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