Failure to Thrive and Picky Eaters Why liquid

Failure to Thrive and Picky Eaters Why liquid calories are not the answer

Disclosures �I have no financial disclosures

Objectives �Definition of failure to thrive (FTT) �Sugar guidelines (AHA/WHO) and addiction �Why not Pediasure �Weight gain and WIC foods �When to supplement �Picky eaters

Definition FTT �Failure to thrive is defined as decelerated or arrested physical growth �It is a sign of undernutrition �FTT is a clinical finding and should never be a diagnosis on its own Cole, 2011

Definition �BMI for age less than the 5 th percentile �Length for age less than 5 th percentile �Weight deceleration crossing two major percentile lines �Weight less than 75% of median weight for age �Weight less than 75% of median weight for length �Weight velocity less than 5 th percentile Cole, 2011

Diagnosis �Any single indicator has a low positive predictive value for true undernutrition �In one study, 27 percent of infants met at least one definition for FTT during the first year of life (Olsen, 2007) �Weight for length is a good indicator of acute undernutrition (Shah, 2002)

Normal growth variants �Genetics- children of small parents �Large-for-gestational-age infants who regress toward the mean �Constitutional delay in growth �Premature infants whose growth parameters are normal when corrected for gestational age Cole, 2011

Growth charts

Source: Cole SZ, Lanham JS. Failure to Thrive: An Update. Am Fam Physician. 2011; 83(7): 829 -834.

Why is FTT important? �Malnutrition can impact growth potential and cognitive development �Obese patients can have significant micronutrient deficiencies (Via, 2012) �Good nutrition is the goal, not just weight gain

Dietary History Nutrition �Overall calories �Set meals vs grazing �Types of food �Juice and milk intake Occupational Therapy �Choking/gagging �Frequent respiratory infections �Overstuffing mouth �Issues with specific or mixed textures

Why are juice and milk bad? �Can interfere with proper nutrition �Can fill kids up so they decrease their intake of solid foods �Excess milk can cause anemia �Juice causes cavities and can increase risk of obesity

Excess juice contributes to FTT �Study looked at 8 children, 14 -27 months old with FTT � 12 to 30 oz per day of fruit juice which contributed to 2560% of daily energy intake �Had lower dietary protein, fat, and micronutrient intake �Decrease in weight and linear growth that coincided with juice consumption �Their diet only provided 78% to 92% of recommended energy intake for age and weight �After nutritional intervention, dietary intake increased to 96% to 116% of recommended intakes. �Weight gain increased significantly in the first month and persisted for follow up of 5 to 18 months Smith, 1994

Juice affects of stature � 163 children that were 2 and 5 years old �Dietary intake recorded over 14 days �Adjusted for child age, gender and energy intake (excluding fruit juice) and maternal height �Child height was inversely related to apple juice and grape juice intake (Dennison, 1999) �Related study showed >12 oz juice per day to be correlated to short stature (Dennison, 1997)

My child has FTT what should I give them? � Pediasure

Liquid calories �Teaches kids to be picky eaters �Perpetuates sweet tooth �Can lead to obesity

How much added sugar do we consume? � 1 to 3 year olds: 12 teaspoons/day � 4 to 8 year olds: 21 teaspoons/day � 14 to 18 year olds: 34. 3 teaspoons/day Source: National Cancer Institute and National Health and Nutrition Examination Survey

Is sugar addictive? �Chronic smokers could reduce tobacco cravings better than sugar cravings �Sugar affects dopamine receptors similarly to cocaine �After consuming sugar there is a surge in serotonin in the brain Di. Nicolantonio, 2018

Oregon Research Institute

Intense Sweetness Surpasses Cocaine Reward �Drug naive rats were allowed to choose between water sweetened with saccharin versus IV cocaine � 132 rats Lenoir, 2007

S-/C+ S+/C+ Lenoir M, Serre F, Cantin L, Ahmed SH. Intense Sweetness Surpasses Cocaine Reward. PLo. S ONE. 2007; 2(8): e 698.

Lenoir M, Serre F, Cantin L, Ahmed SH. Intense Sweetness Surpasses Cocaine Reward. PLo. S ONE. 2007; 2(8): e 698.

Rats and sugar conclusions � 94% of rats preferred saccharin �Same preference observed with sucrose �Increased doses of cocaine were not able to overcome rats choice of saccharin

Reward dysfunction and compulsive eating �Wanted to test effects of restricted or extended access to a palatable diet �Rats had timed access to palatable diet for 40 consecutive days � 0 hr (chow-only) � 1 hr (restricted access) � 18 -23 h (extended access) �Also had ad lib access to standard chow �Palatable diet: bacon, sausage, cheesecake, pound cake, frosting, and chocolate Johnson, 2010

40 days of access to palpable diet Chow Only 0 hour Restricted Access 1 hour Extended Access 18 -23 hour

Johnson PM, Kenny PJ. Addiction-like reward dysfunction and compulsive eating in obese rats: Role for dopamine D 2 receptors. Nature neuroscience. 2010; 13(5): 635 -641.

After 40 days of access to palpable diet Chow Only 0 hour Restricted Access 1 hour Extended Access 18 -23 hour • Permitted only 30 min access per day to palatable diet for 5 -7 days until stable intake • Then split into 2 groups

Unpunished Rats Chow Only Restricted Extended Punished Rats Chow Only Restricted Extended

Johnson PM, Kenny PJ. Addiction-like reward dysfunction and compulsive eating in obese rats: Role for dopamine D 2 receptors. Nature neuroscience. 2010; 13(5): 635 -641.

Infants and sugar A study of 200 infants showed preference for sugar �At birth all infants preferred a sweet solution over water �At age 6 months the preference for the sweet solution was linked to dietary experience �Infants repeatedly fed sweetened water had greater preference for it �Offering foods without added sugar should be advised to help set the infants threshold for sweetness at a lower level De Cosmi, 2017

Serving Cal Fat Protein Carb Sugar Boost Essentials 237 ml 240 9 7 32 15 Boost Essentials 1. 5 237 ml 360 18 10 39 10 Boost Breeze 237 ml 250 54 34 Bright Beginnings Soy 237 ml 240 12 7 26 18 Enfagrow Premium Toddler Transition 5 oz 100 5. 3 2. 6 10. 8 Nutren Jr 250 ml 250 27. 5 Pediasure 237 ml 240 33 12 (14) Pediasure Sidekick 237 ml 150 21 17 0 9 Sugar: 26 gm Sugar: 28 gm 9 7 12. 4 5 7

Pedia. Sure Whole Milk Fage Greek Yogurt Kodiak String Cakes 3, 4” Cheese pancakes Calories 240 160 105 190 80 Fat (g) 9 9 6 2 6 Carb (g) 33 11 3. 5 30 0 Sugar (g) 14 11 3. 5 3 0 8 10 14 8 Protein (g) 7

Healthy weight gain foods Proteins Fats Full fat Greek yogurt Cheese Nut butters Cottage cheese Eggs Beans Meats Chia or flax seeds Whole milk (8 -12 oz per day) Butter Cream cheese Cheese Heavy cream Dressings Avocado Hummus Coconut oil Olive oil

Behaviors around weight gain �Three meals and two snacks per day �No grazing �Limit milk and juice intake �Eat at the table as a family (high chair/booster) �Avoid distractions such as screens

WIC foods

WIC foods Plain: Cal: 75 Fat: 2 g Protein: 5. 5 g Sugar: 9 g Plain Lowfat: Cal: 75 Fat: 1. 75 g Protein: 5. 5 g Sugar: 8 g Strawberry: Cal: 70 Fat: 0 g Protein: 5 g Sugar: 8 g Vanilla: Cal: 105 Fat: 1. 5 g Protein: 5. 5 g Sugar: 17 g Vanilla Lowfat: Cal: 100 Fat: 1. 5 g Protein: 5 g Sugar: 17 g Vanilla: Cal: 70 Fat: 0 g Protein: 5 g Sugar: 9 g

WIC Foods Plain Nonfat: Cal: 60 Fat: 0 g Protein: 5 g Sugar: 8 g Vanilla Lowfat: Cal: 87 Fat: 1 g Protein: 3 g Sugar: 21 g Vanilla: Cal: 130 Fat: 7 g Protein: 2 g Sugar: 14 g Plain Nonfat: Cal: 60 Fat: 0 g Protein: 4. 5 g Sugar: 6. 5 g Vanilla Lowfat: Cal: 105 Fat: 1 g Protein: 3 g Sugar: 17 g Plain Nonfat: Cal: 65 Fat: 0 g Protein: 6 g Sugar: 7. 5 g Vanilla Lowfat: Cal: 100 Fat: . 75 g Protein: 3. 5 g Sugar: 15 g

1 Large Egg Cal: 78 Fat: 5 g Protein: 6 g

An Egg a Day… � 163 infants age 6 to 9 months � 83 infants ate an egg per day for 6 months �Egg group �Increased length for age z score by 0. 63 �Increased weight z score for age by 0. 61 �Reduced stunting by 47% �Reduced underweight by 74% �Reduced intake of sugar sweetened foods Iannotti, 2017

WIC Foods 2 Tbsp Cal: 188 Fat: 16 g Protein: 8 g Sugar: 3 g

Breakfast Ideas �Yogurt Parfait � ½-2/3 cup Whole fat yogurt � 2 -3 Tbsp Frozen or fresh berries or other fruit � 2 -3 Tbsp Cereal � 1 Tbsp Chopped nuts �Peanut butter roll up � 2 -3 Tbsp peanut butter � 1 Whole grain tortilla � 1 Banana �Scrambled eggs with cheese and veggies � Can also add a splash of cream �Oatmeal � Add ins of butter and/or peanut butter

Snack Ideas �Bean and cheese burrito/quesadilla �Peanut butter balls �Peanut butter �Oats �Chia/flax seeds �Cottage cheese with fruit or vegetables �Vegetables dipped in hummus or guacamole �Tuna salad �Tuna �Mayo or cream cheese �Celery

When to supplement

Source: Cole S, Lanham J. Failure to Thrive: An Update. Am Fam Physician. 2011 Apr 1; 83(7): 829 -834.

What to supplement �Home made high calorie smoothies �Fruits �Vegetables �Fats: cream, avocado, chia seeds, etc �Proteins: peanut butter, Greek yogurt, etc

Picky Eaters

Picky eaters �First 1000 days of life are critical to development of eating habits �Children are predisposed to like energy-dense, sugary, salty foods and to reject new foods � 2 to 5 years have increased food neophobia �Dietary patterns and habits are usually stable after the age of 3– 4 years De Cosmi , 2017

Picky eaters-Food exposure �Strongest predictors of food preference �Sweetness �Familiarity �Can teach children to accept and prefer different foods based on exposure �Studies show that a food is eaten more often and is more liked by children after several offers �Acceptance of a green vegetable was observed after at least 8 exposures to it �Other studies have shown children need exposure to a new food 6 to 15 times before increasing intake and preference De Cosmi , 2017

Picky eaters- Environment �Forcing a child to eat a food will decrease the likelihood of the child liking that food �Positive environment also matters to increase willingness to try new foods De Cosmi , 2017

Picky eaters �Offer a non preferred food with a preferred food �Offer the same food multiple times and in different ways �Never force a child to eat a food �Let children play with food/food scientist �Avoid food “jags”

Sequential Oral Sensory SOS Approach to Feeding: Basic Tenets �Tenet 1: Myths About Eating interfere with understanding & treating feeding issues �Tenet 2: Systematic Desensitization based on the hierarchy of steps to eating is the best first approach to feeding treatment �Tenet 3: “Normal Development” of feeding gives us the best blueprint for creating a feeding treatment plan �Tenet 4: Food Hierarchies/Choices play an important role in feeding therapy

Food Scientist � 5 senses �Seeing �Touching �Smelling �Hearing �Tasting

Sources � Cole SZ, Lanham JS. Failure to Thrive: An Update. Am Fam Physician. 2011; 83(7): 829 -834. � Olsen EM, Petersen J, Skovgaard AM, Weile B, Jørgensen T, Wright CM. Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population. Arch Dis Child. 2007; 92(2): 109– 114. � Shah MD. Failure to thrive in children. J Clin Gastroenterol. 2002; 35(5): 371– 374. � Via M. The Malnutrition of Obesity: Micronutrient Deficiencies That Promote Diabetes. ISRN Endocrinology. 2012; 2012: 103472. � Smith MM, Lifshitz F. Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive. Pediatrics. 1994 Mar; 93(3): 438 -43. � Dennison BA, Rockwell HL, Nichols MJ, Jenkins P. Children’s Growth Parameters Vary by Type of Fruit Consumed, Journal of the American College of Nutrition. 1999; 18(4): 346 -352

Sources � Dennison BA, Rockwell HL, Baker SL. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics. 1997 Jan; 99(1): 15 -22. � National Cancer Institute and National Health and Nutrition Examination Survey � American Heart Association � Di. Nicolantonio JJ, O’Keefe JH, Wilson WL. Sugar addiction: is it real? A narrative review. Br J Sports Med. 2018; 52: 910 -913. � Organ Research Institute � Lenoir M, Serre F, Cantin L, Ahmed SH. Intense Sweetness Surpasses Cocaine Reward. PLo. S ONE. 2007; 2(8): e 698. � Johnson PM, Kenny PJ. Addiction-like reward dysfunction and compulsive eating in obese rats: Role for dopamine D 2 receptors. Nature neuroscience. 2010; 13(5): 635 -641. � Iannotti LL, et al. Eggs in Early Complementary Feeding and Child Growth: A Randomized Controlled Trial. Pediatrics. 2017 Jul; 140(1)