Putting Pediatric Nutritional Guidelines into Practice Alayne Gatto

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 FDAapproved 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 D 2/Ergocalciferol: synthesized by plants O Vitamin D 3/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 1000 m. L/day (~33 oz) of infant formula 1 m. L dropper or 1 drop = 400 m. L O Children/Adolescents: 400 IU through food sources or supplementation ( 1 cup milk = 100 IU, salmon(3 oz) = 400 IU; tuna(3 oz) = 150 IU; egg (yolk) = 40 IU O Serum 25(OH)D optimal level - > or = to 50 nmol(20 ng/m. L)

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 mg/day (AI) Supplement: Calcium Carbonate or Citrate? 1 -3 years - 700 mg 4 -8 years - 1000 mg 9 -18 years - 1300 mg O Vitamin D facilitates calcium absorption and promotes bone mineralization O Leafy greens (1/2 c spinach, 120 mg), cheese slice (200 mg), milk (300 mg/cup), calciumfortified foods, soy

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 (3 mg), ½ c beans (3 mg), chicken, dried fruits, molasses, fortified cereals, leafy greens, 1 oz liver (7 mg) 10 small clams (25 mg)

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 (8 g/cup), Broccoli, Avocados (6 g/half), Lentils (15 g/cup), Black Beans, Baked Beans, Berries (8 g/cup), Chia seeds (1 Tbsp/5 g), Flaxseed meal (1 Tbsp/~2 g) 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 1 Tbsp per 1 oz 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 H 2 RAs (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 -6 months, 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 Chartby. Food. 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 development 1 O The following feeding indicators have been associated with a reduced risk of stunting and being underweight 2: 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), 1/2 c dates or prunes(200), banana, mango Vegetables - 2 Tbsp avocado (50), 1 c 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 children may be lacking O Able to back your recommendations with reputable organizations O Give examples of high calorie food options O Promote the importance of good nutrition with ease O Support growing, healthy children