Omeprazole (Prilosec),
Esomeprazole (Nexium)
Reduce the production of acid by blocking the enzyme in the wall of
the stomach that produces acid.
- superior efficacy compared to H2RAs (Zantac, Pepcid, Axid)
- shorter half life noted in children, higher per kg dose
- 30 minutes before a meal
- overuse/Misuse of PPIs in the infant Population
- Increased risk of pneumonia, gastroenteritis, NEC in preterm
infants
Gastroesophageal Reflux: Management
Guidance for the Pediatrician
Surgical Approaches
O Fundoplication – gastric fundus is wrapped
around the distal esophagus
Effects of Early Nutritional Interventions on the Development of
Atopic Disease in Infants and Children: The Role of Maternal
Dietary Restriction, Breastfeeding, Timing of Introduction of
Complementary Foods and Hydrolyzed Formulas
Paper: Greer, FR,, Sicherer, SH. & Burks, A.W.
Pediatrics May 2008:121: 183-191
O Although solid foods should not be introduced before
4-6months, there is no current evidence that delaying
their introduction beyond this period has a significant
protective effect on the development of atopic
disease regardless of whether fed breast milk or
formula. This includes the delay of fish, eggs and
foods containing peanut protein.
http://wholesomebabyfood.momtastic.com/here/Food
ChartbyFood.pdf
Solid Food Introduction
O Delay of complementary foods beyond 6 months may lead
to deficiencies in protein, iron, zinc and vitamins B and D,
and have a negative effect on growth and development1
O The following feeding indicators have been associated with
a reduced risk of stunting and being underweight2:
O Timely food introduction (6-8 months) (P<0.001)
O Minimum acceptable diet*, dietary diversity and
consuming iron-rich foods (P<0.001)
*World Health Organization (WHO) guidance for minimum
acceptable diet is at least 2-3 meals per day and a diverse
diet.
1. Kuo AA et al. Matern Child Health J. 2011;15:1185-1194.
2. Marriott BP et al. Matern Child Nutr. 2012;8(3):354-370.
Sample Diet – 2 year old
High Calorie Foods
Fruits – ½ c raisins (250), 1/2c dates or prunes(200),
banana, mango
Vegetables - 2 Tbsp avocado (50), 1c mashed sweet potato
(250+), corn, carrots
Meats/Proteins – 1 oz macademia nuts (200), dark meat,
beef brisket, ground beef, “peanut” butter, bacon, baked
beans, edaname(soy)
Dairy /Milks– cheese, whole milk yogurts, smoothies,
coconut milk
Grains – muselix cereals, Grapenuts, Cracklin Oat Bran,
granola, trail mixes, wheat germ, quinoa, whole grains
“Fats”/Sugars – Nutella, salad dressings, mayonnaise,
honey,
High calorie meals
Dinner
O Pepperoni veggie pizza, carrot sticks
O Whole wheat spaghetti and meatballs,
sauce, Parmesan cheese, peas
O Rice/beans/brisket, avocado/guacamole
O Dark meat chicken, mashed potatoes, corn
High calorie meals
Lunch
O Burrito with cheese, meat, rice , veggies
O Peanut butter and jelly/banana sandwich,
carrots and dip
O Tuna salad on whole wheat, dried fruit
O Macaroni and extra cheese, cut up mango
and banana
High calorie meals
Breakfast
O Whole milk Yogurt with granola and berries
O Oatmeal with wheat germ, milk, and banana
O Tortilla with scramble egg/cheese/veggies
O Cracklin oat bran cereal and blueberries
O Smoothie made with milk, coconut milk,
fruit, avocado and flaxseed meal or chia
seeds
High calorie beverages?
O High calorie beverages (30 calories/oz) can
often be more harmful than helpful
O Encouraging hunger
O Normal satiety cycle
O Failure to Thrive Conditions
My Goals for You
O Awareness of what nutrients infants and
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children may be lacking
Able to back your recommendations with
reputable organizations
Give examples of high calorie food options
Promote the importance of good nutrition
with ease
Support growing, healthy children