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Early Intervention - What’s New with Health and Nutrition 2012 Infant and Early Childhood Early Intervention - What’s New with Health and Nutrition 2012 Infant and Early Childhood Conference Sharon Feucht MS, RD, CD Nutritionist Center on Human Development and Disability University of Washington March 15, 2012

Objectives: • Identify accepted guidelines for growth and discuss selected nutrients for young children Objectives: • Identify accepted guidelines for growth and discuss selected nutrients for young children • Describe evidence-based strategies and outcomes for promoting appropriate nutritional behaviors for children • Describe a survey of nutrition service delivery for centers providing early support for infants and toddlers (ESIT) with early intervention services

Healthy Infants - Growth Weight 1 -6 months of age - gain about 5 Healthy Infants - Growth Weight 1 -6 months of age - gain about 5 to 7 ounces/week so typically double birth weight by 4 - 6 months 6 -18 months of age - gain about 3 to 5 ounces/week Typically triple birth weight by 12 months Length Infants grow ~ 1 inch per month from B-6 months; ½ inch/month from 6 -12 months; usually increase birth length by 50 percent in 1 st year Bright Futures http: //www. brightfutures. org/nutritionfamfact/pdf/BWEng/IN 611 bw. pdf

Healthy Infant Intake Breast milk and/or formula until infant is 12 months of age Healthy Infant Intake Breast milk and/or formula until infant is 12 months of age Amounts – Varies based on infant Important to have parents respond to hunger and full cues Solids – Introduce at 4 -6 months of age By 1 year drinking from cup; eating from family table appropriate textured foods if developmentally able to do so Bright Futures - http: //www. brightfutures. org/nutritionfamfact/pdf/BWEng/IN 611 bw. pdf

Healthy Children Weight 4 x birth weight by 2 years of age 2 - Healthy Children Weight 4 x birth weight by 2 years of age 2 - 10 years – gain 4 ½ to 6 ½ lbs/year Growth From age 2 years grow 2 ½ to 3 ½ inches per year until puberty Bright Futures - http: //www. brightfutures. org/nutritionfamfact/pdf/BWEng/IN 611 bw. pdf

Children and Nutrition • Children are children; not small adults • Children 1 -5 Children and Nutrition • Children are children; not small adults • Children 1 -5 years are: – exploring food – mastering eating skills, – learning social skills – eating for growth and development

Healthy Children’s Intake • Appetite decreases as growth rate declines • Amount of food Healthy Children’s Intake • Appetite decreases as growth rate declines • Amount of food consumed is unpredictable • Offer food at scheduled mealtimes (3 daily) and snack times (2 -3 daily) • If young children can shovel sand/pour water from a pail they can be taught to serve themselves from bowls/plates – a self help skill that helps self-regulate food intake* Bright Futures - http: //www. brightfutures. org/ *Orlet FJ et al. Children’s bite size and intake of an entree are greater With large portion than with age-appropriate or self-selected portions. Am J Clin Nutr. 2003; 77(5); 1164 -1170).

Toddler’s/Preschoolers Nutrient Needs Energy: • BMR, rate of growth, energy expenditure of activity • Toddler’s/Preschoolers Nutrient Needs Energy: • BMR, rate of growth, energy expenditure of activity • Suggested intake: – Goal: ensure growth (but not excess weight gain), spare protein from being used for energy – For 1 -3 yo: 45 -65% as CHO, 30 -40% as fat, 5 -20% as protein – For 4 -18 yo: 45 -65% as CHO, 25 -35% as fat, 10 -30% as protein • Estimated energy expenditure (EER) – Toddlers (13 -35 months) – Children (3 -8 and 9 -18 years) • Age and sex specific • Include physical activity factor

Toddlers/Preschoolers Nutrient Needs • Protein – needs (g/kg) decrease during childhood – deficiency uncommon Toddlers/Preschoolers Nutrient Needs • Protein – needs (g/kg) decrease during childhood – deficiency uncommon in US (<3% do not meet RDA) • Minerals – – Iron - risk for iron deficiency anemia high Calcium Zinc Potassium • Vitamins – Vitamin D -

Iron • Iron – Heme and nonheme sources • Heme iron readily absorbed by Iron • Iron – Heme and nonheme sources • Heme iron readily absorbed by body • Nonheme absorption is when consumed with foods that contain Vitamin C (ascorbic acid) or meat, poultry, fish • Food sources – ½ of iron from meat, poultry and fish is heme – Rich sources of nonheme iron are fortified breads, cereals and other grain foods.

Zinc • Found in: red meat, poultry, some seafood (oysters, flounder, sole), beans, whole Zinc • Found in: red meat, poultry, some seafood (oysters, flounder, sole), beans, whole grains, some fortified cereal Whole grains are richer sources of zinc than unfortified refined grains – ½ or the grains we eat should be whole grains

2011 Dietary Reference Intakes Calcium and Vitamin D (RDA) • Calcium milligrams/day 1 -3 2011 Dietary Reference Intakes Calcium and Vitamin D (RDA) • Calcium milligrams/day 1 -3 year olds = 700 mg/d 4 -8 year olds = 1, 000 mg/d • Vitamin D International Units/day = 600 IU/d Ø 8 ounces of fortified milk provides ~ 300 mg of calcium and 100 IU of vitamin D Ø 8 ounces of yogurt provides ~ 300 mg of calcium (maybe more); ? vitamin D Ø 1. 5 ounces of cheese provides ~ 300 mg of calcium; ? vitamin D

Toddlers/Preschoolers Intake Patterns • After infancy: – decrease in milk consumption after infancy – Toddlers/Preschoolers Intake Patterns • After infancy: – decrease in milk consumption after infancy – decrease in calcium, phosphorus, riboflavin, iron, and vitamin A – relatively stable intakes of other nutrients • During second year: – decrease in vegetable intake – increase in cereals, grain products, sweets

Preschoolers – Intake Patterns • Frequency: – Small servings of foods 4 -6 times Preschoolers – Intake Patterns • Frequency: – Small servings of foods 4 -6 times per day; routine? – Consider timing – Nap time? Active? Cranky-time? • Portion sizes: – Rule-of-Thumb: 1 Tbsp of each food for every year of age; offer more according to child’s appetite • Quality of foods offered: – Nutrient-dense – Least likely to promote dental caries

Bright Futures Goals • Early development of therapeutic alliance • Develop continuum of social Bright Futures Goals • Early development of therapeutic alliance • Develop continuum of social achievements • Develop continuum of developmental achievements • Develop continuum of health achievements • Goal: Healthy, independent adults or adults with support as needed

Influences on Children’s Nutrition Behavior • The food available to the child • The Influences on Children’s Nutrition Behavior • The food available to the child • The environment for food and eating as related to child development • Parents behaviors and attitudes about food • Societal trends, media • Illness or disease

Promoting Appropriate Nourishment and Food-related Behaviors • Childhood is when dietary and lifestyle patterns Promoting Appropriate Nourishment and Food-related Behaviors • Childhood is when dietary and lifestyle patterns are initiated • Parent must understand the roles that developmental stage, physical, and cognitive skills exert on food-related behaviors

Aspects of experience with food and eating that affect food acceptance patterns • Frequency Aspects of experience with food and eating that affect food acceptance patterns • Frequency of exposure to food • Associative conditioning of food cues to physiological consequences of eating • Associative conditioning of food cues to social context of eating • Learning more about which cues – physiological, environmental, cognitive – are relevant to initiation, maintenance, termination of eating Birch

Factors important in food acceptance and rejection • Social influence: parents, siblings, and care Factors important in food acceptance and rejection • Social influence: parents, siblings, and care providers • Early experience with diversity of foods offered • Conditioned taste acceptance and aversions • Food preferences are the major determinant of food selection • Sweetness and familiarity are the most influential in determining food acceptability

What we know about how children eat… • Likes and dislikes of children are What we know about how children eat… • Likes and dislikes of children are correlated with those of their parents – sons most like fathers, daughters most like mothers • Parental preferences for high-fat, energydense foods – Limits children’s acceptance of a variety of foods – Disrupt a child’s cues for hunger and satiety

What we know about how children eat… • By the age of 5 years What we know about how children eat… • By the age of 5 years – Children’s eating is driven less by depletion cues – Increasingly influenced by external cues, such as • • Physical setting Presence of food Other eaters Time of day Carpenter et al, 2000

Children learn to… • Prefer foods offered in a positive context and dislike foods Children learn to… • Prefer foods offered in a positive context and dislike foods offered in a negative context • Be responsive to energy content of foods in controlling intake • Be responsive to parents attempts at control

Positive adult interactions with children around food • Respect for satiety cues • Expectation Positive adult interactions with children around food • Respect for satiety cues • Expectation of appropriate pace and frequency of eating • Social interaction and communication patterns around food and at meals • Appropriate foods offered • Benefit vs. threat contingencies (no rewards/bribes)

Family Meals Matter Eating a family dinner was associated with healthful dietary intake patterns: Family Meals Matter Eating a family dinner was associated with healthful dietary intake patterns: – more fruits and vegetables – less fried foods – less soda – less saturated fat – lower glycemic load – more fiber and micronutrients from food Gillman et al, Arch Fam Med, 2000

Parents shape food choices by… • Providing nourishing foods at appropriate intervals • Showing Parents shape food choices by… • Providing nourishing foods at appropriate intervals • Showing by food choices preferences for nutritious foods • Not overwhelming the child with choices • Eating with the child • Serving child-sized portions • Not fussing if the child doesn’t eat

Children can continue to: Decide whether they will eat Decide how much they will Children can continue to: Decide whether they will eat Decide how much they will eat Books by Ellyn Satter: How to Get Your Kid to Eat – But Not Too Much Child of Mine – Feeding with Love and Good Sense Secrets of Feeding a Healthy Family

Parents should diffuse the impact of media on children’s food choices by recognizing: • Parents should diffuse the impact of media on children’s food choices by recognizing: • Foods advertised - sweet, high fat • Promotion of foods for non-nourishment capabilities- fun, friends • Promotion of foods to achieve desired body shape

Promoting appropriate nutritionand food-related behaviors • Childhood is when dietary and lifestyle patterns are Promoting appropriate nutritionand food-related behaviors • Childhood is when dietary and lifestyle patterns are initiated • Parent efforts at modification of diet and activity must begin with an understanding of the child’s present behavior

Pithy Guidelines to helping families understand food and meals • • Its not ‘what’ Pithy Guidelines to helping families understand food and meals • • Its not ‘what’ but ‘how’ the family eats together It doesn’t have to be hot to be healthy Focus on food choices not forcing food Start slow, learn as you go Don’t answer the phone during mealtime Turn off the TV If possible get children involved in making meals Cook it quick, but eat it slow Food Reflections, 2000 - http: //lancaster. unl. edu/food

Leadership Model Role of Parent-child relationship Role of person with the disorder Parent provides Leadership Model Role of Parent-child relationship Role of person with the disorder Parent provides care (CEO of care) Child receives care Parent becomes manager of care Child provides some self-care Parent becomes supervisor of care Child becomes manager of care Parent becomes consultant to child Child becomes supervisor of care Child becomes CEO of care

Parenting Leadership • A thoughtful parenting strategy – Parents are involved in a qualitatively Parenting Leadership • A thoughtful parenting strategy – Parents are involved in a qualitatively different way, depending on the child’s age • Focused anticipatory in parenting style – Parents remain consistent and supportive, but negotiate a direct management role for the child

Evidenced Based Messages for All • Decrease screen time to <2 hrs/day; none<2 yrs Evidenced Based Messages for All • Decrease screen time to <2 hrs/day; none<2 yrs age • Minimize sugar-sweetened beverages – SSB (some recommendations say none) • Consume at least 5 servings of fruits and vegetables daily - serving sizes vary • Be physically active 1 hour or more daily (several active periods can add up to 1 hour) • Consume a healthy breakfast daily • Involve the whole family in lifestyle changes • .

Nutrition Education • Offer age-appropriate portion sizes • Satisfy thirst with water • Lower- Nutrition Education • Offer age-appropriate portion sizes • Satisfy thirst with water • Lower- energy (calorie) options – Lowfat/nonfat milk vs. whole/2% – Offer more fruits and vegetables – Zero or almost no sugary beverages; diet soda vs. regular soda? ? – Pretzels or baked chips vs. regular potato chips – Prepare food together at home

Physical Activity for Children Ages 2 -5 years • No specific time recommendations in Physical Activity for Children Ages 2 -5 years • No specific time recommendations in the guidelines; young children should play actively several times each day • Encourage muscle strengthening activities (such as climbing) and bone strengthening activities (such as jumping) 3 days a week

Picky Eaters Handout provided with your packet of materials. What do you suggest to Picky Eaters Handout provided with your packet of materials. What do you suggest to families?

Dietary Guidelines 2010 7 th edition (updated every 5 years) providing advice for those Dietary Guidelines 2010 7 th edition (updated every 5 years) providing advice for those 2 years of age and older, including those at increased risk of chronic disease 2 overall concepts: Ø Maintain calorie balance over time to achieve and sustain a health weight Ø Focus on consuming nutrient-dense foods and beverages

Nutrition Guidance – My. Plate Nutrition Guidance – My. Plate

What’s New for 2010 Ø Meat & Beans now Protein foods Ø Suggest eating What’s New for 2010 Ø Meat & Beans now Protein foods Ø Suggest eating seafood in place of meat or poultry 2 times each week – select some higher in oils (omega 3’s) and lower in mercury such as salmon, trout, herring

What’s New for 2010 Milk Group now Dairy Products (fortified soy milk included) With What’s New for 2010 Milk Group now Dairy Products (fortified soy milk included) With the new RDA* milk for: Ø 2 -3 year-olds increased to 2 cups per day Ø 4 - to 8 -year-olds increased from 2 to 2½ cups per day *A. Catharine Ross, Christine L. Taylor, Ann L. Yaktine, and Heather B. Del Valle, Editors; Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Institute of Medicine. 2011

Tips for consumers Balancing Calories • Enjoy your food, but eat less. Avoid oversized Tips for consumers Balancing Calories • Enjoy your food, but eat less. Avoid oversized portions. Foods to Increase • Make half your plate fruits and vegetables. • Make at least half your grains whole grains. • Switch to fat-free or low-fat (1%) milk. Foods to Reduce • Compare sodium in foods like soup, bread, and frozen meals – and choose the foods with lower numbers. • Drink water instead of sugary drinks. Be Active Your Way

Activity Guidelines • 60 minutes per day – Aerobic ( moderate or vigorous – Activity Guidelines • 60 minutes per day – Aerobic ( moderate or vigorous – 3 days) – Muscle Strengthening (3 days per week) – Bone Strengthening (3 days per week) http: //www. health. gov/paguidelines/default. aspx

What we can do • Encourage families to make sure to include a vegetable What we can do • Encourage families to make sure to include a vegetable and/or fruit with every meal/snack • Eat ½ of grains as whole grains • Do need daily sources of calcium/Vit. D • Screen children you have concerns about for possible referral

Additional Tips • Eat a nutrient-dense breakfast • Reduce intake of sugar-sweetened beverages (SSB) Additional Tips • Eat a nutrient-dense breakfast • Reduce intake of sugar-sweetened beverages (SSB) • Drink low-fat or fat-free milk, small amounts of 100% juice (upper limit of 4 -6 ounces for children 1 -6 years of age)* and WATER *Pediatrics 2001: 107: 1210 -1213 (Reaffirmed October 2006)

Nutrition in Early Support for Infants and Toddlers (ESIT) • Project completed by Deonna Nutrition in Early Support for Infants and Toddlers (ESIT) • Project completed by Deonna Hughes, MS, RD, CD while a LEND nutrition trainee at the Center on Human Development and Disability at UW • Ask me about LEND = Leadership Education in Neurodevelopmental and Related Disabilities

Survey of Early Intervention Centers on Available Nutrition Services Deonna Hughes MS RD CD Survey of Early Intervention Centers on Available Nutrition Services Deonna Hughes MS RD CD LEND Nutrition Trainee

Objective of Survey • Evaluate level of involvement and impact of RDs at ESIT Objective of Survey • Evaluate level of involvement and impact of RDs at ESIT programs and NDCs of WA State • For those who employ/consult RD: – logistics of employing/consulting with the RD – amount of RD contribution – approach to providing nutrition services and feeding therapy • For those who do not employ/consult RD: – challenges and barriers

Goal • Offer nutrition services by a RD to all children at nutrition risk Goal • Offer nutrition services by a RD to all children at nutrition risk served by ESIT and NDCs Statistics • 2009/10 National Survey of Children with Special Health Care Needs – 15. 1% of children ages 0 -17 years old have a SHCN – 15% of children in WA have a SHCN

2009/10 Washington CSHNC http: //www. childhealthdata. org/learn/NS-CSHCN 2009/10 Washington CSHNC http: //www. childhealthdata. org/learn/NS-CSHCN

Nutrition Risks for Children 0 -5 years with SHCN in WA • A survey Nutrition Risks for Children 0 -5 years with SHCN in WA • A survey of children <3 years old in EI programs found 79% to 90% had one or more nutrition risk factors (1) • In Washington State – 15 % of 0 -17 years olds have a SHCN 8% of 0 -5 year olds have a SHCN - Based on reference estimate this means 34, 105 -38, 854 children 0 -5 years of age may have a nutrition risk factor (2) 1. Bayerl CT, Ries JD, Bettencourt MF, Fisher P. Nutrition issues of children in early intervention programs: primary care team approach. Semin Pediatr Gastroenterol Nutr. 1993; 4: 11 -15 2. 2009/2010 National Survey of Children with Special Health Care Needs http: //www. childhealthdata. org/learn/NS-CSHCN.

Why are these children at higher risk for nutrition concerns? • Altered growth – Why are these children at higher risk for nutrition concerns? • Altered growth – short stature, growth retardation • Increased or decreased energy needs due to medical condition, limited mobility • Over/Under weight and failure to grow • Inadequate nutrient intake – may be related to feeding difficulties including oral motor difficulties; self-feeding delays; behavioral issues; disrupted parent-child feeding interactions; anorexia; or increased needs Continued on next slide

Why are these children at higher risk for nutrition concerns? • • • Bowel Why are these children at higher risk for nutrition concerns? • • • Bowel management issues Medication-nutrient interactions Special diets, e. g. renal, diabetic, PKU Dental issues impacting feeding/diet Use of complementary and alternative medicine (CAM) including supplements alternative diets/megavitamins Van Riper C. Position of the American Dietetic Association: Providing nutrition services for people with developmental disabilities and special health care needs. J Am Diet Assoc. 2010; 110: 296 -307

Survey • Created in collaboration with RDs at CHDD • Online survey • Max. Survey • Created in collaboration with RDs at CHDD • Online survey • Max. of 21 Qs for programs w/RD, max. of 10 for those w/o • Contacted all ESIT Local Lead Agencies (n = 35) for local contacts (school districts, EI centers, etc. ) • Contacted all 15 NDCs – Some are a part of ESIT system

N = 39 Results N = 39 Results

Average # of clients served/year • All respondents: range of 3 to 3, 000, Average # of clients served/year • All respondents: range of 3 to 3, 000, median = 90 • Those that have RD (n=9): range of 22 to 3, 000, median = 341 • Those that do not have RD (n=30): range 3 to 1160, median = 50

Results from those that do have RD… Results from those that do have RD…

Other: family scholarships Other: family scholarships

Other: team recommendation, physician request, ARNP Other: team recommendation, physician request, ARNP

Other: Ongoing team training, feeding team lead, coordination of care with medical doctors/ other Other: Ongoing team training, feeding team lead, coordination of care with medical doctors/ other service providers

Results from those that do not have RD… Results from those that do not have RD…

Yes, provide referrals to: • County/public health department (x 5) • PCP makes referral Yes, provide referrals to: • County/public health department (x 5) • PCP makes referral (x 5) • Hospitals (x 7) • WIC RDs (x 3) • RDs within larger health care system (x 2) • Consult with RD from local ESIT program (x 2) • CHDD (x 1) • Community RD holds monthly consults (x 1) • Home care company (x 1)

Yes: PHN works at WIC w/ RD, RD part of feeding team, consult via Yes: PHN works at WIC w/ RD, RD part of feeding team, consult via email within a large healthcare system, contact CHDD, home care co.

Other: • RDs already within Health Care System • local schools provide most of Other: • RDs already within Health Care System • local schools provide most of Birth to Three services • not many families identify nutrition as an area of concern

Questions for all on Feeding Therapy Questions for all on Feeding Therapy

Other: parent, family therapist, COTA/L w/ specialized training, psych Other: parent, family therapist, COTA/L w/ specialized training, psych

Summary of Observations • Majority of ESIT and NDCs do not offer nutrition • Summary of Observations • Majority of ESIT and NDCs do not offer nutrition • Those who have RD seem to serve more clients per year • Funding is provided from a variety of sources • RDs are offering variety of services to programs • Programs not employing RD perceive a need for 10 or less hours/month from RD – Biggest barriers were lack of funding and not enough perceived need

Limitations • Unable to contact all EI providers • Limited response • Large variation Limitations • Unable to contact all EI providers • Limited response • Large variation in size of programs/# clients seen • Surveys subject to bias of responder

Next Steps • Create a profile of programs with RDs to serve as a Next Steps • Create a profile of programs with RDs to serve as a model to those that do not • Provide education to ESIT and NDCs that do not offer nutrition services or feeding therapy on the need and potential model

References 1. Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, References 1. Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Visser S, Kogan MD. Trends in the Prevalence of Developmental Disabilities in US Children, 1997– 2008 2. Bayerl CT, Ries JD, Bettencourt MF, Fisher P. Nutrition issues of children in early intervention programs: primary care team approach. Semin Pediatr Gastroenterol Nutr. 1993; 4: 11 -15. 3. Pediatrics. Published online May 23, 2011 (doi: 10. 1542/peds. 2010 -2989).

Resources for Families and Professionals Resources for Families and Professionals

http: //www. brightfutures. org http: //www. brightfutures. org

http: //www. ellynsatter. com http: //www. ellynsatter. com

http: //www. cnpp. usda. gov http: //www. cnpp. usda. gov

http: //www. kidnetic. com http: //www. kidnetic. com

http: //www. nutritionexplorations. com http: //www. nutritionexplorations. com

http: //www. earlyliteracylearning. org/ index. php • Goal of Center for Early Literacy Learning http: //www. earlyliteracylearning. org/ index. php • Goal of Center for Early Literacy Learning (CELL): • to promote the adoption and sustained use of evidence-based early literacy learning practices • See this site for resources for early childhood intervention practitioners, parents, and other caregivers of children, birth to five years of age, with identified disabilities, developmental delays, and those at-risk for poor outcomes. • See CELL Pops and Posters at the website

http: //www. nutritionforkids. com http: //www. nutritionforkids. com

Other Resources • http: //www. eatright. org/kids/ • Healthy Active Living for Families • Other Resources • http: //www. eatright. org/kids/ • Healthy Active Living for Families • www. healthychildren. org

Let’s Move Initiative – http: //www. letsmove. gov/ • White House, US Depts of Let’s Move Initiative – http: //www. letsmove. gov/ • White House, US Depts of HHS, Education, Agriculture and AAP joint effort – others supporting also • 4 Pillars 1. Healthy Schools 2. Access to affordable & healthy food 3. Raising children’s physical activity level 4. Empower family to make healthy choices

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