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iIntroduction
Paediatric Nutrition and Dietetics
General
Rowan Stewart APD
ii Paediatric Nutrition and Dietetics
Special Acknowledgements
The support of the dietitians who have contributed to Paediatric Nutrition and Dietetics is warmly acknowledged. Special thanks goes to Kathy Beck for the thought and insight she dedicated to the book's format and for her collaboration, support and help in bringing our team of experts together. Thank you to Melissa Gilroy for her contributions, suggestions and direction. Thanks goes to Sally McCray, (Director Nutrition and Dietetics at Mater Health Services, Mater Children's and Mater Children's Private Hospital, Brisbane) and Dr. Robyn Littlewood (Director, Nutrition and Dietetics Department, Royal Children's Hospital, Brisbane) for their ongoing support of this project.
Recognition must also be given to the people who contributed to the design and format. Thank you to Eric Liu who demonstrated persistence and patience whilst working on the design and to Nicole Simpson, Genna Ravizza and Jennifer Hall as proofreaders.
Final thanks goes to Hume, Grace and Olivia Campbell to whom the book is dedicated.
For Health Professionals
Paediatric Nutrition and Dietetics provides information about general paediatric conditions requiring nutritional intervention. The editor, authors, contributors and reviewers of the text have endeavoured to provide accurate and up-to-date information, however, it is recommended that judicious professional assessment be applied when using this resource. The editor accepts no responsibility for omissions or inaccuracies in the content of Paediatric Nutrition and Dietetics, nor the clinical decisions made by health professionals applying the information in this text. Users are advised to confirm that the information here complies with recent changes in evidence and protocol. Medical reference ranges vary between hospitals and clinical practices. It is advised that clinicians follow the protocol at their locality.
Australian Publishing Campbell House 161 Breakfast Creek RoadNewstead, BrisbaneQueensland 4006AustraliaTel: +61 (0)7 3852 0923
All rights reserved. No part of Paediatric Nutrition and Dietetics may be reproduced, electronically transmitted, photocopied, stored in computer retrieval networks, or used in any form, without the editor’s permission. To contact, Rowan Stewart, please go to australiandietitian.com.
First edition printed in 2012
ISBN 978-0-9805086-4-2
Set in Museo Sans by Eric Liu — Communication and DesignPrinted and bound in Brisbane, Australia by Kingswood Press
The editor's policy is to use printers who embrace the Sustainable Green Print (SGP) program.
iiiIntroduction
Foreword
It is with great pleasure that I write the foreword for Paediatric Nutrition and Dietetics.
This book has been created through bringing paediatric experts together to share the most up-to-date information for health professionals and students. It is a follow-on from the widely popular Handbook of Clinical Nutrition and Dietetics 4th Edition, which has assisted dietitians and dietetic students over many years. Now with this new guide, paediatric dietitians, teachers and student dietitians alike have a practical guide which provides comprehensive information on the nutritional management of infants, children and adolescents.
Paediatric Nutrition and Dietetics contains information on guidelines, protocols and procedures used in the clinical setting meeting the needs of paediatric nutrition health practitioners. In addition to nutrition in the normally developing child, it covers paediatric conditions with the potential to adversely affect growth and development including diabetes, inflammatory bowel disease, coeliac disease, cerebral palsy and cystic fibrosis. It also offers information on adverse food reactions including allergies and intolerances, eosinophilic oesophagitis and FPIES. Sample PES statements are presented for each condition. Complete nutrition profiles of feeds and formulae, for use in infants, children, and adolescents, are included and the companies providing these products to the Australian market have been consulted to ensure profiles are current and accurate. This is the first of two books on paediatric nutrition and dietetics, the second of which is due for release in 2013 and will focus on the nutritional management of more specialised and complex paediatric conditions.
This addition to the handbook range will be an invaluable tool for novice and experienced dietitians alike and provides a quick, current reference for practitioners to be used in conjunction with more comprehensive texts and information.
Sally McCray
Director Nutrition and Dietetics Mater Health Services, Brisbane (Encompassing Mater Children’s and Mater Children’s Private Hospitals)
iv Paediatric Nutrition and Dietetics
1 Normal Paediatric Development and Growth
Nutrition Assessment by Clinical Measure..................................................................................................1
Developmental Milestones
1–24 Months .....................................................................................................................................................1
2 Years ................................................................................................................................................................4
3 Years ................................................................................................................................................................ 5
4 Years ................................................................................................................................................................6
5 Years ................................................................................................................................................................ 7
Standard Anthropometric Measurements .................................................................................................8
Growth ...................................................................................................................................................................8
Growth Charts ......................................................................................................................................................8
Anthropometric Measurements .......................................................................................................................9
Length/Height/Stature ......................................................................................................................................10
Height Prediction Equations ............................................................................................................................11
Tibial Length ................................................................................................................................................ 12
Upper-arm Length ..................................................................................................................................... 13
Knee Height ................................................................................................................................................. 13
Standard Deviation Scores (Z Scores) ........................................................................................................... 14
Weight................................................................................................................................................................... 15
Amputation .......................................................................................................................................................... 16
Head Circumference ......................................................................................................................................... 17
Body Mass Index ................................................................................................................................................ 18
Tricep Skinfolds...................................................................................................................................................20
Arm-muscle Circumference ...........................................................................................................................20
Assessing Body Composition ..........................................................................................................................22
Abdominal Quadrants .......................................................................................................................................22
References ..........................................................................................................................................................23
Table of Contents
vIntroduction
2 Requirements for Infants and Children
Nutrient Reference Values (NRVs) Abbreviations and Definitions ..................................................25
Estimated Average Requirement (EAR) .........................................................................................................25
Recommended Dietary Intake (RDI) ..............................................................................................................25
Adequate Intake (AI) ..........................................................................................................................................25
Estimated Energy Requirement (EER) ...........................................................................................................25
Upper Level of Intake (UL) ...............................................................................................................................25
Overview of Nutrients .......................................................................................................................................26
Energy Requirements .....................................................................................................................................27
Schofield Equation.............................................................................................................................................30
Harris-Benedict Equation .................................................................................................................................30
NRVs for Macronutrients .................................................................................................................................. 31
NRVs for Water-soluble Vitamins and Choline ........................................................................................... 31
NRVs for Fat-soluble Vitamins .......................................................................................................................33
NRVs for Major Minerals ..................................................................................................................................34
NRVs for Minor Minerals ..................................................................................................................................35
Calculating Requirements in the Clinical Setting ..................................................................................46
Energy Requirements ........................................................................................................................................46
Protein Requirements ......................................................................................................................................46
Fat Requirements ..............................................................................................................................................47
Fluid Requirements ...........................................................................................................................................47
References ..........................................................................................................................................................47
3 Infant and Childhood Nutrition
Breastfeeding ....................................................................................................................................................49
Contraindications to Breastfeeding ...............................................................................................................49
Nutrient Profile of Breastmilk ..........................................................................................................................50
Reasons for Complimentary/Supplementary Feeds ................................................................................. 51
Indications for Supplemental Feeds ..............................................................................................................52
Infant Satiety Signals .........................................................................................................................................52
Introducing Solids............................................................................................................................................53
Infant Development and Oral Intake .............................................................................................................53
Food Group Recommendations for Children Aged 1–18 years .............................................................54
References ..........................................................................................................................................................55
vi Paediatric Nutrition and Dietetics
4 Nutrition Assessment
Nutrition Assessment ......................................................................................................................................57
Clinical Assessment of Nutritional Status of Infants and Toddlers ..................................................58
Dietary Assessment (Infants) ...................................................................................................................... 60
Dietary Assessment (Children <5 years) ................................................................................................... 61
Dietary Assessment (School-age Children) ............................................................................................62
Dietary History Template ...............................................................................................................................63
Laboratory Reference Ranges......................................................................................................................65
Template: Communication Form for Medical and Allied Health Practitioners ............................68
Malnutrition in Children.................................................................................................................................69
Subjective Global Nutrition Assessment in Children .................................................................................69
Nutrition Screening Tools .............................................................................................................................69
Paediatric Yorkhill Malnutrition Score (PYMS) .............................................................................................69
Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) ........................................69
PYMS Screening Form ......................................................................................................................................70
STAMP Screening Form ....................................................................................................................................72
Malnutrition and Health Care Costs .......................................................................................................... 74
References .......................................................................................................................................................... 74
5 General Paediatric Conditions
Faltering Growth .............................................................................................................................................. 75
Criterion for Measuring Faltering Growth .................................................................................................... 75
Eating Behaviour Problems...........................................................................................................................81
Obesity ................................................................................................................................................................87
Type 1 Diabetes .................................................................................................................................................93
Type 2 Diabetes ..............................................................................................................................................105
Iron-deficiency Anaemia ............................................................................................................................ 108
Refeeding Syndrome .................................................................................................................................... 113
Alternative Diets and Religious Influences ............................................................................................ 114
Vegetarian Diets ............................................................................................................................................... 114
Essential and Non-essential Amino Acids .................................................................................................. 114
World Religions; Dietary Practices and Rationale .................................................................................... 115
6 Cystic Fibrosis and Cerebral Palsy
Cystic Fibrosis .................................................................................................................................................. 117
Cerebral Palsy .................................................................................................................................................129
References ........................................................................................................................................................136
viiIntroduction
7 Gastroenterology
Constipation ...................................................................................................................................................137
Bristol Constipation Scale .............................................................................................................................. 141
Common Laxatives ..........................................................................................................................................142
Commercial Fibre Supplements ...................................................................................................................143
Acute Gastroenteritis ...................................................................................................................................145
Dehydration....................................................................................................................................................... 147
Inflammatory Bowel Disease ......................................................................................................................148
Crohn's Disease ................................................................................................................................................148
Ulcerative Colitis ..............................................................................................................................................149
Gastro-oesophageal Reflux ........................................................................................................................153
Lactose Intolerance .......................................................................................................................................156
References ........................................................................................................................................................160
8 Food Hypersensitivity
Food Hypersensitivity ................................................................................................................................... 161
Coeliac Disease ..............................................................................................................................................162
Gluten-free Diet ...............................................................................................................................................165
Food Allergy ....................................................................................................................................................168
IgE-mediated Food Allergy ............................................................................................................................169
Non-IgE-mediated Food Allergy ..................................................................................................................169
Anaphylaxis Management ..............................................................................................................................169
Cow's Milk Protein Allergy ..........................................................................................................................173
Food Intolerance ............................................................................................................................................ 174
Eosinophilic Oesophagitis ..........................................................................................................................178
Food Protein-induced Enterocolitis Syndrome (FPIES) .....................................................................182
Food Additives; Name and Code .................................................................................................................184
References ........................................................................................................................................................187
viii Paediatric Nutrition and Dietetics
9 Oral and Enteral Paediatric Formulae
Nutrition Support ...........................................................................................................................................189
Detailed Guidelines for Enteral Feeding ..................................................................................................... 191
Modes of Delivery ............................................................................................................................................192
Decision Process for Paediatric Enteral Nutrition Support ....................................................................193
Decision Process for Placement of Enteral Nutrition Support .............................................................194
Placement Options for Enteral Tube Feeding Systems for Gastric and Jejunal Nutrition ..............194
Indications and Contraindications for Oral Supplements ......................................................................195
Indications and Contraindications for Enteral Nutrition .........................................................................195
Feeding Complications, Potential Causes and Treatments ...................................................................196
Standard Bottle Feeds .....................................................................................................................................197
Specialised Oral and Enteral Formula .........................................................................................................198
Starting Rates ....................................................................................................................................................198
Enteral Feeding Order .....................................................................................................................................199
Chart Entry Suggestions .................................................................................................................................201
Gastrointestinal Tract and Absorption Sites ............................................................................................. 202
Infant Formulae ............................................................................................................................................. 203
Human Milk Fortifiers ..................................................................................................................................... 203
Standard Infant Formulae ............................................................................................................................. 204
Infant Soy Formulae ........................................................................................................................................ 211
Goat Formulae ..................................................................................................................................................212
Modified-lactose Formulae ...........................................................................................................................213
Thickened Formulae .......................................................................................................................................214
Low Birthweight ...............................................................................................................................................215
Renal and Liver Disorders ..............................................................................................................................216
Metabolic and Fat Malabsorption Disorders .............................................................................................. 217
Constipation and Diarrhoea ..........................................................................................................................218
Elemental Feeds ...............................................................................................................................................219
Semi-elemental Paediatric Formulae ....................................................................................................... 220
Standard Paediatric Formulae .......................................................................................................................221
High-energy Paediatric Oral and Enteral feeds, 1.5kcal/6.3kJ per mL ...............................................223
Energy, Protein, Fat and Fibre Supplements ............................................................................................. 224
Oral Supplements Suitable for Older Adolescents .............................................................................225
Powdered Oral Supplements ........................................................................................................................225
Liquid Oral Supplements, 1kcal/4.2kJ per mL .......................................................................................... 226
Liquid Oral Supplements, 1.25kcal/5.3–6.3kJ per mL ............................................................................227
Liquid Oral Supplements 2.0kcal/8.4kJ per mL ....................................................................................... 228
Liquid Oral Supplements for Cancer and Respiratory Conditions ...................................................... 229
Liquid Oral Supplements for Diabetes and Glucose Intolerance ........................................................ 230
Liquid Oral Supplements for Renal Conditions ....................................................................................... 230
Liquid Oral Supplements for Surgery/Wound Healing ...........................................................................231
ixIntroduction
Nutrient Profiles of Texture Modified Products ...................................................................................231
Thickened Resources, Nestlé Australia .......................................................................................................231
High-energy, High-protein Puddings .........................................................................................................232
Nutrient Profiles of Enteral Formulae for Older Adolescents ..........................................................233
Standard Formulae, 1.0-1.2kcal/4.2kJ per mL ..........................................................................................233
Standard Formulae with Fibre, 1.0kcal/4.2kJ per mL ............................................................................. 234
Enteral Formulae, 1.5kcal/6.3kJ per mL .....................................................................................................235
Enteral Formulae with Fibre, 1.25–1.5kcal/5.25–6.3kJ per mL ............................................................ 236
Enteral Formulae, 2.0kcal/8.4kJ per mL .....................................................................................................237
Elemental Formulae ........................................................................................................................................237
Special-purpose Enteral Feeds for Critical Care ..................................................................................... 238
Special-purpose Enteral Feeds for Diabetes, Glucose Intolerance, Low Sodium ........................... 238
Clinical Information ..................................................................................................................................... 239
Company Contact Details ......................................................................................................................... 239
References ..................................................................................................................................................... 239
10 Fortification
Fortification Strategies for Infants ................................................................................................................241
Fortification Strategies for Toddlers and Older Children ....................................................................... 242
Fortification Guidelines .............................................................................................................................. 242
Parameters to Check when Manipulating Feeds......................................................................................243
Terminology for Increased-strength Formula ..........................................................................................243
Concentrating Infant Feeds ....................................................................................................................... 244
Concentrating Feeds for Breastfed Infants at Home ............................................................................. 244
Increasing the Strength of Infant Formula in Hospital (Formula Room) ........................................... 244
Increasing the Strength of Infant Formula at Home ..............................................................................245
1¼ Strength-formula Recipes for At-home Preparation .......................................................................245
Ready Reckoner for Manipulated Infant Feeds ........................................................................................ 246
Common Modular Additives...................................................................................................................... 246
High-energy, High-protein Diets ..............................................................................................................251
High-energy Diets for Infants (<12 months) ..............................................................................................251
High-energy Diets for Children (>12 months) ..........................................................................................252
High-energy, High-protein Meal Ideas .......................................................................................................253
Sample Education Sheet for Carers ............................................................................................................ 254
References ..................................................................................................................................................... 254
x Paediatric Nutrition and Dietetics
11 Food Composition Tables
Infant Foods .....................................................................................................................................................255
Heinz Infant and Toddler Foods .................................................................................................................. 256
Macronutrients in Common Foods ............................................................................................................ 260
Calcium ............................................................................................................................................................. 264
Iodine ................................................................................................................................................................. 266
Iron ......................................................................................................................................................................267
Phosphorous .................................................................................................................................................... 268
Potassium ......................................................................................................................................................... 269
Sodium ...............................................................................................................................................................273
Zinc ......................................................................................................................................................................275
Folate ..................................................................................................................................................................276
Vitamin K ............................................................................................................................................................277
Alcohol ...............................................................................................................................................................278
Cholesterol ........................................................................................................................................................279
Caffeine ............................................................................................................................................................. 280
Fibre.....................................................................................................................................................................281
Moisture Content of Foods .......................................................................................................................... 283
Intravenous (IV) Fluid Composition ............................................................................................................ 283
IV Glucose Solutions in Viaflex Plastic Bag (Baxter) ................................................................................ 283
Key ...................................................................................................................................................................... 284
References ..................................................................................................................................................... 284
Appendices
Appendix 1 — Texture Modifications
Texture Modifications ................................................................................................................................ 285
Texture Modified Foods ................................................................................................................................. 286
Texture Modified Fluids...................................................................................................................................287
Texture A — Soft .............................................................................................................................................. 288
Texture B — Minced and Moist .................................................................................................................... 289
Texture C — Smooth Pureed........................................................................................................................ 290
Appendix 2 — Medical Abbreviations
Medical Abbreviations .................................................................................................................................... 293
Appendix 3 — Glossary
Glossary of Terms ............................................................................................................................................297
xiIntroduction
Appendix 4 — Growth Charts
Measuring Techniques and Table Directions ............................................................................................300
Boys and Girls in Utero (24–42 wks) ...........................................................................................................301
Girls Head Circumference (In utero 28–40 wks and 0–12 mth) ........................................................ 302
Girls (0–3 yrs) — Weight Percentile ............................................................................................................ 303
Girls (0–3 yrs) — Length Percentile ............................................................................................................ 304
Girls (1–3 yrs) — Head Circumference ...................................................................................................... 305
Record Sheet for All Ages ............................................................................................................................. 305
Girls (2–18 yrs) — Weight Percentile .......................................................................................................... 306
Girls (2–18 yrs) — Height Percentile ........................................................................................................... 307
Girls (2–18 yrs) – Height Velocity ............................................................................................................... 308
Girls (2–18 yrs) — Head Circumference .................................................................................................... 309
Boys in Utero (24–42 wks) and Post Natal (0–3 years) ..........................................................................310
Boys (0–3 yrs) — Weight Percentile ............................................................................................................ 311
Boys (0–3 yrs) — Length Percentile ............................................................................................................312
Boys (1–3 yrs) — Head Circumference .......................................................................................................313
Record Sheet for All Ages ..............................................................................................................................313
Boys (2–18 yrs) — Weight Percentile ..........................................................................................................314
Boys (2–18 yrs) — Height Percentile ...........................................................................................................315
Boys (2–18 yrs) — Height Velocity ...............................................................................................................316
Boys (2–18 yrs) — Head Circumference .................................................................................................... 317
Boys (2–18 yrs) — Body Mass Index ............................................................................................................ 317
Girls (2–18 yrs) — Stages of Puberty ...........................................................................................................318
Boys (2–18 yrs) — Stages of Puberty...........................................................................................................319
Boys (2–18 yrs) — Stretched Penile Length .............................................................................................. 320
References ....................................................................................................................................................... 320
World Health Organisation Growth Charts
Head Circumference for Age, Boys .............................................................................................................322
Head Circumference for Age, Girls .............................................................................................................323
Length for Age, Boys ...................................................................................................................................... 324
Length for Age, Girls........................................................................................................................................325
Weight for Age, Boys ...................................................................................................................................... 326
Weight for Age, Girls .......................................................................................................................................327
Appendix 5 — Conversion Factors
Conversion Factors ....................................................................................................................................... 328
Conversion of Pounds to Kilograms .......................................................................................................... 329
Conversion of Inches to Centimetres ........................................................................................................ 330
Appendix 6 — Contacts
Contact Information .......................................................................................................................................331
xii Paediatric Nutrition and Dietetics
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