Assignment #2 – Nutrition During Childhood Case Study Due: Friday, July 10

25 points

DIRECTIONS Please type out your responses and number your answers for each question. Your responses should be concise and reflect a lot of thought. Assignments must be typed and submitted on time with proper format and correct grammar, spelling and punctuation. Assignments will be accepted up to 1 week past the due date and 2 points will be deducted from your final score for each day an assignment is overdue. Staple sheets together before handing them in, and be sure to put your name on your work. Include a reference list (including class notes and book) of those citations that you used for your answers. For question #1, please fax (970-351-1489); scan and email; or mail your growth charts to Alena Clark. If mailing the charts, they must be postmarked by Friday, July 12 to: Dr. Alena Clark; Dietetics Program; University of Northern Colorado; Campus Box 93; Greeley, CO; 80639. DO NOT MAIL OR FAX YOUR ENTIRE CASE STUDY!

PART 1 Joey is a 2 year old boy. His mother considers him to be a picky eater. He loves whole milk and sometimes will only drink at a meal and pick at the other foods. His favorite foods are Fruity Pebbles® cereal, chicken nuggets, tomatoes, mashed potatoes and cheese. His mom is concerned that he is not getting enough nutrients and often forces him to eat or allows him to eat Fruity Pebbles® for every meal. Joey carries his sippy cup filled with juice (favorite kind – SunnyD) around with him during the day in case he gets thirsty. Joey often goes to bed with a bottle of formula as he “will not go to bed without one”. Joey is having difficulty with potty training. His mom states that he also seems pale and more tired during the day and he is complaining of an itchy rash on his arm.

Lab Values Hemoglobin: 10.2 g/dL

Growth history (obtained from medical records): weight height Birth 6# 1 oz. 21 in. 6 months 13# 4 oz. 24 in. 12 months 17# 9 oz. 27 ½ in. 18 months 20# 1 oz. 27 ½ in. 2 yrs 22# 4 oz. 30 in.

Part 1 Questions (15 points):

1. Print off and plot Joey’s weights-for-age and heights-for-age on the WHO growth charts (plot all available). When would it be appropriate to chart his BMI percentile on a growth chart? Growth chart is available below (2 points): http://www.cdc.gov/growthcharts/data/who/grchrt_boys_24lw_9210.pdf

It would be appropriate to begin charting his BMI percentile on a growth chart now at and over 2 years old. 1

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2. Assess Joey’s growth from birth to now. How is he doing in regards to height, weight and BMI? (1 point).

Joey’s weight has doubled from birth by 4 months of age as expected 2 and continued to increase at a steady rate following his own curve into the 5% percentile for the weight-for-age, lower than expected according to the curve for his birthweight on the WHO Child Growth Standards. His length/height is well below the expected height-for-age and his 6 month plateau in growth between 12 and 18 months is also concerning. 3

3. Is Joey’s hemoglobin level in the normal range? What is the DRI for iron for Joey? What would you recommend based on your assessment of his hemoglobin? (2 points).

Joey’s hemoglobin levels are below the hemoglobin concentration for diagnosis of anemia (<11.0 g/dL 1-2 yearsor <11.1g/dL at 2-5 years) for his age group at 10.2g/dL 1. The DRI of iron for toddlers is 7mg/d. Based on his hemoglobin and current diet, I would recommend offering iron rich foods (i.e. lean meats) along with vitamin C rich foods (i.e. fruits and vegetables) as well as supplementation with iron drops at a dose of 3mg/kg per day (at 10kg currently, he would require 30mg) and repeat screening in 4 weeks to see if his hemoglobin concentration increases. If there is an increase greater than 1g/dL, the diagnosis is confirmed and iron treatment and reinforcement should continue. If, however, hemoglobin levels are unresponsive to treatment, further diagnostic testing is needed to rule out other nutritional deficiencies, chronic inflammation or infections.1

4. What are your thoughts about the nutritional adequacy (protein, calories, carbohydrates, vitamins and minerals) of a diet based on foods he eats frequently? Include reasons and evidence to support your answer for each of the above areas. (3 points).

The nutritional adequacy of Joey’s current diet is lacking. His current sources of protein (chicken nuggets and cheese) in are high in calories and fat, but low in vitamins and minerals. His current sources of carbohydrates (fruity pebbles, mashed potatoes and sunnyD), although fortified, are high in sugar and low in fiber, which may be contributing to potty training difficulties. Without an adequate measure, his caloric intake may also be low. His habit of drinking milk instead of eating is probably interfering with his ability to consume other foods, as he fills quickly on it rather than on other nutrient dense foods. His preference for tomatoes may lead to an interest in other fruits and vegetables of similar colors and textures if offered throughout the day, but may be contributing to his rash if there is an allergy and should be monitored. 4

5. What nutritional concerns (list at least three) do you have for Joey and his mother given all of the information listed above? For each nutrition concern, list 1 suggestion to help improve each concern (3 points).

I am concerned about Joey’s lack of nutrient dense foods, as he is a toddler he will fill quickly on juice and should be offered fruits and vegetables with adequate fiber instead of high sugar juices and cereals. This may help with his potty training. His low energy, pallor, and low hemoglobin are concerning and suggestive of inadequate iron consumption. He should have lean meats cut up for him in place of chicken nuggets for adequate protein and iron consumption and be offered alongside his fruits and

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vegetables several times throughout the day for maximum absorption and consumption. It may take numerous exposures to become accustomed or accepting of a new food. I am also concerned about his bedtime bottle feeding habit, which can lead to tooth decay, and should be discouraged. He needs routine dental care. His bedtime may benefit from having adequate snacks and remaining active throughout the day. 1,2,4

6. List 6 additional questions you would like to ask his mother (2 points).

• When did Joey begin consuming whole milk? If in infancy, this may have contributed to blood loss/anemia 5

• What does Joey’s daily routine consist of? To have a better understanding of when he is eating and how.

• Who provides each meal throughout the day? Is he at daycare or a babysitters? • How are his meals presented to him? Are they diverse and offered frequently? • How often are new foods presented? • Has he seen a healthcare provider for the rash, and when did it begin, what

circumstances were surrounding the rash? To investigate a possible food allergy or reason for food avoidance.

• Is Joey receiving dental care, and are his teeth brushed twice a day?

7. What would you prioritize as the nutrition problem of highest priority at this time? Why? (1 point).

The primary nutrition problem I see at this point is iron deficiency anemia, which can lead to delayed cognitive development and behavioral disturbances, and should be addressed immediately. 1

8. We often focus on what is wrong with a patient. What is going well with Joey’s nutrition and eating habits given the information that you know? List at least 2 areas. (1 point).

It is good that Joey has continued to gain weight and grow to some extent. He also shows interest in some foods which can be expanded to include a variety through patience and persistence.

Part 2 Activity (10 points): Your boss, Fran, received a phone call from Joey’s mother. Joey is now growing according to the growth charts and is trying a variety of new foods. She wanted to call to thank you. Because you did such a great job, Fran would like you to develop an educational material piece that everyone in your office can use in future nutrition counseling sessions with young children. USING CREATIVITY IS A MUST!

For the activity, develop an educational material piece that you could give to a young child and/or his or her parent that would provide them with information on nutrition during childhood.

Points for Part 2 Activity: ✓ 3 points – realistic nutrition tip(s) ✓ 3 points – accurate nutrition tip(s) ✓ 4 points – creativity

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For Part 2 of the assignment, please either email the actual educational piece or if it is something that cannot be mailed, please take a digital photo of your work and email it to the instructor by the above due date and time. I would also encourage you to post Part 2 to the discussion board link. Please only post your part 2, not your entire case study.

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References:

1. Brown JE. Toddler and Preschooler Nutrition. In: Nutrition Through the Life Cycle, 5th ed. Stamford, CT: Cengage; 2014: 273-301.

2. Clark A. Nutrition During Infancy. [PowerPoint]. Greeley, CO: UNC- Distance Dietetics Program; 2015. Accessed July 8, 2015.

3. Clark A. Child Growth and Growth Assessment. [PowerPoint]. Greeley, CO: UNC- Distance Dietetics Program; 2015. Accessed July 8, 2015.

4. Clark A. Nutrition and Feeding of Preschool Children. [PowerPoint]. Greeley, CO: UNC- Distance Dietetics Program; 2015. Accessed July 8, 2015.

5. Brown JE. Infant Nutrition. In: Nutrition Through the Life Cycle, 5th ed. Stamford, CT: Cengage; 2014: 227-251

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