Sharon Feucht MS, RD,CD Nutritionist Center on Human Development and Disability

1. Early Intervention - What’s New with Health and Nutrition2012 Infant and Early Childhood Conference Sharon Feucht MS, RD,CD Nutritionist Center on Human Development and Disability University of Washington March 15, 2012

2. 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

3. 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 1st year Bright Futures - http://www.brightfutures.org/nutritionfamfact/pdf/BWEng/IN611bw.pdf

4. Healthy InfantIntake 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/IN611bw.pdf

5. Healthy Children Weight 4x 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/IN611bw.pdf

6. 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

7. 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).

8. 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

9. 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 -

10. 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.

11. 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

12. 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 • 8 ounces of fortified milk provides ~ 300 mg of calcium and 100 IU of vitamin D • 8 ounces of yogurt provides ~ 300 mg of calcium (maybe more); ? vitamin D • 1.5 ounces of cheese provides ~ 300 mg of calcium; ? vitamin D

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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, energy-dense foods • Limits children’s acceptance of a variety of foods • Disrupt a child’s cues for hunger and satiety

21. 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

22. 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

23. 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)

24. 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

25. 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

26. 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

27. 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

28. Promoting appropriate nutrition- and 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

29. 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

30. Leadership Model Role of Parent 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 becomesmanager of care Parent becomesconsultant to child Child becomessupervisor of care Child becomesCEO of care

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

32. 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 • .

33. 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

34. 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 activities (such as jumping) 3 days a week

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

36. Dietary Guidelines 2010 7th 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: • Maintain calorie balance over time to achieve and sustain a health weight • Focus on consuming nutrient-dense foods and beverages

37. Nutrition Guidance – MyPlate

38. What’s New for 2010 • Meat & Beans now Protein foods • 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

39. What’s New for 2010 Milk Group now Dairy Products (fortified soy milk included) With the new RDA* milk for: • 2-3 year-olds increased to 2 cups per day • 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

40. 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

41. 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/guidelines/default.aspx

42. 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

43. 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)

44. 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

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

46. 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

47. 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

48. 2009/10 Washington CSHNC - http://www.childhealthdata.org/learn/NS-CSHCN

49. 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) • 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 • 2009/2010 National Survey of Children with Special Health Care Needs http://www.childhealthdata.org/learn/NS-CSHCN .

50. 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