General Paediatric Dietetics and Allergy

Nutritional Assesment

growth- accurate and recent weight as growing continuously. Looking at trends (up or down?) and concern if sudden increase/decrease in weight as may indicate disease e.g. coeliac disease may show up as weight drop and CMPI when breast feeds replaced with formula

Anthropometry: calculate weight for heigh for babies and young children or BMI for older children

Assessing intake

Assessing requirements

talk to parents/ carer and ask about concerns, compare with history from medical notes e.g. vomiting, appetite, diarrhoea, abdo pain etc , what has been tried already, fluid/food chart, growth, calculate average daily intake for energy, protein and fluid taking into account losses due to vomiting, calculate average daily intake for energy/protein/fluid (consider losses due to vomiting)

Always use actual weight

Great Ormand Street Hospital booklet used (GOSH)

Increased requirements e.g. cystic fibrosis (breathing etc), cardiac babies (fluid restricition), malabsorption, hypertonia (cerebral palsy- tensing of muscles increases requirements) severe epilepsy, coeliac disease (iron, calcium), IBD

decreased requirements- hypotonia (cerebral palsy- relaxed/floppy muscles), immobility (muscular dystoprophy)

Pre term babies (before 37 weeks)

differing requirements from term babies- optimum weight gain 13-15g/kg/day (overfeeding can lead to metabolic syndrome later in life)

Energy: 110-135kcals/kg/day (usually 120kcals/kg or less)

Fluid- maybe restricted depending on condition but normally 150-200mls/kg/day

Protein: optimum intake 3-3.6g/kg/day and high protein >4.3 can lead to metabolic stress

Can fortify breast milk with prosource / human milk fortifier. Do not know quality of breastmilk

Breast fed babies

May need to get mum to express milk and bottle feed but can be difficult if baby not used to bottle

if growth is faltering ensure hind milk used, baby latching on, mum's diet is ok

Older children

Diet history from parent or carer

Meals and snacks (how much? how often?

who feeds? when and where?

family mealtimes

child's appetite?

consistency of food

main concern? behavioural issues?

any vitamin supplements?

does child vomit? if so, frequency?

stool frequency and consistency?

3 day food diary for quantitative assessment although may have limitations (different carers, recording bias etc)

fussy eating/behavioural issues, especially food allergy or intolerance

Dietary reference values

EAR (estimated average requirements), RNI (reference nutrient intake), LRNI (lower reference nutrient intake)

E.G. CALCIUM RNI 525mg, EAR 400mg, LRNI 240mg

E.G. IRON LRNI 3.7mg, RNI 6.9mg, EAR 400mg

if concerned about iron, look at ferritin (ferritin is like 'bank balance' and iron like 'savings card'

Crohn's patients who need modulen liquid diet for 8 weeks - start with 75% EAR and gradually increase to 120% EAR (flavour modulen with nesquick for flavour as low patient uptake). After 8 weeks reintroduce food. Modulen is intended to give gut rest, has anti-inflammatory. Usually given NG

Cystic fibrosis patients- 120-150% EAR to maintain growth rate

Food refusal

common in children with low variety

WHO guidelines are weaning from 6 months but used to be 4 months. Third world countries breastfeeding. should be eating iron rich foods by 7 months.

Baby led weaning useful for tolerating lumps.

combination of cutlery and using hands/ baby led weaning (important to have variety of textures)

common in premature babies, boys (around 18 months when it begins),

tips for food refusal - ask if they want blue or red spoon, which plate for sense of control

How problems are maintained

food association with distress

parental reinforcement of fads

lack of boundaries/structure

confusuion between differing opinions e.g. nursery, gradnparents, healthcare proffessionals

general suggestions: get parent to expect child to eat, no TV on, eat at table etc

disrupted relationship between parent and child e.g. post natal depression, parent doesn't like mess , problems reinforced by attachment theory

e.g. baby wipes between each mouthful bad as tastes chemical

lack of separation enhanced by COVID- constant effort to please child

Understand parents feelings

Management

depending on age, reward chart with non-food rewards

food chaining

snacking

food play away from mealtimes

Poor appetite management

resolve medical issues e.g. reflux, constipation

check excessive fluid intake (volume, type)

check snacking

advise on increasing calorie intake if growth is faltering

always give dessert

Lack of variety/ taste and texture management

2-4 new foods per month, small quantity

serve small quantity of new food with familiar foods every day

can take 10-15 exposure to a new food before it is accpeted

increase size of portions gradually

increasing textures/refusing lumpy foods - bite and dissolve foods e.g. cheese straws, cheerios, pink wafer biscuits

avoid mixed textures e.g. stage 2 jars, fruit yoghurt

Extreme food refusal management

each stage will be much slower

slower stages - may need separate plate, start with food similar to accepted food, start with crumb and gradually increase portion sizes, build up child's confidence that other foods are safe, need to be systematic and patient, reward each stage, correct nutritional deficiencies

Hypersensitive child management

encourage them to do shopping together,

include shopping, planning meals, cooking

'feely' bad if child is old enough

messy play

avoid noisy distractions at meatlimes e.g. TV

Autism- some children E and D improves in nursery as don't like to be different but for others may not work

Allergy definition

Food hypersensitivity- umbrella term that refers to any unpleasant and reproducible reaction to food = can be either food allergy or non-allergic food hypersensitivity

IGE much quicker reactions in comparison to IGE mediated

14 major common food allergens

only 5% of children with perceived food allergy had a food allergy

NEED TO KNOW: Timing, symptoms, re-producibility

Cow's Milk Protein Allergy (CMPA)

Non-IGE mediated often delayed (2-72 hrs post ingestion)- eczema, URTI, gut symptoms e.g constipation/ diarrhoea

Management of CMPA- breast milk is gold standard, mother exclude milk and soya

Common causes of food intolerance

salicylates in fruit and vegetables (casues non specfiic red rash, behaviour in children and young people with ASD)

Food labelling- common food allergens not covered by UK laww include lentils, chickpeas and kiwi

Natasha's Law- prepacked for direct sale / PPDS is food packed at same place its sold. foods include meat pies made on site, sandwiches and baked goods packed on site