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 Nutritional Assessing Assessment Management 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 Assess growth chart • Avoid vitamin/mineral deficiencies Review intake and selected blood test • Manage symptoms Assess symptoms after intervention • Reduce anxiety Parent Proxy QoL (cardiac module exists) • Advice on complementary foods 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. P ediatr Allergy Immunol 2012: 23: 307 – 314.

DRACMA (2010) ESPGHAN (2012) 1 st choice 1 st choice Clinical presentation Australian Guidelines (2009) BSACI (2014) Anaphylaxis AAF AAF AAF AAF eHF if < 6 months Acute urticaria or No specific mention, but eHF in eHF Soya if > 6 months eHF general as 1 st line angioedema eHF if < 6 months No specific mention, but eHF in Soya if > 6 months eHF but if symptoms whilst Atopic eczema/dermatitis eHF general as 1 st line treatment eHF if >6 months if also presenting exclusively breastfed then AAF with faltering growth EoE AAF AAF (for EGID) AAF AAF eHF if < 6 months Gastroesophageal reflux No specific mention but eHF in Soya if > 6 months eHF (unless faltering growth then eHF general as 1 st line treatment disease eHF if >6 months if also presenting AAF) with faltering growth eHF if < 6 months Cow’s milk protein -induced AAF (complicated by growth Soya if > 6 months eHF (unless faltering growth then eHF eHF if >6 months if also presenting AAF) enteropathy faltering) with faltering growth FPIES eHF AAF eHF AAF eHF if < 6 months No specific mention, but eHF in Soya if > 6 months eHF (unless faltering growth then Proctocolitis eHF general as 1 st line treatment eHF if >6 months if also presenting AAF) with faltering growth

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 Markers to be 1. Measurement of considered: nutritional blood markers 1. Vitamin D and need to be guided by bone profile diagnosis/diet history 2. Iron status 2. What is the sensitivity and 3. Growth specificity of the marker? deficiencies and ++ 3. Do you measure whole gastrointestinal blood, plasma, red blood symptoms: zinc cell or white cell….. 4. Occasionally 4. What are the factors that selenium impact on the results 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.

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

Falt ltering Growth – when is is catch up growth too much? The Thrifty Catch-Up Fat Phenotype 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.

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

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