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