The Grow Clinic and the Nutrition Prescription

Transcription

1 The Grow Clinic and the Nutrition Prescription Emily Sylvester, MS, RD, LDN, IBCLC Southeastern pediatric nutrition conference November 9 th, 2018

2 Disclosures Founder/Owner Breastfeeding Home Not to be discussed today

3 EVENT S OVERALL OBJECTIVES/OUTCOMES: Describe evidence-based methods for prevention and treatment of malnutrition and micronutrient deficiencies PRESENTATION OBJECTIVES Identify strategies that the Grow Clinic uses to effectively target failure to thrive Identify successful home-based, trauma informed interventions to assess, diagnose, and treat failure to thrive Identify ways that home based strategies can be incorporated into clinical nutrition care

4 GROW CLINIC-defining FTT FTT should be used as a clinical finding and not as a diagnosis Symptom Refers to children who fail to grow as expected for their age or gender due to undernutrition Wt < 3 rd percentile for age and gender Steady predictable weight gain Crossing of 2 major percentiles on standard weight curves below a previously established rate of growth

5 Primary Indicators of FTT When Single Data Point Available (ASPEN) Patricia Becker, MS, RD, CSP, LDN, CNSC1; Liesje Nieman Carney, RD, CSP, LDN3; Mark R. Corkins, MD, CNSC, FAAP2; Jessica Monczka, RD, LDN, CNSC4; Elizabeth Smith, RD, LDN, CNSC3; Susan E. Smith, RD, CSP, LD5; Bonnie A. Spear, PhD, RDN, LD6; Jane V. White, PhD, RD, LDN, FAND7; Academy of Nutrition and Dietetics; and American Society for Parenteral and Enteral Nutrition Weight-for-height z score BMI-for-age z score Mild Malnutrition Moderate Malnutrition Severe Malnutrition -1 to to or greater -1 to to or greater Length/heightfor-age z score No data No data -3 or greater

6 What causes failure to thrive? Child may not be taking in enough nutrition to support normal weight gain Children may have increased needs for calories. i.e. certain types of congenital heart disease Children may be unable to properly digest and absorb food, thereby limiting their ability to properly utilize nutrition for growth.

7 Identify strategies the Grow Clinic uses to effectively target FTT

8 The Grow Clinic, Boston Medical Center Est Patient population: Primarily under 2 years of age Publically insured Low Income Diverse ethnicities (Haitian Creole, Portuguese Creole, Hispanic, African, Middle Eastern) Immigrant children Psychosocial difficulties and hardships

9 The Grow Clinic, Boston Medical Center Referral/contact with PCP Follow-up clinic visit Q 1-2times/mo RD/LICSW home vsit Follow-up school, daycare, medical supplies, DCF, WIC Clinic Visit: RD, LICSW, MD anthros, labs, workup

10 The Grow Clinic Goal of treatment is to establish optimal growth velocity while supporting the family Home visit is key Multidisciplinary team is key

11 Grow Clinic Treatment of FTT Medical Nutritional Developmental Social

12 FTT Nutrition Prescription Provide high-kilocalorie diet, with three scheduled meals and two to three scheduled snacks every day. Aim to increase daily energy intake by 10% from baseline, using increased energy strategies as outlined in handouts. Provide education to caregivers regarding appropriate mealtime and feeding interventions. Monitor weight and length/height once or twice weekly for infants younger than 3 months old until consistent weight gain is established, weekly for infants 3 to 6 months old, and monthly for older children until weight gain commences.

13 The Home Visit

14 Grow Clinic and the Home Visit Benefits Barriers to Medical Nutrition Therapy Access to frequent clinical follow-up Full disclosure of nutrition and social information Lack of access to family members/community involved in care Lack of time Benefits to Home Visit Flexible to family schedule No transportation needed People are more comfortable and open in home Can be investigative Can travel to care centers Can meet other members of household Flexible scheduling Use of actual environment to maximize teaching

15 Grow Clinic and the Home Visit Benefits Cont d Barriers to Medical Nutrition Therapy Lack of timing to watch feeding Provision of adequate nutrition monitoring and support Ability to perform trauma informed care Benefits to Home Visit Visits planned around eating time Better understanding with multiple observations Can bring feeding tools/foods for demonstration 3 day recall follow through Portion size and food brand understanding *See later Slide

16 Grow Clinic FTT Nutritional Management MNT for medical diagnosis/conditions (adjusting caloric intake, Macronutrient intake, types of foods) Cardiorespiratory abnormalities EoE Food Parenting Feeding styles Parenting practices Specific feeding behaviors Key: MNT-medical nutrition therapy EoE- Eosinophilic esophagitis

17 Grow Clinic FTT Nutritional Management cont d Poor appetite Neuromotor/ neurosensory abnormalities Not retaining or utilizing nutrients

18 Causes of Poor Appetite Medications Malnutrition/ Ketosis Reflux Food allergy Constipation Hypercalcemia Force feeding Lead Poisoning Inflammatory Bowel Disease Gluten Sensitive Enteropathy Hepatitis Depression Iron deficiency

19 Child Not Retaining or Utilizing Nutrients Vomiting/Reflux Infectious Diarrhea (look for travel or day care or shelter history) Malabsorption Syndromes Metabolic Disorders

20 Grow Clinic FTT Psychosocial Treatment Assess economic circumstances Address survival issues Rule out domestic violence Individualize intervention Mobilize community resources Address family internalization of FTT "Failure to thrive" is the fear at the root of so much of our parenting. My child was diagnosed with "failure to thrive." Am I a failure as a parent? Snackdinner.com

21 3 mo full term female Birth Hx: maternal ETOH use?fas; exposure to prednisone + oxycodone Case Study: Complimentary Foods Living with mom and 2 older sisters; mom working to maintain sobriety DCF, TAFDC, SNAP, WIC, SSI application pending Referral from primary care at BMC

22 Weight for Age

23 Weight for Length

24 Grow Clinic Trauma Informed Approach and the Home Visit SIX KEY PRINCIPLES OF A TRAUMA-INFORMED APPROACH Safety Trustworthiness and Transparency Peer Support Collaboration and Mutuality Empowerment, Voice and Choice Cultural, Historical, and Gender Issues

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27 Identify successful home-based, trauma informed interventions to assess, diagnose, and treat failure to thrive Identify ways that home based strategies can be incorporated into clinical nutrition care

28 Keys for Successful FTT Interventions: Understand influences on food practices can be deep rooted and complex There needs to be practical support that engages with parents and equips them with the necessary knowledge, skills and self-confidence Need to include support on dealing with fussy eating and managing on a tight budget Celebrate Success! Methodological development of an exploratory randomised controlled trial of an early years nutrition intervention: the CHERRY programme (Choosing Healthy Eating when Really Young)Maternal and Child Nutrition (2014), 10, pp

29 Interventions-Infants Concentration of formula D/c or decrease volume of water/juice offered increase feeding frequency Foods/liquids in bottle Reflux/Constipation management Vitamin D with Breastfeeding infants Correct formula mixing? Introduction of solid foods appropriate? Feeding positions Evaluate breastfeeding/bottle feeding; OT consult

30 3 mo full term female Birth Hx: maternal ETOH use?fas; exposure to prednisone + oxycodone Case Study: Complimentary Foods Living with mom and 2 older sisters; mom working to maintain sobriety DCF, TAFDC, SNAP, WIC, SSI application pending Referral from primary care at BMC

31 Interventions-Food Parenting Permissive Authoritarian Identify feeding style and resulting child feeding behavior Neglectful Authorative

32 Video

33 Interventions-Poor Appetite Frequent feeding Small portions Presentation of foods in fun ways Child help in shopping and prep Nil grazing of food or beverage Limit meal time to minutes (or less!) Self feeding No force feeding Beverages after eating times but within time frame of eating time Limit juice Add calories/nutrient dense foods Daycare school interventions? 2-3 options at eating time Limit screen time/distractions

34 3 mo full term female Birth Hx: maternal ETOH use?fas; exposure to prednisone + oxycodone Case Study: Complimentary Foods Living with mom and 2 older sisters; mom working to maintain sobriety DCF, TAFDC, SNAP, WIC, SSI application pending Referral from primary care at BMC

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36 Interventions- Neuromotor/ neurosensory Seating Size of food pieces Liquid thickness Consistency preferences Relaxation and visualization before mealtime Sitting with family Gradual exposure Set meal times Expand on familiar foods Take food out of boxes or containers Get messy with food Concentrate on the food, not on the behavior

37 3 mo full term female Birth Hx: maternal ETOH use?fas; exposure to prednisone + oxycodone Case Study: Complimentary Foods Living with mom and 2 older sisters; mom working to maintain sobriety DCF, TAFDC, SNAP, WIC, SSI application pending Referral from primary care at BMC

38 Interventions-not retaining or utilizing nutrients Food to symptom associations Increase calories/nutrient density Initiate MVI Initial/ repeat assessments Bone density Label reading Cooking instructions Oral supplement Consider Probiotic/prebiotic Alter compositions of meals/snacks Iron, vitamin D deficiency

39 Starting Pediatric Supplement Look at: Dietary recall Anthropometrics Family motivation Current beverage intake

40 In the END Early identification and management of the issues causing FTT are critical Use of multidisciplinary and trauma informed approaches can be important Key components of FTT nutrition prescription Addressing food parenting Encouraging in-home strategies to feed with poor appetite Establishing nutrition recommendations for not retaining/utilizing nutrients