Nutritional Management and Assessing Outcome Rosan Meyer (RD, PhD) - - PowerPoint PPT Presentation

Nutritional Management and Assessing Outcome

Rosan Meyer (RD, PhD) And Luise Marino, Hinke Kruizenga, Nicolette Wierdsma 2020

Conflict of In Interest

• Academic lectures for:
• Danone/Nutricia
• Mead Johnson
• Nestle
• Research grant holder: Danone/Nutricia
• Board member: CoMISS Nestle

Overv rview of Presentation

Nutritional Assessment Nutritional Management Assessing Outcome

Need for Early In Intervention

Source: Tanner, Whitehouse and Takaishi data 1966

Nutritional Management should Consider Outcome fr from the Start

Nutritional objectives

• Catch up weight gain
• Avoid vitamin/mineral deficiencies
• Manage symptoms
• Reduce anxiety
• Advice on complementary foods

Assess growth chart Review intake and selected blood test Assess symptoms after intervention Parent Proxy QoL (cardiac module exists) Number of foods introduced and feeding practice

https://www.bda.uk.com/practice-and-education/nutrition- and-dietetic-practice/outcomes.html

Marino et al. Cardiology in the Young 2018; 28: 938–948.

Nutritional Management

Nutritional Management

Im Impact of f Concentration and Feed Modulation

• Energy:Protein ratio disturbed ++ (as low as 6% of

energy from protein)

• Weight gain = fat mass and limited LBM
• Dehydration = ↑ Renal Solute Load
• Diarrhoea + vomiting
• Osmolality ↑ (> 400 mOsm/kg)
• Fat content
• Accuracy of mixing at home
• Taste??

Jeff SG. Journal of the Royal College of General Practitioners, 1989, 39, 113. Meyer et al. Pediatr Allergy Immunol 2012: 23: 307–314.

Clinical presentation DRACMA (2010) 1st choice ESPGHAN (2012) 1st choice Australian Guidelines (2009) BSACI (2014)

Anaphylaxis AAF AAF

AAF AAF

Acute urticaria or angioedema eHF No specific mention, but eHF in general as 1st line

eHF if < 6 months Soya if > 6 months eHF

Atopic eczema/dermatitis eHF No specific mention, but eHF in general as 1st line treatment

eHF if < 6 months Soya if > 6 months eHF if >6 months if also presenting with faltering growth eHF but if symptoms whilst exclusively breastfed then AAF

EoE AAF AAF (for EGID)

AAF AAF

Gastroesophageal reflux disease eHF No specific mention but eHF in general as 1st line treatment

eHF if < 6 months Soya if > 6 months eHF if >6 months if also presenting with faltering growth eHF (unless faltering growth then AAF)

Cow’s milk protein-induced enteropathy eHF AAF (complicated by growth faltering)

eHF if < 6 months Soya if > 6 months eHF if >6 months if also presenting with faltering growth eHF (unless faltering growth then AAF)

FPIES eHF AAF

eHF AAF

Proctocolitis eHF No specific mention, but eHF in general as 1st line treatment

eHF if < 6 months Soya if > 6 months eHF if >6 months if also presenting with faltering growth eHF (unless faltering growth then AAF)

Smith et al. Clinical Nutrition 37 (2018) 1005e1012

Vitamin and Mineral Supplements

• Single micronutrient supplement?
• Vitamin D
• Multivitamin?
• Multivitamin and mineral supplement?
• 100% of DRV or more? If more, is this a problem?
• Drops? Syrup or patches…..
• Timing of supplementation

Assessing Vitamin and Mineral Status

Meyer R. Pediatr Allergy Immunol. 2018;29:689. Tricon et al. Tricon S, Willers S, Smit HA, et al. Nutrition and allergic disease. Clin Exp Allergy Rev. 2006;6(5):117‐188.

• 1. Measurement of

nutritional blood markers need to be guided by diagnosis/diet history

• 2. What is the sensitivity and

specificity of the marker?

• 3. Do you measure whole

blood, plasma, red blood cell or white cell…..

• 4. What are the factors that

impact on the results Markers to be considered:

• 1. Vitamin D and

bone profile

• 2. Iron status
• 3. Growth

deficiencies and ++ gastrointestinal symptoms: zinc

• 4. Occasionally

selenium

URL dowload ebook: https://www.flipsnack.com/amberbellnhs/recipe- book.html Hard copies: http://www.southamptonhospitalcharity.org/index.php?id =41&product=72

Incorporating nut butters Ages 1 – 3 years: an extra 200 - 300kcal, 7.5g protein per day Ages 4 – 5 years: an extra 300 – 500kcal, 12.5g protein per day

Dulloo et al. International Journal of Obesity (2006) 30, S23–S35 Fall & Kumaran. Philos Trans R Soc Lond B Biol Sci. 2019 Apr 15;374(1770):20180123 Reynolds et al. Nutrients. 2015 Sep 21;7(9):8090-111.

Falt ltering Growth – when is is catch up growth too much?

The Thrifty Catch-Up Fat Phenotype

Monitoring Catch-up Weight Gain

• Regular monitoring is essential for catch up growth:
• Frequency of monitoring depends on the aimed catch-up rate, age, access
• How much is too much?
• Research better established in neonates
• Monitor growth regularly so that it does not exceed aimed growth gain

rate

Shoham et al. Food Nutr Bull. 2009 Sep;30(3 Suppl):S464-74. Golden M.H. Food and Nutrition Bulletin 2009;30:S267-S342 Garner et al.

Monitoring Catch-up Length/Height Gain in

• Himes Acta Paediatr 88: 120±5. 1999: highlights frequency of length/height measurement

frequency

• Soliman et al 2019: 39% catch up growth after 4 months and rest after 9 months
• Measurement should:
• Use the correct equipment
• The WHO technique
• Lying down until 2 years of age
• Standing up > 2 years of age
• Hymes. Arch. Dis. Child. 2000;82;197-201

Assessing Nutritional Pathways of Care

Conclusion

• Dietary management should be evidence based, taking into account:
• Diagnosis
• Nutritional status
• Parent/Family QoL
• Consequences of nutritional management should be considered (using

available evidence)

• Food = medicine
• Dietary management should be practical to implement
• A dietary management plan should from the start consider outcome

measurements

• Dietitians need to set outcome measurements for practice
• Quality assurance framework assist in achieving outcome

Thank You